Upstream: How to solve problems before they happen

by Dan Heath

To prevent problems, upstream leaders must unite the right people (caregivers, insurers, patients). They must hunt for leverage points and push for systems change (unnecessary hospitalizations, ACOs). They must try to spot problems early (by, say, monitoring blood sugar levels). They must agonize about how to measure success—avoiding both ghost victories and unintended consequences. And finally they must think about the funding stream: how to find someone who’ll pay for prevention.

He considers the Y2K bug a near-miss—a catastrophe narrowly avoided thanks to a successful global mobilization of talent and energy.

But with Y2K, there’s just one data point: January 1, 2000. And, fortunately, by virtue of fortune or preparation or both, it turned out to be no big deal.

In 2019, Beriwal said of Hurricane Pam, “We predicted the consequences almost to the scientific bull’s-eye.

“Contraflow” is an emergency procedure in public transportation in which all the lanes of a highway are temporarily switched to flow in the same direction.

During Ivan, drivers were stopping frequently to ask cops questions, and the cops thought that they were helping by giving good answers.30 But those conversations were actually creating bottlenecks and contributing significantly to the traffic jam. For Katrina, the lesson was clear: no talking, wave ’em forward.

The Hurricane Pam simulation is a model example of upstream effort: convening the right people to discuss the right issue in advance of a problem.

Preparing for a major problem requires practice. In theory, that’s not complicated. What makes it complicated in reality is that this kind of practice runs contrary to the tunneling instinct discussed earlier in the book.

Planning for speculative future ones is, by definition, not urgent. As a result, it’s hard to convene people.

It’s hard to convince people to collaborate when hardship has...

That’s the vision, too, for disaster preparedness. Emergency simulations aren’t supposed to be perfect predictions, just credible ones, and ideally, the parties involved get multiple opportunities to practice.

When disaster strikes, they will already know the players involved. They’ll understand the linkages in the system.

An authority convenes the right players and aligns their focus. They escape their tunnels and surround the problem. And they try to make tweaks to the system—like improvements to contraflow—that will boost their readiness for the next disaster.

When it comes to innovation, there’s an accelerator but no brake.

Bostrom conjured a metaphor for this fumbling-forward habit: Imagine that humanity is pulling balls out of a giant urn, where the balls represent inventions or technologies. The urn contains some white balls, which represent beneficial technologies like antibiotics, and some gray balls, which represent the mixed-blessing types.

Bostrom considers whether there might be a black ball in the urn, representing a technology that will destroy the civilization that invents it.

Our civilization has a considerable ability to pick up balls, but no ability to put them back into the urn. We can invent but we cannot un-invent. Our strategy is to hope that there is no black ball.”

It requires only two conditions: first, a set of actors who would welcome mass destruction, and second, a technology that makes mass destruction available to the masses.

Imagine if, someday, those DNA printers could be brought into the home—perhaps in the spirit of offering genetically tailored medicine—and someone could home-cook a copy of the 1918 Spanish flu. One human being could trigger the end for all of us.

There’s a concept called “the prophet’s dilemma”: a prediction that prevents what it predicts from happening. A self-defeating prediction.

Maybe what society needs is a new generation of enlightened Chicken Littles.

Not the fear-entrepreneurs using hysteria to hock consulting services. But people like Bostrom, who founded the Future of Humanity Institute to attract interest in research about existential risks and humanity’s long-range future.

“Thousands of concerned citizens wrote NASA letters, worried that they were at risk from Moon germs,” wrote Michael Meltzer in his fascinating book When Biospheres Collide.

“Backward contamination”52 is the contamination of Earth by a returning spaceship—aka the Andromeda scenario—and “forward contamination” is the contamination of another planet with organisms from Earth.

When the Apollo astronauts came back from the Moon, they were immediately put into quarantine.

They weren’t unduly worried that the astronauts would bring back deadly Moon bugs. But, to their credit, they worried about what they didn’t know.

The person in charge of these efforts was a NASA employee called the Planetary Protection Officer (originally the Planetary Quarantine Officer).

In 2005, Tricia Dyal’s husband, Justin, a Marine in a special operations role, was deployed to Iraq.

Desperate to give her daughter some comfort, Tricia called her great-aunt Mary, a gifted crafter, and asked if she could rig up a doll with Justin’s picture on it.

Other Marines had shared stories about coming home to find that their kids were scared of them for a few weeks after they returned.

It gradually dawned on Tricia that the dolls shouldn’t be just for her daughters, or for friends of friends. The dolls were for every family that suffered from the absence of a loved one.

She and Darnell started a business, Daddy Dolls. Within a year, they had distributed more than 1,000 Daddy Dolls to military kids.

Upstream thinking is not just for organizations, it’s for individuals. Where there’s a recurring problem in your life, go upstream. And don’t let the problem’s longevity deter you from acting. As an old proverb goes, “The best time to plant a tree is 20 years ago. The second-best time is now.”

“Be impatient for action but patient for outcomes.”

At the same time, it can take a while for action to bear fruit. Downstream work is narrow and fast. Upstream is broad and slow(er).

Chip, chip, chip. And that’s how upstream victories are won. An inch at a time, and then a yard, and then a mile, and eventually you find yourself at the finish line: systems change. Be impatient for action and patient for outcomes.

Macro starts with micro. When we think about big problems, we’re forced to grapple with big numbers.

The lesson is clear: You can’t help a thousand people, or a million, until you understand how to help one.

To affect millions requires systems change. But even systems change usually starts up close: Someone understands a problem so well that they formulate and lobby for a new policy at the city or state level, and it works, and later other state leaders see that the policy works and they embrace it, too.

Favor scoreboards over pills.

The people in the field who are doing the hard work should receive timely, useful data that allows them to learn and adapt.

I’m using a scoreboard as a metaphor for this continuous flow of data, which provides a way to judge in real time whether you’re succeeding or failing.

You can use the Pill Model to establish that an intervention works but, when it comes time to scale it, people should be encouraged to tweak it (not d...

Don’t obsess about formulating the perfect solution before you begin your work; instead, take ownership of the underlying problem and start slogging forward.

In pursuit of those goals, they attended a series of classes on healthy habits taught by a lifestyle coach, who also consulted with them one-on-one.

We can’t not invest in a program because it saves people’s lives!

“The Centers for Medicare & Medicaid Services has made a determination that costs associated with expected improvements in longevity are not appropriate for consideration in the evaluation of net program spending.”

We are drawn to the glory of the rescue and the response.

Our heroes should also include a teacher who skips lunch to help a freshman with math, in hopes that she’ll get back on track to graduate.

These should be our heroes, too: The people who are unsatisfied with normal. People who clamor for better.