Upstream: The Quest to Solve Problems Before They Happen

by Dan Heath

Or we could settle for a pretty good solution that’s equipped with so many built-in feedback loops that it can’t help but get better over time. The second option is the one that systems thinkers would endorse.

Based on these ideas, we can formulate some questions to guide a decision about whether or not to stage an upstream intervention. Has an intervention been tried before that’s similar to the one we’re contemplating (so that we can learn from its results and second-order effects)? Is our intervention “trial-able”—can we experiment in a small way first, so that the negative consequences would be limited if our ideas are wrong? Can we create closed feedback loops so that we can improve quickly? Is it easy to reverse or undo our intervention if it turns out we’ve unwittingly done harm?

Upstream work hinges on humility.

So now we’re forced to grapple with part/whole confusion: If protecting waterways and marine life, specifically, is our goal, then a plastic bag ban is a great idea. But if making the whole environment better is the goal, then it’s less clear. There are competing effects to consider.

This infrastructure of evidence has existed for a mere blip in human history. When it comes to upstream thinking, we’re just starting to get in the game.

“Systems can’t be controlled, but they can be designed and redesigned. We can’t surge forward with certainty into a world of no surprises, but we can expect surprises and learn from them and even profit from them.… We can’t control systems or figure them out. But we can dance with them!”

But sometimes averages don’t just blur an underlying reality, they obliterate it.

Public health efforts suffer from what is effectively a punishment for success. “In public health, if you do your job, they cut your budget, because no one is getting sick,”

So, in short, reactive efforts succeed when problems happen and they’re fixed. Preventive efforts succeed when nothing happens. Who will pay for what does not happen?

Even in a simple case like this one, then—where a good payoff awaited an investment—the inertia pushed against prevention.

That’s an example of what’s called the “wrong pocket problem”: a situation where the entity that bears the cost of the intervention does not receive the primary benefit.

We can pay to fix problems once they happen, or we can pay in advance to prevent them. What we need are more business and social entrepreneurs who can figure out how to flip payment models to support the preventive approach.

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.

It’s the perfect illustration of our collective bias for downstream action.

In these efforts to prepare for uncertain or unpredictable problems—like Y2K or hurricanes—we’re seeing familiar themes. 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.

What if, for certain kinds of problems, being “prepared” isn’t good enough? What if avoiding a problem requires perfection?

Nick Bostrom, a Swedish philosopher at the University of Oxford, contemplates whether technological innovation has left modern society on the verge of a similar kind of vulnerability—a situation in which the fate of everyone could hinge on a single bad break or bad actor. The context of his comments is mankind’s tendency to keep pushing for new innovations almost without regard for the consequences. Scientists and technologists rarely cross a formal threshold where they ask themselves, Should this thing be invented? If it can be invented, it will be. Curiosity and ambition and competitiveness push them forward, forward, forward. When it comes to innovation, there’s an accelerator but no brake.

We can invent but we cannot un-invent.

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

Future of Humanity Institute

Click Here to Kill Everybody

And maybe we need to start building a system that can act on the warnings of these enlightened Chicken Littles.

When Biospheres Collide.

astrobiology.)

Planetary Protection Officer

One of her predecessors, Catharine Conley, said something striking about the office’s history: “So far as I can tell, planetary protection is the first time in human history that humans as a global species decided to prevent damage before we were capable of doing something.” May there be a second time.

How can you, personally, move upstream? Consider your own problem blindness. Which problems have you come to accept as inevitable that are, in fact, nothing of the kind?

Have you come to accept problems in your relationships that might be avoidable? Sometimes a bit of upstream thinking can open up new possibilities.

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.” That’s a quote from Maureen Bisognano, the president emerita of the Institute for Healthcare Improvement, and it struck me as the perfect motto for upstream efforts. The world is full of groups who engage in lofty discussions—and feel virtuous doing so—but never create meaningful change. Change won’t come without action.

Downstream work is narrow and fast. Upstream is broad and slow(er).

When I think of the conviction—and stubbornness—it takes to sustain upstream efforts, I think of advocates like Sally Herndon, who worked for years in North Carolina for an anti-smoking initiative called Project ASSIST.

It was clear they weren’t going to deliver a knockout blow. Herndon knew that their only hope was to chip away at the problem.

Think of it: It took her team a full decade to succeed in one-tenth of the state’s districts. And this was supposed to be the easy fight. That’s stamina.

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.

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

That’s because you don’t understand a problem until you’ve seen it up close. Until you’ve “gotten proximate” to the problem, as we explored in the chapter on leverage points.

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.

Worse, the cardinal rule of the Pill Model is: Don’t change the pill in the middle of a test. Even if you’ve had an epiphany—Aha! A different formulation of this pill would be much better!—you can’t replace people’s supply with the new-and-improved version, because then you’ve confounded the whole experiment. So, in South Carolina, nurses are essentially forbidden from learning/improving/innovating during the six-year span of the trial.

Contrast the Pill Model with a mind-set focused on continuous improvement—what I’ll call the Scoreboard Model. In the Scoreboard Model, you get a group of people together who’ve agreed to take ownership of a problem, and you arm them with data to assess their progress.

“data for learning” rather than “data fo...

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

A final way you can apply upstream thinking, as an individual, is to change the organization you work for. Could you be the person who improves a system from within?

Then came a fateful meeting at which the actuaries revealed that they couldn’t, in fact, certify DPP as a cost-saving program. The reason? It helped people live longer. And when people live longer, their health care costs more.

And then something happened that should give hope to anyone who has ever felt like an insignificant cog in a giant wheel.

Calculators are appropriate for determining how much doctors and hospitals should be paid, calculators are not appropriate for determining how long people should be allowed to live.

Yet it captures so well what an upstream success looks like. Quiet but powerful, with effects that ripple across time. A modest sentence that will extend and save lives.

“Try and leave this world a little better than you found it,” goes a famous quote, but until I researched it, I never realized that the source was Robert Baden-Powell, founder of the movement that gave us the Boy Scouts, Girl Guides, and Girl Scouts, and someone who taught multiple generations of kids to “Be Prepared.” That is to say: Anticipate the future and be ready to shape it.