Upstream: The Quest to Solve Problems Before They Happen

by Dan Heath

“A lot of people on the force want to play cops and robbers,” he said. “It’s much easier to say ‘I arrested this guy’ than to say ‘I spent some time talking to this wayward kid.’ ”

That’s one reason why we tend to favor reaction: Because it’s more tangible. Downstream work is easier to see. Easier to measure. There is a maddening ambiguity about upstream efforts.

Your victories are stories written in data, starring invisible heroes who save invisible victims.

A telltale sign of upstream work is that it involves systems thinking:

Across the political spectrum, we think the best way to “buy health” is to invest two-thirds of our money into systems that make people healthy (food, housing, etc.) and one-third into systems that heal sick people. To say it a different way, for every $1 we spend on downstream health care, most of us think it would be wise to spend $2 upstream.

The average spending pattern over time, across other developed countries, is that for every $1 a nation spends downstream, it spends between $2 and $3 upstream. There is one outlier among those nations and, yep, it’s us. In the US, for every $1 spent downstream, we spend roughly $1 upstream. That’s the lowest proportion of upstream spending to downstream among our peer countries.

“That article was a stunner to me and I think to other pediatricians across this country,” said Sanders in an oral history taken in 2004. Sanders was a pediatrician and county health director who lived in Murfreesboro, Tennessee. He was passionate about prevention. While a medical student, he had delivered one of the first polio vaccine shots ever administered in Tennessee.

In 1977, after intense lobbying, the Child Passenger Protection Act finally made it to the floor of the legislature for a vote, and it passed with about two-thirds support.I On January 1, 1978, Tennessee became the first state in the US to require car seats for children under the age of four.

scarcity “makes us less insightful, less forward-thinking, less controlled. And the effects are large. Being poor, for example, reduces a person’s cognitive capacity more than going one full night without sleep.

Systems are machines that determine probabilities.

A fair and just society is built on fair and just systems. And as obvious as that may seem, even the people who strive for fairness and justice sometimes forget it.

“The law is just a set of rules based on inputs from power sources,” said Iton. “If you want to change the rules, you’ve got to change the power inputs so that the outcome will be different.”

“There is one developed country—and only one—in which it is not only legal, but easy and convenient, to amass a private arsenal of mass slaughter,” wrote David Frum in the Atlantic. “That country also happens to be the one—and the only one—regularly afflicted by mass slaughters perpetrated by aggrieved individuals.” Frum, a former speechwriter for George W. Bush, is not exactly a liberal. Talk about national problem blindness.

We cannot be naïve about this phenomenon of gaming. When people are rewarded for achieving a certain number, or punished for missing it, they will cheat. They will skew. They will skim. They will downgrade. In the mindless pursuit of “hitting the numbers,” people will do anything that’s legal without the slightest remorse—even if it grossly violates the spirit of the mission—and they will find ways to look more favorably upon what’s illegal.

“The best time to plant a tree is 20 years ago. The second-best time is now.”

The first rule of medicine “Primum non nocere,” “First do no harm,” binds not just doctors but all who serve in the health field, including actuaries. Perhaps especially actuaries since a bad doctor can only harm a few people but a bad actuary can harm millions. Therefore, the office should adopt a firm rule of never calculating in an estimate the resulting added cost resulting from saving a person’s life. 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.