Upstream: The Quest to Solve Problems Before They Happen

by Dan Heath

When you spend years responding to problems, you can sometimes overlook the fact that you could be preventing them.

Downstream actions react to problems once they’ve occurred. Upstream efforts aim to prevent those problems from happening.

So often in life, we get stuck in a cycle of response. We put out fires. We deal with emergencies. We handle one problem after another, but we never get around to fixing the systems that caused the problems.

I prefer the word upstream to preventive or proactive because I like the way the stream metaphor prods us to expand our thinking about solutions.

Downstream efforts are narrow and fast and tangible. Upstream efforts are broader, slower, and hazier—but when they work, they really work. They can accomplish massive and long-lasting good.

while we have a wide spectrum of available options to address the world’s problems, we’ve mostly confined ourselves to one tiny stretch of the landscape: the zone of response. React, react, react.

our attention is grossly asymmetrical. We’re so focused on saving the drowning kids in the river that we fail to investigate why they need saving at all.

Remember, both countries spend roughly the same on health (upstream and downstream) as a percentage of GDP. Norway is not spending more; it’s just spending differently. We cranked up the treble, Norway cranked up the bass. Our choice as a nation has been to get better and better at fishing drowning kids out of the river.

That’s just how it is—so no one questions it. That’s problem blindness.

Every system is perfectly designed to get the results it gets.

To succeed upstream, leaders must: detect problems early, target leverage points in complex systems, find reliable ways to measure success, pioneer new ways of working together, and embed their successes into systems to give them permanence.

“tunneling”: When people are juggling a lot of problems, they give up trying to solve them all. They adopt tunnel vision. There’s no long-term planning; there’s no strategic prioritization of issues. And that’s why tunneling is the third barrier to upstream thinking—because it confines us to short-term, reactive thinking. In the tunnel, there’s only forward.

People who are tunneling can’t engage in systems thinking. They can’t prevent problems; they just react.

It’s a terrible trap: If you can’t systematically solve problems, it dooms you to stay in an endless cycle of reaction. Tunneling begets more tunneling.

We all have colleagues who actually seem to relish those manic “stay up all night to meet the critical deadline” adventures. And it’s not that the day doesn’t need saving, sometimes, but we should be wary of this cycle of behavior.

How do you escape the tunnel? You need slack. Slack, in this context, means a reserve of time or resources that can be spent on problem solving.

Ponder this fact for a moment: The most successful preventive habit we have developed as a species is for the preservation of our… lungs brains hearts teeth.

There’s a paradox inherent in preventive efforts: We’ve got to create an urgent demand to fix a problem that may not happen for a while. We’ve got to make the upstream feel downstream, in other words.

“The world avoided” is an evocative phrase. In some ways it’s the goal of every upstream effort: To avoid a world where certain kinds of harm, injustice, disease, or hardship persist. The path to “the world avoided” is a difficult one because of the barriers we’ve seen: problem blindness (I don’t see the problem), lack of ownership (That problem is not mine to fix), and tunneling (I can’t deal with that right now).

How Will You Unite the Right People?

The lesson of the high-risk team’s success seems to be: Surround the problem with the right people; give them early notice of that problem; and align their efforts toward preventing specific instances of that problem.

sitting around a table together and looking at data. Discussing how the fresh data in front of them would inform the next week’s work.

“data for the purpose of learning.”

‘It’s important to set up data systems that are useful for people on the front lines.’

groups do their best work when they are given a clear, compelling aim and a useful, real-time stream of data to measure their progress, and then… left alone.

The team members hold each other accountable, and the data keeps them honest and keeps them pushing.

Upstream work is about reducing the probability that problems will happen, and for that reason, the work must culminate in systems change. Because systems are the source of those probabilities. To change the system is to change the rules that govern us or the culture that influences us.

Let’s not sabotage upstream efforts by subjecting them to a test we never impose on downstream interventions.

That’s the kind of perspective that is spreading quickly—a growing appreciation for the importance of the upstream factors that influence health.

But with upstream efforts, success is not always self-evident.

We’ve seen two kinds of ghost victories so far—one is caused by an effort that’s buoyed by a macro trend,

The second kind of ghost victory happens when measures are misaligned with the mission.

There is also a third kind of ghost victory that’s essentially a special case of the second. It occurs when measures become the mission. This is the most destructive form of ghost victory, because it’s possible to ace your measures while undermining your mission.

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.

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...

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

Tiny shifts in large systems can have powerful effects. So, together, by wading our way upstream, we can approach a world where the preservation of health is as valuable as the treatment of disease.

“Be impatient for action but patient for outcomes.” That’s a quote from Maureen Bisognano,

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.

If you want to help solve big problems in the world, seek out groups who have ambitious goals coupled with close-up experience.

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.

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