Upstream: The Quest to Solve Problems Before They Happen

by Dan Heath

In 2012, Ryan O’Neill, the head of the customer experience group for the travel website Expedia, had been sifting through some data from the company’s call center. One number he uncovered was so farfetched as to be almost unbelievable. For every 100 customers who booked travel on Expedia—reserving flights or hotel rooms or rental cars—58 of them placed a call afterward for help.

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.

Surely we’d all prefer to live in the upstream world where problems are prevented rather than reacted to. What holds us back?

One thing is that there's no glory in fire preventon, but plenty of glory in firefighting.

Expedia’s executives were not oblivious. They were aware of the huge volume of calls. It’s just that they were organized to neglect their awareness.

Notice what was missing: It was no group’s job to ensure that customers didn’t need to call for support. In fact, no team really stood to gain if customers stopped calling. It wasn’t what they were measured on.

Okerstrom’s point is that focus is both the strength and the weakness of organizations. The specialization inherent to organizations creates great efficiencies. But it also deters efforts to integrate in new, advantageous ways. In upstream ways.

Back in 2009, I spoke with a deputy chief of police in a Canadian city; it was one of the conversations that sparked my interest in upstream thinking. He believed that the police force was unduly focused on reacting to crimes as opposed to preventing them. “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.’ ”

My Uncle was a cop for thirty years and retired in the 1960s. He said this shift was reflected in the change from calling what cops do "police work" and calling it "law enforcement" instead. He said that changed the emphasis and turned police officers into "the procurement arm of the criminal justice system."

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.

In this book, I’m defining upstream efforts as those intended to prevent problems before they happen or, alternatively, to systematically reduce the harm caused by those problems.

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

It’s not that the upstream solution is always right. And it’s certainly not the case that we should abandon downstream work—we will always want someone there to rescue us. The point is that our attention is grossly asymmetrical.

My goal in this book is to convince you that we should shift more of our energies upstream: personally, organizationally, nationally, and globally. We can—and we should—stop dealing with the symptoms of problems, again and again, and start fixing them.

Our exploration will come in three stages. First, we’ll grapple with the three forces that push us downstream, impeding our ability to prevent problems. Then, in the heart of the book, we’ll study the seven fundamental questions that upstream leaders must answer. We’ll study both successful and unsuccessful prevention efforts, uncovering strategies that succeeded and obstacles to beware. Finally, we will consider “far upstream” thinking: What do you do when you’re facing a problem that has never happened before (and may never happen at all)?

What the world needs now is a quieter breed of hero, one actively fighting for a world in which rescues are no longer required. How many problems in our lives and in society are we tolerating simply because we’ve forgotten that we can fix them?

In 1999, the doctor and sports trainer Marcus Elliott joined the staff of the New England Patriots, whose players had been plagued by hamstring injuries. At the time, there was a kind of fatalistic mind-set about injuries. People thought that injuries were “just a part of the sport,” said Elliott. “It’s just the nature of the sport and they’re just freak injuries.” Football is a tough game; players will get hurt. It’s inevitable. Elliott’s philosophy was different. He thought that most injuries were simply the result of bad training. In most NFL training environments, the focus was on getting bigger and stronger. Even though players’ bodies—and the positions they played—differed greatly, the training was mostly the same. “It’s almost like walking into a doctor’s office and—without interviewing you, without conducting any tests on you—he gives you a prescription,” he said. “It makes no sense. But that’s how the training of professional athletes was conducted.… It was a one-size-fits-all program.”

Problem blindness is the first of three barriers to upstream thinking that we’ll study in this section. When we don’t see a problem, we can’t solve it. And that blindness can create passivity even in the face of enormous harm. To move upstream, we must first overcome problem blindness.

Inattentional blindness leads to a lack of peripheral vision. When it’s coupled with time pressure, it can create a lack of curiosity.

In a therapeutic context, that normalization is desirable. But habituation cuts both ways: Imagine instead that what’s being normalized is corruption or abuse.

The term sexual harassment was coined in 1975 by the journalist Lin Forley, who’d been teaching a course at Cornell University about women and work. She invited female students to a “consciousness raising” session and asked about their experience in the workplace. “Every single one of these kids had already had an experience of having either been forced to quit a job or been fired because they had rejected the sexual overtures of a boss,” she said in a 2017 interview with On the Media host Brooke Gladstone. Forley cast about intentionally for a term—a label—that would capture these shared experiences, and she settled on sexual harassment. She later wrote in the New York Times, “Working women immediately took up the phrase, which finally captured the sexual coercion they were experiencing daily. No longer did they have to explain to their friends and family that ‘he hit on me and wouldn’t take no for an answer, so I had to quit.’ What he did had a name.”

They call this sense of legitimacy “psychological standing,” inspired by the concept of legal standing. You can’t bring a suit in the justice system simply because something offended your sensibilities—you’ve got to show that it affected you. The evidence that you were harmed gives you standing to bring a case. The young man who’s reluctant to join a protest against date rape may feel he lacks psychological standing, since he hasn’t been affected personally by the issue.

This, in essence, was the same thing Ray Anderson had demanded of his staff: Let’s tell our story as if we were 100% responsible for the environmental degradation we cause. And when you look at the world that way, you start to see angles of influence: computer controls on boilers, methods for melting down old carpet, incentives for dredging the seas of nylon nets. You start to surface strands of causation that were always there—but buried.

In my research, I sought out stories like these—people who stopped reacting to problems and started preventing them. I found them oddly inspirational. I started micro-analyzing my own life, looking for recurring irritants that I could vanish with a bit of upstream witchcraft.

We would expect big problems in life to crowd out little problems. We don’t have the bandwidth to fix everything. But this issue of “bandwidth” is actually more insidious than that: Researchers have found that when people experience scarcity—of money or time or mental bandwidth—the harm is not that the big problems crowd out the little ones. The harm is that the little ones crowd out the big ones.

The psychologists Eldar Shafir and Sendhil Mullainathan, in their book Scarcity, call this “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.

As the authors write, 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. It is not that the poor have less bandwidth as individuals. Rather, it is that the experience of poverty reduces anyone’s bandwidth.” When people’s resources are scarce, every problem is a source of stress.

Saving the day feels awfully good, and heroism is addictive.

The need for heroism is usually evidence of systems failure.

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.

Think of it as structured slack: A space that has been created to cultivate upstream work. It’s collaborative and it’s disciplined. The same idea was used in the Chicago Public Schools effort to reduce the dropout rate: The Freshman Success Teams had a standing meeting where they reviewed progress on a student-by-student basis. This kind of forum will never happen “naturally”: It’s no trivial feat to carve out time from teachers’ already crazy schedules.

Success stories like this one can acquire inevitability in retrospect. Of course we fixed the ozone layer—we had to! But there were countless ways for the whole effort to have blown up.

“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).

The current version of the tool asks female victims of abuse to mark on a calendar the approximate dates, over the previous year, when they were abused. Then they are asked to answer 20 yes/no questions about the abuser, including: Is he unemployed? Does he threaten to harm your children? Does he control most or all of your daily activities? For instance: Does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car?

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. To clarify that last point, this was not a group that was organized to discuss “policy issues around domestic violence.” This was a group assembled to stop particular women from being killed.

The other point of connection between the two stories is the primacy of data, which was a theme I observed repeatedly in my research, and one that surprised me. I knew data would be important for generating insights and measuring progress, but I didn’t anticipate that it would be the centerpiece of many upstream efforts. I mean this even in a literal sense—what the teachers and counselors in Chicago were doing, and what the high-risk team members in Newburyport were doing, was 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.

McCannon believes that 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.

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.

A well-designed system is the best upstream intervention.

What follows are examples of some simple, imgenious changes that solved a big problem

Systems change is important within organizations as well as outside them. Consider, for instance, the efforts of many organizations to hire a more diverse workforce. The first thing to realize is that if you have a large organization filled with a relatively homogenous population of employees, then that composition did not happen by chance. Remember the quote: “Every system is perfectly designed to get the results it gets.” I’m not implying that these hiring systems were engineered consciously to discriminate. In this age, not many organizational leaders are opposed to diversity. But good intentions can’t overcome bad systems. (Just as, in the Chicago Public Schools, no teachers or administrators were opposed to a higher graduation rate. Quite the opposite. Still, for many years they unwittingly served a system that failed half its students.)

Systems change starts with a spark of courage. A group of people unite around a common cause and they demand change. But a spark can’t last forever. The endgame is to eliminate the need for courage, to render it unnecessary, because it has forced change within the system. Success comes when the right things happen by default—not because of individual passion or heroism.

Yes, but. It takes passion and courage to get there. Courage especially the kind that rocks the boat is usually in short supply. It also takes persistence, the ability to act courageously for a long time. System change is neither simple, quick, or easy

(Upstream leaders should be wary of common sense, which can be a poor substitute for evidence.)

One of the most baffling and destructive ideas about preventive efforts is that they must save us money. Discussions of upstream interventions always seem to circle back to ROI: Will a dollar invested today yield us more in the long run? If we provide housing to the homeless, will it pay for itself in the form of fewer social service needs? If we provide air conditioners to asthmatic kids, will the units pay for themselves via fewer ER visits? These aren’t irrelevant questions—but they aren’t necessary ones, either. Nothing else in health care, other than prevention, is viewed through this lens of saving money.

in most health systems, doctors would actually lose income by trying, because they’re paid on a fee-for-service model. The more acts of maintenance they can cram in a day, the better, and talking for an extra 15 minutes to a stressed or lonely patient doesn’t count as maintenance. (In chapter 11,

This is the model of an early-warning story: Data warns us of a problem we wouldn’t have seen otherwise—say, needing ambulances deployed closer to nursing homes at mealtimes. And that predictive capacity gives us the time to act to prevent problems.

But while technology can aid our early-detection efforts, sometimes the best sensors are not devices, but people.

When everything is cause for alarm, nothing is cause for alarm.

Frum, a former speechwriter for George W. Bush, is not exactly a liberal. Talk about national problem blindness.

Read this line again. It says to me that Heath is surprised that someione who is "not exactly a liberal" gets it -- it being what Heath believes.

To make matters worse, it’s the curse of preventing rare problems that we may never really know when we’ve succeeded.

because there is a separation between (a) the way we’re measuring success and (b) the actual results we want to see in the world, we run the risk of a “ghost victory”: a superficial success that cloaks failure.

This is the essence of intuitive heuristics: When faced with a difficult question, we often answer an easier one instead, usually without noticing the substitution.”