Key concepts:
“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” (p. 5).
“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” (p. 6).
Moving Upstream: Don’t get stuck in response mode only. Look “upstream” to get in front of problems before they happen.
Problem Blindness. We have to first be aware of a problem to solve it.
A Lack of Ownership. The people who can address the problem need to believe that the problem is theirs to fix.
Tunneling. People with tunnel vision only act reactively and in the short term. But it is important to think of prior causes as well as effects.
How Will You Unite the Right People? Gather together a diverse, interdisciplinary group who share a unified objective.
How Will You Change the System? “Rethink every part of the mis-engineered system” (p. 109).
Where Can You Find a Point of Leverage? Use smart strategies – customized to your situation – to get close to the problem. “The postmortem for a problem can be the preamble to a solution” (p. 124).
How Will You Get Early Warning of the Problem? “To anticipate problems, we need eyes and ears in the environment” (p. 143).
How Will You Know You’re Succeeding? Examine successes to make sure they aren’t “ghost victories” (p. 153). Figure out if your efforts (rather than something else) are truly contributing to your success.
How Will You Avoid Doing Harm? Think broadly and honestly and enact change strategically, remaining alert to unintended consequences to your success.
The Chicken Little Problem: Distant and Improbable Threats. You can prepare for possible disaster and have that disaster never materialize. Is that because you prepared well, or because it wasn’t actually going to be a disaster on the level you predicted? Sometimes both things can be true, or partly true. Assess both positive and negative outcomes with care and nuance.
You, Upstream. With some forethought, we can prevent negative outcomes or at least “blunt their impact” (p. 231).
The Three Barriers to Upstream Thinking
Problem Blindness: The first and, arguably, most important barrier to upstream thinking is problem blindness. “When we don’t see a problem, we can’t solve it” (p. 23). Telltale signs of this barrier include the belief that a certain type of problem is inevitable or unpreventable, like the weather. It just happens. “That’s just how it is,” or, “I can’t do anything about it,” and so on (p. 24).
A Lack of Ownership: In many cases, simultaneous with the first barrier of problem blindness comes the barrier of lack of ownership. Even when a problem is identified with real data, those in a position to design and implement a solution often deflect or deny it by saying phrases such as, “That’s not my problem, it’s theirs” or “There’s nothing I can do about this.”
Sometimes politics or bottom-line goals are involved, and leaders simply act in their own self-interest. Other times there is no clear authority to guide a solution, and people are not sure if they can legitimately take something on. In combating this concern about “psychological standing” – the sense of reluctance or sense of a lack of legitimacy in acting upon a problem – Heath suggests asking questions of accountability. “I choose to fix this problem, not because it’s demanded of me, but because I can, and because it’s worth fixing” (p. 55).
Tunneling: Time and resource scarcity can lead to procrastinating on less urgent things in life. Some examples of these overlooked things are cleaning, medical care, or writing a will. These are things that have real costs in time and resources and are easy to put off for more (seemingly) pressing needs (p. 60).
Tunneling is a concept where one’s focus is strictly on pressing or immediate issues, so that peripheral – but often important – tasks are neglected. We can rationalize quick fixes which can negatively impact ourselves or others. Quick fixes are things like regularly using supplies from another department, taking painkillers to ignore a symptom, or consistently relying on credit to support an unsustainable lifestyle.
Seven Questions for Upstream Leaders
How Will You Unite the Right People? The first step is to “recruit a multifaceted group of people and organizations united by a common aim” (p. 76). The core team should be selected strategically. Attract people who can address all the key dimensions of the issue and then organize all those people’s efforts (p. 82).
How Will You Change the System? Regardless of the size and scope of the problem, assessing and changing a system can be complex and time-consuming. Whether the issue is poverty, resource scarcity, auto fatalities, equality and opportunity, or a country’s most pressing medical epidemics, the point is to commit to changing the system for the long game.
Where Can You Find a Point of Leverage? There is no easy way to identify a point of leverage to bring about change. In searching for a leverage point, you may first consider “the risk and protective factors for the problem you’re trying to prevent” (pp. 125, 126). The leverage point may involve a very particular subpopulation, or it may be investing much in a small area of focus, if that area is causing an inordinate burden upon the system. Costs and benefits should both be carefully considered. The goal must save the system money and/or provide moral returns for society (pp. 125-128).
How Will You Get an Early Warning of the Problem? An early warning of a problem gives us greater ability to resolve it. The value of early warning signals depends on the severity of the problem. It may not be needed for a small lightbulb, but it may be very valuable if that bulb’s function is essential for safety, such as at the top of a lighthouse. Advance warnings, which are too short, may be ineffective to avoid disaster (p. 137). Technology and the Internet of Things will enable faster response times and predictable data models, but sometimes the best sensors are people who witness a potential problem, such as errant behavior or threat, who then act to prevent a possible disaster.
How Will You Know You’re Succeeding? Downstream efforts attempt to restore the previous state – victory is definitive. However, success is not always self-evident with upstream efforts. There is a risk of a “ghost victory,” which is “a superficial success that cloaks failure,” such as changing the definition of a crime which results in a statistical reduction of that crime (p. 153). Importantly, short-term measures used to determine success should have time devoted to “pre-gaming,” or brainstorming “how the measures may be misused” or misinterpreted (p. 168).
How Will You Avoid Doing Harm? Wise leaders try to anticipate effects beyond their immediate work. For example, could tampering with an ecosystem by killing one destructive species result in population overgrowth of another? Some questions to guide a decision about whether or not to stage an upstream intervention are wise to consider. Can we learn from a previously implemented solution? Can we experiment with a small pilot program first to mitigate widespread consequences? “Can we create closed feedback loops to improve quickly? Is it easy to reverse or undo our intervention if it turns out we’ve unwittingly done harm?” (pp. 184-185).
Who Will Pay for What Does Not Happen? “Paying for upstream efforts boils down to three questions: Where are there costly problems? Who is in the best position to prevent those problems? And, how do you create incentives for them to do so?” (p. 201). In the healthcare industry, “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 on (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” (p. 204).
The Chicken Little Problem – Distant and Improbable Threats
In 1999, a worldwide scare of the “Y2K Bug” was predicated on the assumption that computer systems upon which societies depended were
at risk of becoming non-functional in the minutes following the turn of the millennium. Many preventative measures were implemented swiftly within IT systems, and the impending bug did not become a serious issue. Was this near-miss a success because of widespread alarm, coordination, and efforts? Or was it a hoax and never really a concern at all? That depends on who you talk to. Acting upon a potential threat, in any event, does not mean that resources were wasted.
You, Upstream
Heath suggests three things to help choose where you should invest your time or money into moving further upstream.
“Be impatient for action but patient for outcomes.” Action is necessary for real change, but it can take a while for that action to produce results. It takes “conviction” and “stubbornness” to sustain upstream efforts. 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” (pp. 234-235).
“Macro starts with micro.” “You can’t help a thousand people, or a million, until you understand how to help one.” To understand a problem, you have to see 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” (pp. 236-237).
“Favor scoreboards over pills.” Under the “Pill Model,” progress is not assessed until the end or the test or trial, and there is no adjustment made with new information. The “obsession with testing becomes a hindrance to scale and learning” (p. 237).
However, with the “Scoreboard Model,” progress is assessed as you go. “You get a group of people to come together who have agreed to take ownership of a problem, and you arm them with data to assess their progress” (p. 238). The question is, “How can we make progress this week?”
Don’t initially demand a perfect solution. Take ownership and be flexible to change (p. 239).
Downstream efforts attempt to restore the previous state – victory is definitive. However, success is not always self-evident with upstream efforts. There is a risk of a “ghost victory,” which is “a superficial success that cloaks failure,” such as changing the definition of a crime which results in a statistical reduction of that crime.
Heath, D. (2020). Upstream: The Quest to Solve Problems Before They Happen. New York: Avid Reader Press.