Upstream: The Quest to Solve Problems Before They Happen (Heath, Dan)
Notes from relevant books on Foreign Policy, Diplomacy, Defence, Development and Humanitarian Action.
Heath, Dan. Upstream: The Quest to Solve Problems Before They Happen. Avid Reader Press / Simon & Schuster, 2020.
These are my personal notes from this book. They try to give a general idea of its content, but do not in any case replace reading the actual book. Think of them as teasers to encourage you to read further!
Chapter 1: Moving Upstream
You and a friend are having a picnic by the side of a river. Suddenly you hear a shout from the direction of the water - a child is drowning. Without thinking, you both dive in, grab the child, and swim to shore. Before you can recover, you hear another child cry for help. You and your friend jump back in the river to rescue her as well. Then another struggling child drifts into sight … and another … and another. The two of you can barely keep up. Suddenly, you see your friend wading out of the water, seeming to leave you alone. “Where are you going?” you demand. Your friend answers, “I’m going upstream to tackle the guy who’s throwing all these kids in the water.”
“When we create organizations, we’re doing it to give people focus. We’re essentially giving them a license to be myopic. We’re saying: This is your problem. Define your mission and create your strategy and align your resources to solve that problem. And you have the divine right to ignore all of the other stuff that doesn’t align with that.”
That’s one reason why we tend to favor reaction: Because it’s more tangible. Downstream work is easier to see. Easier to measure.
A telltale sign of upstream work is that it involves systems thinking: Because authorities are aware of the risk of drowning, life preservers are purchased and distributed to locations where they will be readily available if an emergency happens.
When Ebola starts to spread in a foreign nation, it becomes an international priority—and afterward it’s hard to attract funding to support the local health systems that could prevent the next outbreak.
Section 1: The Three Barriers to Upstream Thinking
Chapter 2: Problem Blindness
“problem blindness”—the belief that negative outcomes are natural or inevitable.
“Every system is perfectly designed to get the results it gets,”
“Teachers thought that the kids [who failed] would think, ‘I need to work harder,’ ” Duncan said. “Sometimes that happens. But the majority of fourteen-year-olds, if they fail, interpret that as: ‘I don’t belong, I’m not good enough.’ They withdraw.” But how do you keep students on track? Keep in mind: the FOT metric is just a prediction—it doesn’t solve anything, just as your smoke detector doesn’t put out fires.
‘My job is to make sure all students are succeeding in my class. So I need to find out why they’re struggling if they’re struggling.’ ” As a teacher, if you accept that your job is to support students, not appraise them, it changes everything.
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.
How many of the radiologists—focused on a search for potentially cancerous nodules—would notice the gorilla? Not many: 20 out of 24 missed it entirely. They had fallen prey to a phenomenon called “inattentional blindness,” a phenomenon in which our careful attention to one task leads us to miss important information that’s unrelated to that task.
What Lin was doing, with the term sexual harassment, was the opposite: She wanted to problematize the normal.
Chapter 3: A Lack of Ownership
What’s odd about upstream work is that, despite the enormous stakes, it’s often optional. With downstream activity—the rescues and responses and reactions—the work is demanded of us. A doctor can’t opt out of a heart surgery; a day care worker can’t opt out of a diaper change. By contrast, upstream work is chosen, not demanded.
This lack of ownership is the second force that keeps us downstream. The first force, problem blindness, means: I don’t see the problem. (Or, This problem is inevitable.) A lack of ownership, though, means that the parties who are capable of addressing a problem are saying, That’s not mine to fix.
Who’s best positioned to fix it, and will they step up? The leaders at CPS made the graduation rate their problem. They took ownership.
“what often prevents people from protesting is not a lack of motivation to protest, but rather their feeling that they lack the legitimacy to do so.”
extend psychological standing
“Unless somebody leads, nobody will. That’s axiomatic. I asked, ‘Why not us?’
“We became a culture of dreamers and doers.”
The question they asked themselves was not: Can’t someone fix this problem? It was: Can we fix this problem?
“I’m accountable for this. Let me tell you how I’m responsible. I’ve heard rumors that you weren’t getting along, and I’ve heard from your boss that there was trouble. You know what I did? I looked the other way. I thought, They’ll work it out. I ignored you and I’m sorry.”
“I’d like each of you to tell the story of this situation as though you’re the only one in the world responsible for where we are.”
Forrest’s question can help us filter out the noise in complex situations. What if you told the story of your relationship problems as if you were the only one responsible?
Chapter 4: Tunneling
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.
“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.
In fact it’s poverty that leads to short-sighted financial decisions. 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.”
“Their costs are immediate, loom large, and are easy to defer, and their benefits fall outside the tunnel. So they await a time when all urgent things are done.”
What Tucker is describing is a system that never learns. Never improves. “I was really shocked, to be honest with you,” Tucker said. Shocked because what Tucker had observed was the utter absence of upstream action.
It’s a terrible trap: If you can’t systematically solve problems, it dooms you to stay in an endless cycle of reaction.
Tunneling is not only self-perpetuating, it can even be emotionally rewarding.
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.
This kind of forum will never happen “naturally”: It’s no trivial feat to carve out time from teachers’ already crazy schedules.
“When we create organizations, we’re doing it to give people focus. We’re essentially giving them a license to be myopic.”
(Racehorses wear blinders so they’ll ignore distractions and run faster.)
our own brains are designed for tunneling.
There are only two areas of concern that seem to reliably trigger our upstream instincts: our kids and our teeth.
For years we’ve been laughing at those dumb metaphorical frogs that won’t jump out of the boiling pot until it’s too late. Turns out we’re the frogs.
“creating urgency” is basically coopting the power of tunneling for good.
Holes are urgent; slow depletion of the ozone layer isn’t.
Climate scientists use the phrase “the world avoided” to discuss the problems that were prevented by the ozone layer agreements. “
Section 2: Seven Questions for Upstream Leaders
Chapter 5: How Will You Unite the Right People?
How will you unite the right people?
many upstream efforts are a kind of volunteer work. Chosen, not obligated.
So the first step, as in many upstream efforts, was to surround the problem—to recruit a multifaceted group of people and organizations united by a common aim.
Academic research has identified a number of risk factors for teenage substance abuse: Having friends who drink or smoke is an obvious risk. Another is having lots of unstructured time available
(Interestingly, research suggests the quantity of time spent matters more than quality—which was not altogether welcome news for many Icelandic parents, Sigfúsdóttir reported.)
had the realization that people were not getting addicted to drugs so much as changing the chemistry of their brains,” said Milkman. “So the corollary to that was natural highs.” In other words, we shouldn’t fight teenagers’ instinct to “get high.” Instead, we should give them safer ways to get high.
Teens don’t just need more activities of any kind, they need activities with natural highs: games, performances, workouts, exhibitions. Activities that compel them to take physical or emotional risks.
Doctors prescribe, miners dig, teachers teach, and upstreamers meet.
To react to a customer’s call required the effort of just one call-center representative. But to prevent that customer from calling at all required integration among multiple teams of people.
primacy of data,
distinguishes “data for the purpose of learning” from “data for the purpose of inspection.”
It’s no longer just taking care of the problem, which is what we were doing historically, but ending the problem.”
IF IT’S GLAMOUR YOU’RE AFTER, GET BACK DOWNSTREAM.
critical shifts en route to ending veteran homelessness: a shift in strategy, a shift in collaboration, and a shift in data.
Chapter 6: How Will You Change the System?
a 15-to 20-year gap in life expectancy is massive. You can’t account for it with a few incremental factors. It takes huge, systemic forces to produce a disparity like that.
It wasn’t a particular thing that was causing the life expectancy gap. It was everything.
“Of course, there are smart kids of color in the inner city! There are millions of them. We’re celebrating this one kid—who deserves to be celebrated—but we’re not asking the real question: Why is this such a rare story?”
We forced you to climb Everest to get ahead in life—and you did it! Congratulations!
The writer David Foster Wallace once told a story: “There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says ‘Morning, boys. How’s the water?’ And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, ‘What the hell is water?’
Everyone in this whole ecosystem got paid—except for the low-income people. They got coached. Think about this program through the lens of systems change. In some ways, the program actually entrenched the very inequalities that spawned it, by creating wonderful job opportunities for well-intentioned and well-educated leaders, but none for the people it was meant to serve.
when it comes to your health, your ZIP code matters more than your genetic code.
How did Iton and his team propose to reverse the odds in these fraught communities? Would they start with a focus on chronic diseases such as diabetes or asthma? By building visible symbols of health such as community gardens? By attracting grocery stores to fill food deserts? No, their vision was to start with power: showing the citizens in these neighborhoods how to fight for themselves and to reshape their environments.
“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.”
Chapter 7: Where Can You Find a Point of Leverage?
The Greek polymath Archimedes said, “Give me a lever long enough and a fulcrum on which to place it, and I shall move the world.” It’s an inspiring quote for change leaders.
So in the pursuit of systems change, where do you start? What do you do in, say, the first month of what might be a decades-long effort? You look for a point of leverage. This chapter is about that hunt.
(Upstream leaders should be wary of common sense, which can be a poor substitute for evidence.)
You can let your anger overwhelm you so that you act like a “savage,” Tony D taught them, or you can channel it to become a “warrior.”
Because they see—in the kids that they work with—they see a lot of tragedy. A kid is shot. People fail. People get arrested. What they never got to see is what would have happened if they hadn’t been there.”
strategy used by the Crime Lab’s leaders to find those leverage points is closer to universal: Immerse yourself in the problem.
Many successful upstream interventions are actually very expensive programs targeted at small groups of people.
A necessary part of finding a viable leverage point is to consider costs and benefits.
The reason to house the homeless or prevent disease or feed the hungry is not because of the financial returns but because of the moral returns. Let’s not sabotage upstream efforts by subjecting them to a test we never impose on downstream interventions.
“power of proximity.”
Chapter 8: How Will You Get Early Warning of the Problem?
When we can foresee a problem, we have more maneuvering room to fix it. That’s why a key question bearing on upstream efforts is: How can you get early warning of the problem you’re trying to solve?
It turns out that emergencies follow predictable patterns. There are patterns in time (more 911 calls during the day than at night) and patterns in geography (more calls from areas with older citizens than younger ones).
forward-deploying ambulances around the city,
This is the model of an early-warning story: Data warns us of a problem we wouldn’t have seen otherwise—
That’s alarm fatigue, and it’s a critical problem.
It’s a shocking moment, but not as shocking as what comes next: The video is replayed, quickly, to show us that the shooter was in the background of almost every scene: flipping off another student, being bullied at his locker, sitting alone at lunch, surfing gun videos on the web, and posting on social media a picture of himself with a gun. The signs were right in front of us, but we didn’t see them. Our attention was elsewhere. The Evan video was a sensation—
Chapter 9: How Will You Know You’re Succeeding?
risk of a “ghost victory”: a superficial success that cloaks failure.
the first kind of ghost victory, your measures show that you’re succeeding, but you’ve mistakenly attributed that success to your own work. (The team applauds itself for hitting more home runs—
but it turns out every team in the league hit more, too, because pitching talent declined.) The second is that you’ve succeeded on your short-term measures, but they didn’t align with your long-term mission. (The team doubled its home runs but barely won any more games.) And the third is that your short-term measures became the mission in a way that really undermined the work. (The pressure to hit home runs led several players to start taking steroids, and they got caught.)
The rich people believed they would get served, so they called, and they were served. The poor people believed they’d be neglected, so they didn’t call, and they were neglected. Boston had created two self-fulfilling prophecies.
Getting short-term measures right is frustratingly complex. And it’s critical. In fact, the only thing worse than contending with short-term measures is not having them at all.
when measures become the mission. This is the most destructive form of ghost victory,
“paired measures.” Grove pointed out that if you use a quantity-based measure, quality will often suffer. So if you pay your janitorial crew by the number of square feet cleaned,
Chapter 10: How Will You Avoid Doing Harm?
“As you think about a system, spend part of your time from a vantage point that lets you see the whole system, not just the problem that may have drawn you to focus on the system to begin with,” wrote Donella Meadows in an essay.
The cobra effect occurs when an attempted solution to a problem makes the problem worse. The name derives from an episode during the UK’s colonial rule of India, when a British administrator was worried by the prevalence of cobras in Delhi. He thought: I’ll use the power of incentives to solve this problem! A bounty on cobras was declared: Bring in a dead cobra, get some cash. “And he expected this would solve the problem,” said Vikas Mehrotra, a finance professor, on the Freakonomics podcast. “But the population in Delhi, at least some of it, responded by farming cobras. And all of the sudden, the administration was getting too many cobra skins. And they decided the scheme wasn’t as smart as initially it appeared, and they rescinded the scheme. But by then, the cobra farmers had this little population of cobras to deal with. And what do you do if there’s no market? You just release them.”
The answer was almost laughably clear: F2F interactions plunged by about 70% in both companies. Meanwhile, email and messaging activity spiked. When people were placed closer together so that they’d talk more, they talked less.
The thing to do, when you don’t know, is not to bluff and not to freeze, but to learn. The way you learn is by experiment— trial and error, error, error.”
“The first thing I would say is you just need to be aware that whatever the plan you have is, it’s going to be wrong,”
we don’t succeed by foreseeing the future accurately. We succeed by ensuring that we’ll have the feedback we need to navigate.
Feedback loops spur improvement. And where those loops are missing, they can be created.
But improvement shouldn’t require heroism! Online marketing messages don’t get better because of heroics—they get better because the feedback is so quick and targeted that you almost can’t escape improvement.
Staff meetings are a great example of a human endeavor—like fistfighting and potty training—that never improve. We get a lot of practice in meetings, but as Michael Jordan said, “You can practice shooting eight hours a day, but if your technique is wrong, then all you become is very good at shooting the wrong way.”
“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!”
Chapter 11: Who Will Pay for What Does Not Happen?
man who dropped his life insurance because he had kept the thing up 20 years, and never derived any benefit from it yet.
The natural life span of human beings today is not that different than it was a hundred years ago. What’s different is that we’re saving a lot of people—especially babies and children—from dying too early.
The group pegged the total national spending on public health specifically at $ 88.9 billion, just 2.5% of total health care spending in the United States in 2017.
“In public health, if you do your job, they cut your budget, because no one is getting sick,”
What the MRI statistic illustrates is a simpler idea about our fee-for-service system: When you get paid for something, you do more of it. (No doubt we also “lead the world” in dental X-rays. And just imagine if TSA agents were paid by the grope.)
reactive efforts succeed when problems happen and they’re fixed. Preventive efforts succeed when nothing happens. Who will pay for what does not happen?
“wrong pocket problem”: a situation where the entity that bears the cost of the intervention does not receive the primary benefit. One pocket pays, but the returns are scattered across many pockets.
“We spent three years trying to figure out how to make the rules allow us to do something that everybody in the room understood on day one was the most obvious thing in the world,”
Section 3: Far Upstream
Chapter 12: The Chicken Little Problem: Distant and Improbable Threats
If a job called for 300 boats, participants would have to find those boats and not just wish them to exist. If planners needed fifteen semitrucks to haul generators to New Orleans, they had to identify where they would get them,
“Contraflow” is an emergency procedure in public transportation in which all the lanes of a highway are temporarily switched to flow in the same direction.
There’s a concept called “the prophet’s dilemma”: a prediction that prevents what it predicts from happening. A self-defeating prediction.
Chapter 13: You, Upstream
“The best time to plant a tree is 20 years ago. The second-best time is now.”
Three suggestions
· “Be impatient for action but patient for outcomes.”
· Macro starts with micro.
· Favor scoreboards over pills.
A final way you can apply upstream thinking, as an individual, is to change the organization you work for.
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.