Upstream by Dan Heath

I can’t say that I found this book to be earth shattering, but I did enjoy the stories of individuals, cities, and corporations and how they transformed themselves to “solve problems before they happen”, as Heath puts it on his cover. Health describes his theory of “Upstream” or “Upstreaming”, by espousing the belief that efforts to prevent problems — any problems — from happening in the first place is a far better option than “downstream action”, where we react to problems after they have already occurred. He makes a compelling case, and of course, he is absolutely right. Reaction is tangible and easy to measure, like when a lifeguard saves someone from drowning or a firefighter puts out a fire, for example. But how do we prevent people from drowning in in the first place and how do we stop that fire from ever getting started? Heath makes his best case for “Upstream” efforts within the U.S. health care system, where we spend an absurd amount of money fixing people’s ailments and not even close to enough money on preventing those ailments from happening. Doctor’s get paid to diagnose and treat patients with expensive exams and MRI’s and to prescribe pills, but they don’t get paid nearly enough to sit and have an actual conversation with someone who is struggling with a mental health crisis. One interesting health related example he mentioned was that for every $1 we spend on the fluoridation of our water, society saves $20 on avoided dental costs. Another that stuck out was his anecdote about hurricane disaster planning before Hurricane Katrina, and how Katrina could have been much, much worse if not for those that worked so hard beforehand to prevent an unmitigated disaster (which it was, of course, but not at the scale it could have been). A good read for business executives, thought leaders, and those that favor proactive, preventative solutions to major problems, Upstream flows from beginning to end — and makes a whole lot of sense in between.

• downstream actions react to problems once they’ve occurred; Upstream efforts aim to prevent those problems from happening
• the specialization inherent to organizations creates great efficiencies, but it also deters efforts to integrate in new, advantageous ways
• we tend to favor reaction — because it’s more tangible
• downstream work is easy to see, easier to measure
• Upstream efforts are those intended to prevent problems before they happen or, alternatively, to systematically reduce the harm caused by those problems
• upstream is better than preventative or proactive because the stream metaphor prods us to expand out thinking about solutions
• upstream, as in a direction
• best time to prevent aggressive behavior is when the criminal is still in his mother’s tummy (child development theory)
• upstream efforts are broader, slower, hazier — but when they work, they really work
• US health care system is designed almost exclusively for reaction
• for every $1 we spend on downstream health care, it would be wise to spend $2 upstream
• now, it’s $1 to $1 — lowest proportion of upstream spending to downstream among our peer countries
• compared to other counties, we spend more money fixing people’s ailments and less keeping them healthy
• we’re downstream — other countries are upstream
• Norway — 49 weeks paid parental leave, for example
• we allocate the pot differently — we’d be wise to either add upstream spending or shift it from downstream to upstream
• to go upstream is a declaration of agency: I don’t have to be at the mercy of these forces, I can control them, I can shape my world
• problem blindness: belief that negative outcomes are natural or inevitable
• Chicago school system — prediction of success they found was based on a student’s completion of five full year course credits and that student not failing more than one semester of a core course, such as math or English — Freshman On-Track
• every system is perfectly designed to get the results it gets
• the students that graduate from Chicago (and elsewhere) will see a lifetime wage increase on average of $300K to $400K
• to succeed upstream, leaders must deter problems early, target leverage points in complex systems, find reliable ways to measure success, pioneer new ways of working together, and embed their success into system to give them permanence
• inattentional blindness — careful attention to one task leads us to miss important information that’s unrelated to that task
• habituation: we grow accustomed to stimuli that are consistent
• the escape from problem blindness begins with the shock of awareness that you’ve come to treat the abnormal as normal
• next comes a search for community: do other people feel this way
• with recognition comes strength
• people voluntarily hold themselves responsible for fixing problems they did not create
• I was not the one who created this problem, but I will be the one to fix it
• upstream work is often optional
• downstream — rescues and responses and reactions — work is demanded of us
• upstream work is chosen, not demanded
• lack of ownership is the second force that keeps us downstream
• what often prevents people from protesting is the feeling that they lack legitimacy to do so — psychological standing
• car seats had been in existence since the 1930’s to elevate kids so they could look out the window, not for safety — so they wouldn’t pester the driver
• a few pediatricians answered the call to get car seats for safety in states, and then federally
• Interface, a carpet company, went from 800M to 1B in one year without increasing the amount of raw materials consumed — no one told them to stop harming the environment, but they (and their CEO) demanded it of themselves
• we should push against complacency — what harms do we accept that we’re capable of changing?
• I choose to fix this problem, not because it’s demanded of me, but because I can, and because it’s worth fixing
• when people experience scarcity (money, time, example), the harm is that the little problems crowd out the big ones
• tunneling: when people are juggling a lot of problems, they give up trying to solve them all, develop tunnel vision
• in the tunnel, there is only forward
• poor people have less bandwidth, experience of poverty reduces anyone’s bandwidth
• when people’s resources are scarce, every problem is a source of stress
• tunneling can also be caused by a scarcity of time
• tunneling begets more tunneling
• the need for heroism is usually evidence of a systems failure
• how do you escape the tunnel? you need slack: reserve of time or resources that can be spent on problem solving
• a block of time when staffers can emerge from the tunnel and think about systems-level issues, a space that has been created to cultivate upstream work
• focus can accelerate work and make it more efficient, but it puts blinders on people
• when the emphasis is always forward, forward, forward, you never stop to ask whether you’re going in the right direction
• climate change changes too slowly to spark urgency — lacks a human face
• “If climate change had been visited on us by a brutal dictator or an evil empire, the war on warming would be this nation’s top priority”
• creating urgency is coopting the the power of tunneling for good
• the term ozone hole was not embraced until the mid 80’s, well after the term came out
• the notion of a “hole” made the problem easier to visualize and invoked an action mindset
• holes are urgent — slow depletion of the ozone layer isn’t
• supporters needed to feel more urgency and opponents needed to feel less
• how will you unite the right people?
• Iceland — change the culture surrounding teenagers by reducing the risk factors for substance use and boosting protective ones
• distinction between informal and formal sports participation — the latter that counts
• when they’re done right, upstream meetings can be energizing: creative and honest and improvisational, with the kind of camaraderie that emerges from the shared struggle to achieve something meaningful
• empowerment — giving communities, giving parents, giving kids a voice (Iceland) — each one of them gets a role
• surround the problem — each party (above) had something to contribute
• shared goal that keeps them contributing even in stressful situations
• surround the problem with the right people, give them early notice of that problem, align their efforts toward preventing specific instances of that problem
• data for the purpose of learning
• clear, compelling aim and a useful, real time stream of data to measure their progress, and then … left alone
• one city (Rockford, IL) ended homelessness by getting people into housing a soon as possible, not making then have to earn it
• data takes you away from philosophical insights. you move away from anecdotal fights about what people think is happening to what is happening
• functional zero — number of homeless people on the street it lower than the city’s monthly housing placement rate
• In Cleveland, a 4 mile walk from Shaker Heights to the Baldwin Water treatment plant took about 80 minutes, and over the span of that walk, 23 years of life expectancy vanished
• sense of lack of control of people — communities were incubators of chronic stress
• well established link between chronic stress and a variety of health problems, among them cardiovascular disease, diabetes, inflammation
• systems are machines that determine probabilities
• upstream work is about reducing the probability that problems will happen, and for that reason, the work must culminate in systems change
• to change the systems is to change the rules that govern us or the culture that influences us
• for every $1 spent on fluoridation, society saves $20 in avoided dental costs
• parenting is the rare exception where upstream thinking comes naturally
• systems change start with a spark of courage
• success comes when the right things happen by default — not because of individual passion or heroism
• odds have shifted
• leverage points — immerse yourself in the problem
• early successful pilots prove difficult to scale
• the postmortem for a problem can be the preamble to a solution
• many successful upstream interventions are actually very expensive programs targeted at small groups of people
• many people who commit violent crimes end up being victimized by violent crimes
• when you can precisely target a group of people who are causing big problems on an ongoing basis, you can afford to spend a small fortune trying to help them
• nothing else in health care, other than prevention, is viewed through the lens of saving money
• power of proximity — find ways to get proximate to the poor and vulnerable
• how can you get an early warning of the problem you are trying to solve?
• some EMS systems spread their ambulances strategically around cities to ensure that the entire population they cover is only a short drive away
• most mass shootings are planned 6 weeks in advance
• Sandy Hook Promise — launched a program focused on warning signs, which include a strong fascination with firearms, acting aggressively for seemingly minor reasons, extreme feelings of social isolation, bragging about access to guns … and explicit threats of violence
• their team broadened work to include students vulnerable to bullying and self-harm, especially for suicidal tendencies and cutting
• social withdrawal, an attraction to violence
• with upstream efforts, success is not always self evident
• risk of a “ghost victory”: superficial success that cloaks failure
• rich people believe that they will get served, poor people believed they’d be neglected so they don’t call for service (Boston’s 311 system for reporting things in the city)
• Kahneman — our brains, when confronted with complexity, will often perform an invisible substitution, trading a hard question for an easy one
• wrong short term measures can doom upstream work — short term measures, however, are indispensable
• CompStat — drop in crime in NYC in the 90's
• tendency to lessen the severity of crimes in order to dodge criticism became known as “downgrading”
• as it became harder and harder to sustain the real decline in crime, it became more and more tempting to fiddle with the numbers instead
• when people are rewarded for achieving a certain number, or punished for missing it, they will cheat
• Andy Grove — “paired measures”: balance quantity measures with quality measures
• “pre gaming” — meaning the careful consideration of how the measures might be misused
• 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
• especially in the short term, changes for the good of the whole may sometimes seem to be counter to the interests of a part of the system
• cobra effect — when an attempted solution to a problem makes the problem worse
• open floor concepts in offices reduce F2F interactions, e-mail and messaging spikes
• we need prompt and reliable feedback, constant, trial and error, error, error
• the only way you’re going to know something’s wrong is by having feedback mechanisms and measurement systems in place
• we succeed by ensuring that we’ll have the feedback we need to navigate
• feedback loops spur improvement
• while paper bags and reusable bags are far better than plastic ones from the perspective of keeping waterways clean, they are worse in other ways — require far more energy to produce and ship than do plastic bags, which increases carbon emissions
• if protecting the waterways and marine life, specifically, is our goal, then a plastic bag ban is a great idea; but if making the whole environment better is the goal, then it’s less clear
• CA voters passed a statewide ban in 2016, without the thicker plastic bag loophole — significantly reduced single use plastics
• Chicago — 7 cent tax on all paper and plastic bags — working out well
• systems can’t be controlled, but they can be designed and redesigned
• at the turn of the century, almost 1 out of every 5 kids was dead before their fifth birthday
• 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
• in public health, if you do your job, they cut your budget, because no one is getting sick
• reaction over prevention
• reactive efforts succeed when problems happen and they’re fixed — preventive efforts succeed when nothing happens
• wrong pocket problem: a situation where the entity that bears the cost of the intervention does not receive the primary benefit
• we can pay to fix problems once they happen, or we can pay in advance to prevent them
• Acountable Care Organization: a model of the ACA, which says that if you can reduce visits by managing patients health better, then the savings are shared (doctors have come together to use this practice in some states)
• capitation: a payment model (Kaiser) where they are both the insurer and the provider — KP providers get paid a flat fee, per person served
• KP doctors don’t have an incentive to order an unnecessary MRI scan, because they don’t get paid any more for doing it
• also held accountable to quality of life metrics and patient satisfaction metrics
• the right people must hunt for leverage points and push for systems change, spot problems early, measure success, and think about the funding stream
• post Katrina, possible that two dissonant points might both be true — the disaster response for the people stranded in new orleans was bad, and that many thousands of lives were saved because of the planning that was sparked by Hurricane Pam (prior to Katrina)
• effect’s were terrible, but they could have been much worse
• contraflow — emergency procedure in public transportation in which all the lanes of a highway are temporarily switched to flow in the same direction
• main reason that 1700 people died in Katrina, not 60K
• convening the right people to discuss the right issue in advance of the problem
• FEMA cancelled what amounted to 15K in disaster planning beforehand
• when it comes to IT security, for example, weakest links are often colleagues in a business
• emergency simulations aren’t supposed to be perfect predictions, just credible ones, and ideally, the parties involved get multiple opportunities to practice
• prophet’s dilemma — prediction that prevents what it predicts from happening (Y2K bug); warnings that the sky would fall triggered the very actions that kept the sky from falling
• spirit of upstream thinking — with some forethought, we can prevent problems before they happen, and even when we can’t stop them entirely, we can often blunt their impact
• “the best time to plant a tree is 20 years ago. the second best time is now”
• be impatience for action but patient for outcomes
• macro starts with micro
• you can’t help a thousand people, or a million, until you understand how to help one
• you don’t understand a problem until you see it up close
• seek out groups who have ambitious goals coupled with close-up experience
• favor scoreboards over pills — people in the field who are doing the hard work should receive timely, useful data that allows them to learn and adapt
• take ownership of the underlying problem and start slogging forward
• we don’t know very much about how to scale up successful programs in the social sector