Upstream: The Quest to Solve Problems Before They Happen
Dan Heath
320 pages, Avid Reader Press/Simon & Schuster, 2020
So often in life, we get stuck in a cycle of response. We put out fires. We deal with emergencies. We stay downstream, handling one problem after another, but we never make our way upstream to fix the systems that caused the problems. Firefighters extinguish flames in burning buildings, doctors treat patients with chronic illnesses, and call-center reps address customer complaints. But many fires, chronic illnesses, and customer complaints are preventable. So why do our efforts skew so heavily toward reaction rather than prevention?
One reason upstream thinking is uncommon—and difficult—is that our ecosystem of organizations has been built for reaction. Consider a woman who suffers domestic violence. Many organizations are available to serve her after an incident: The health system can treat her injuries. The district attorney can press charges. A local shelter can provide temporary housing. Each institution “owns” a part of the reaction. But if we ask: Whose job is it to prevent a woman from being abused—or to prevent a pattern of abuse from escalating? There’s no answer. There are many “owners” of reaction but no owner of prevention. And without a clear owner, upstream work is often impossible.
In this excerpt from Upstream: The Quest to Solve Problems Before They Happen, we explore a successful upstream effort to overcome this barrier. A team in Rockford, Illinois, led the city to become the first in the US to eliminate veteran and chronic homelessness. And what they discovered is that the key to unlocking a complex problem like homelessness was as simple—and as complicated—as a list of names.—Dan Heath
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In 2014, Larry Morrissey, then mayor of Rockford—the second-largest city in Illinois—was asked to join the Mayor’s Challenge, a campaign promoted by the federal government with the goal of ending veteran homelessness in communities around the nation. Morrissey was approaching the midpoint of his third term as mayor, and he’d been working on the issue of homelessness since he first took office, nine years prior. He was skeptical of the Challenge.
“For a decade, I’d been working on homelessness,” he said. “In my first term, we developed this 10-year plan to end homelessness, and we hadn’t done it. If anything, maybe things had gotten worse. … What’s gonna change?” Goaded by his colleagues, Morrissey reluctantly agreed to join the campaign.
Less than a year later—on December 15, 2015—Rockford became the first city in the United States to have effectively ended veteran homelessness. How could the city spin its wheels on homelessness for nine years and then achieve dramatic success in less than one?
The city changed its approach in many ways, and it began with a mental shift: They were not going to “deal with” homelessness anymore, or “work on it” or “combat it.” They resolved to end it. Jennifer Jaeger, Rockford’s community services director, and one of the key leaders in the work on homelessness, called it her “I believe in fairies moment.”
“The very first step is to believe you can actually do it,” said Jaeger. “It’s hard. It’s a big mind shift. It’s no longer just taking care of the problem, which is what we were doing historically, but ending the problem.”
In my new book Upstream, I analyze the work of leaders such as Jaeger and Morrissey who have escaped the cycle of reaction that so often characterizes our work: putting out fires, responding to emergencies, “taking care” of problems. These leaders were determined to push upstream to prevent those problems from happening. Rather than treat childhood asthma, could you prevent it? Medical leaders at Cincinnati Children’s Hospital conducted some hotspotting work and traced a disproportionate number of asthma cases to a few specific housing units with subpar conditions. They partnered with Legal Aid lawyers to intervene.
Rather than punish teenage criminals, could you prevent them from committing crime? The Becoming a Man program in Chicago, which teaches young men to slow down their thinking and resist escalation when in conflict, reduced arrests significantly.
One of the most surprising patterns I discovered in this upstream work was the push for “zero”—the desire not just to mitigate problems but to eliminate them. I found groups all over the country who aspired to zero: An effort in Detroit to eliminate suicides. The Vision Zero network, which aspires to eliminate all traffic fatalities. And the Built for Zero network, a methodology and movement for ending homelessness—and one that played a major role in Rockford’s success.
In Rockford, the team’s goal to end homelessness forced them to change the design of their systems and the way they collaborated. They embraced a methodology called “housing first.” In the past, the opportunity to receive housing was like a carrot dangled in front of homeless people to encourage them to fix themselves: to receive substance abuse treatment, or treatment for mental illness, or job training. The idea was that homeless people needed to earn their way into housing.
“Housing first” flips that sequence. It says that the first step in helping the homeless—not the last—is to get them into housing as soon as possible. “I stopped thinking of people as ‘homeless’ and started thinking of them as people without houses,” said Jaeger. “All a homeless person is is somebody without a house. The same issues homeless people have, people who are housed have. … People who are housed can start working on those other issues.” To support that goal, Rockford created a single point of entry for homeless people—in the past, the outreach had been fragmented—which allowed the city to be strategic about who has housed. For the first time, the most vulnerable people in the community would be housed the quickest.
The most striking shift in Rockford’s work related to the way groups collaborated. In any city, there are many organizations who are involved in the issue of homelessness: the Veterans Administration, the fire department, the police department, the health and mental health systems, social service agencies, and homeless shelters. In most cities, the people in these organizations stay in their silos, reacting to the specific issues that affect their own work. But in Rockford, they have spanned those silos. They’ve chosen to surround the problem of homelessness, treating it as a shared concern. Representatives from all those organizations meet on a regular basis, and when they meet, their discussions revolve around what’s called a “by-name list.”
The by-name list is a real-time census of all the homeless people in Rockford, listed by name in a Google Doc. It includes notes on their history and their health and their last-seen location. Angie Walker, one of Jaeger’s colleagues, described how she might kick off a typical meeting: “I would say, ‘John Smith, he is 32. He stated he was fleeing domestic violence. He last said he’s with friends. Who here has seen John Smith?’” And the fire department might say, Oh, we took him to the hospital last week—he might still be there. Then someone from the mental health team might say, No, I was under the bridge two days ago and I saw John. A worker at the local homeless shelter, the Carpenter’s Place, might add, John has come for lunch quite a bit recently. And then the group would make a plan. Okay, Carpenter’s Place, it seems like you see him the most. Could you check with him and find out where he’s staying and what he needs? And let him know that when he’s ready, we have housing available for him.
These meetings had happened in the past, but the use of the by-name list transformed them. Mayor Morrissey said that, previously, the meetings had been “bitch sessions.” “We’d sit around and we’d talk about what’s broken,” he said. Jennifer Jaeger said the meetings “feel alive now. The data itself feels like it’s sort of a living creature. Because it talks. It talks to us. … It tells us, ‘You need to look at this, you need to think about this.’”
An uncannily similar approach is being used by a partnership in Newburyport, Massachusetts, led by the Jeanne Geiger Crisis Center, to combat the risk that domestic violence will escalate to homicide. A “Domestic Violence High-Risk Team” was formed, including representatives from the DA’s office, the police, the health care system, and victim’s advocacy groups. As in Rockford, the team’s collaboration centers on a by-name list, identifying women who have suffered abuse and who are thought to be at the highest risk of further violence. The team identifies ways of keeping each woman safe, ranging from creating “emergency plans” to ensuring that the police will more closely monitor an abuser. Since 2005, the team has accepted over 172 high-risk cases. In the 10 years prior to the formation of the high-risk team, there were eight domestic violence-related deaths in the area. And in the 14 years since the high-risk team began to serve, not one woman has been killed in a domestic-violence related homicide. Zero.
In Rockford, the homelessness team embraced its new approach—housing first, single point of entry, the by-name list—and housed 156 veterans in 2015, essentially eliminating veteran homelessness in the city. Rockford has become a model for other cities trying to do the same. It’s remarkable, really, how much changed in Rockford—given how little had changed. What hadn’t changed: the people involved with homelessness, the resources they had at their disposal, and the city’s macro conditions. Simply by changing the way they collaborated, and the goals that guided their collaboration, their efforts became dramatically more effective.
"We have a tendency in the social sector to focus on high-flying visions. Getting to zero on something, whether it is homelessness or students dropping of school, gives partners something very concrete and measurable to rally around. That is the power of zero," said Jeff Edmonson, who, as an executive at the foundation Ballmer Group, has repeatedly convened these "zeroistas” to learn from each other.
To be clear, the rhetoric about “zero” is doing none of the work here. It would be easy for a politician in L.A. to deliver high-minded speeches about achieving a homeless population of “zero” (preferably on a timeline that ensured he or she would be safely out of office before the deadline). The magic emerges when rhetoric crosses over into reality. When the players in a system take the zero target seriously, they are forced to recalibrate their work to serve individual human beings in all their diversity. Because there’s no margin for error in “zero.”
What if, to eliminate a complex problem, leaders must break it down to a scale where “by-name” style work is possible? That kind of discipline is possible even within very large systems. Take Chicago Public Schools, a huge, $6 billion urban school district that has increased its graduation rate by over 20 percentage points in the last decade—a massive success story affecting tens of thousands of students’ lives. The heart of the change happened at the level of the school: Ninth-grade faculty members met every month to discuss at-risk students on, yes, a name-by-name basis.
When we think about big problems, we’re forced to grapple with big numbers. What would it take to solve problems for a thousand people? Our first instinct might be to say: We’ll have to think about the big picture, because we can’t very well intervene individually with 1,000 people. But that notion, as it turns out, is exactly wrong. The team in Rockford housed homeless people using a by-name list. The domestic violence high-risk team protected women using a by-name list.
The push for zero compels leaders to understand problems at such a granular level of detail that they begin to spot new leverage points. The teams gather better data, they correct flaws in the system, and they collaborate more effectively (and enthusiastically). Macro starts with micro.
The lesson for upstream leaders is clear: You can’t help a thousand people, or a million, until you understand how to help one.