Heath, Dan. (2020). Upstream.  New York:  Avid Reader Press

The Opening Parable:

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 or 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.”

Health parable (adapted from the original, which is commonly attributed to Irving Zola)

I see this latest book by Dan Heath as a masterful example of systems thinking, reflective thinking forward and backward, and a helpful process for education and business.  The book is complete with multiple examples and is a learning opportunity for those who read it and apply upstream thinking.

A major premise of the book is: “Every system is perfectly designed to get the results it gets. I know W. Edwards Deming has said something similar in his work.  Deming suggests, quit blaming people and look at the system which is creating the behaviors.

A story told later in the book is called the Cobra Effect.  In India there were too many cobras.  So, they put a bounty on the skins of cobras.  Bring in a skin, get some money.  A cottage industry sprang up which started raising cobras.  They would bring in the skins and get money.  Soon they were spending a lot of money for cobra skins.  So, they quit paying for cobra skins.  Guess what, the people who were raising cobras released the cobras.  Now they had more cobras than before.  Ah, unintended consequences.

One of the first vignettes is about Expedia.  In 2012 there were about two million calls from customers asking for information that the customers had already received.  This represented over 50% of the customers.  OK educators, how much time and money is spent on answering questions that were in newsletters, websites, etc.? When Expedia calculated the cost – $100 million. Yikes

Wanting to be helpful, Expedia staff responded as quick as they could. So, the question became how do they prevent that amount of phone calls? They added a ‘press 2’ to the phone call that would automatically resend the itinerary.  Phone calls for this kind of help went from 58% to 15%.  What a great zero-cost way to save money and time.

Many times administrators say they are so busy.  Yes, they are.  Aren’t we all in the field of education?  Larry Cuban wrote an article in 1985 for Kappan about superintendents as fire fighters.  Cuban basically said leaders need to do three things:

  1. Put out fires: Schools have to be safe physically and emotionally.
  2. Fireproof: Create systems so fires don’t start.
  3. Start fires: What and where can you start fires for learning?

I think Upstream is concentrating on #2.  This is the most productive way to save time, energy, and money.  We need smart thinking for crazy times. Yes, that is a book title  read years ago.

Another helpful story is about police officers.  One stands on the street corner where lots of accidents happen.  Cars see the officer and slow down.  Another police officer hides in the bushes and catches speeders and gives them tickets.  The question is, which one is seen as most valuable?  Probably the one who is busy giving tickets.  The one who is preventing accidents probably doesn’t get much recognition.  Think about analogies in schools.

As I work with principals, many are really good at putting out fires.  They get recognized for it.  Unfortunately, they become arsonists.  Most of us do what we get rewarded for.  AND, those leaders spend less time on learning and more on control.  What a paradox.  How many principal meetings spend time on sharing ideas on how to prevent fires?  Most meetings I have attended over the years spend most of our time on how to put out fires, not prevention or starting the fire for learning.

Systems tend to reward reaction to rather than prevention for.  We need Upstream  thinking in many places.  Health care costs about $3.5 billion dollars.  Research I have read said that 80% of our health care could be reduced by five things.  No smoking, no or reduced drinking and drugs, better sleeping habits, healthy eating, and reducing stress.  Hmmm, wonder if we could model and teach kids this?

Good Intentions Guarantee Nothing.  It is the actions of smart, committed professionals that will change our educational system and schools by raising positive citizens.

One more story from Chicago Public Schools.  In 1998 the graduation rate was 52.4%. Once they started looking at the data, freshman (9th grade) was where most students were dropping out.  What they found was if the schools could keep more freshman on track, the graduation rate would increase.  Upstream, 9th grade, had a huge effect on 12th grade graduation. CPS started a program of Freshman On Track (FOT).

Two surprisingly simple factors: (1) a student’s completion of five full-year course credits; and (2) that student’s not failing more than one semester of a core course, such as Math or English… Those two factors, combined, became known as the Freshman On-Track (FOT) metric. Freshmen who were on-track by this measurement were 3.5 times more likely to graduate than students who were off-track.

What amazed the leaders was:  ‘Freshman On-Track’ matters more than everything else put together. Conspicuously absent from the calculation were: income, race, gender, and—perhaps most incredibly—the student’s own academic performance through eighth grade.

I have personal experience with this in an urban setting.  As a high school principal I came into a situation, in 1995, where most of our dropout rate was in 9th grade.  After reviewing the data with the administrative team, we asked for teacher volunteers to work with freshman.  We brought 85 freshman together, with adults, to tell us what would keep them in school.  At the opening of a one day planning session a student shouted out, to me, “you’re the principal, you figure it out.”

Actually I did know many things that would work.  Big deal, I know. What was important was that the students had a voice.  What we came up with was creating a family which had students with the same teachers for the whole year except for electives.  We reduced the dropout rate by 50% the first year.  When asked by others what my goal was, it was simple to me.  I wanted every 9th graders to become a 10th grader.  I didn’t need two or three pages of educationese describing the vision, mission, and values.

Here are three barriers to upstream thinking:

  1. Problem Blindness: you must ask questions surfacing what is really going on and what contributes to the problem. This takes a ruthless assessment of reality.
  2. A Lack of Ownership: those working on the problem must take ownership. If everyone works in siloes, nobody is responsible.  The alternative is everyone is responsible. Upstream work is chosen, not demanded. The question is not: Who suffers most from the problem? The question is: Who’s best positioned to fix it, and will they step up?
  3. Tunneling: under pressure we focus on doing what we always have done. Our vision narrows, working harder rather than stepping back and considering alternatives to solving the problem. Tunneling begets more tunneling. Tunneling is not only self-perpetuating, it can even be emotionally rewarding.

The next section deals with the Seven Questions for Upstream Leaders. There are vignettes in each chapter.

  1. HOW WILL YOU UNITE THE RIGHT PEOPLE? Doctors prescribe, miners dig, teachers teach, and up streamers meet.
  2. HOW WILL YOU CHANGE THE SYSTEM? A great quote in the book is, You can’t solve a dynamic problem with static data.”
  3. WHERE CAN YOU FIND A POINT OF LEVERAGE? Upstream leaders should be wary of common sense, which can be a poor substitute for evidence
  4. HOW WILL YOU GET EARLY WARNING OF THE PROBLEM? After Sandy Hook, leaders started focusing on mental health issues, not just the access to guns.
  5. HOW WILL YOU KNOW YOU’RE SUCCEEDING? There are three types of ghost victories. These are ways we think we are succeeding but are actually not.
  • your measures show that you’re succeeding, but you’ve mistakenly attributed that success to your own work
  • you’ve succeeded on your short-term measures, but they didn’t align with your long-term mission
  • your short-term measures became the mission in a way that really undermined the work
  1. HOW WILL YOU AVOID DOING HARM? One of the stories involved lawsuits coming from a playground in Brooklyn. Many kids were breaking their legs on the swings.  Once they investigated, they found the swings were too long causing the broken legs.
  2. WHO WILL PAY FOR WHAT DOES NOT HAPPEN? When you get paid for something, you do more of it. Preventive efforts succeed when nothing happens. Who will pay for what does not happen? “We under-invest in the services and policies that would keep people healthier so that they would not develop those illnesses or have the injuries or suffer from premature deaths that we know could be avoided.”

Paying for upstream efforts ultimately boils down to three questions: Where are the costly problems? Who is in the best position to prevent those problems? And, how do you create incentives for them to do so?

Good intentions guarantee nothing. It boils down to good thinking, good actions, and using the feedback loops for assessing the positives and negatives.  I found some very good models in this book.


Cuban, Larry. (1985). Conflict and Leadership in the Superintendency.”  Phi Delta  Kappan. V.67, no.1, Sept. 1985.  Pp.28-30

Mitroff, I. 1997). Smart thinking for crazy times. San Francisco: Berrett-Koehler. 17, 28