Heading upstream

There's a very basic concept in Public Health known as "going upstream". The cartoon above illustrates the concept. (if you "click" on the picture it should zoom up to a bigger size.)

Imagine our hero, Tim, sees smoke coming up over the mountain, but he cannot see the source because the mountain is in the way. Say the smoke is killing the crops and Tim wants to "fix" the problem. Where should he go to start looking for the solution?

He could head towards the largest amount of smoke, to the right.
He could head towards the "center" of the problem, directly above.
He could head towards the "worst problem area" or densest smoke, to the upper left.
or
He could follow the smoke "upstream", going around the mountain or possibly over it, until he finds the "source" of the smoke.

I relate to this problem. I was in Edmonton once, visiting, and went to the top of a high rise building to catch the view. We saw all this distant smoke and asked where it was coming from. They said, "Oh, that's from a forest fire in the Rocky Mountains, about 45 miles west from here." So, we got in the car and headed west and went to fight the fire, 50 miles up a dirt logging road from Revelstoke. I'll describe our narrow midnight escape someday.

But, the point is, it is not really true that "Where there's smoke, there's fire." Many people seem to take that much too literally, and head for the densest smoke to look for the fire. Others head for the "center" of the visible problem, and others head for the largest amount of smoke.

In Public Health, we're taught to forget all that, sigh, pack a bag, and head "upstream" to locate the actual source of the problem. Often the source is not visible from where we are.

So, whether it's cancer along the Mississippi river, or developmental problems from lead paint poisoning, or gunshot wounds in the Emergency Room, we follow the Toyota Way and ask "Why?" at least five times - the same way you always got in trouble with your parents when they told you to do something.

For example - Why are so many children getting poisoned by old lead-based paint? Because the paint is peeling off and hasn't been replaced.
Why?
Because they live in terrible housing that's falling apart and neglected.
why?
Because they're poor and the poor are exploited and no one seems to care. Because despite tremendous technology, we can't make decent housing for $1000. Because despite amazing science we can't make companies and jobs that seem able to stay alive and in business. Because the people who could help don't realize there is a need, or are overwhelmed with how large the need is. Because the people who live there don't realize they could get subsidized housing in a much better place and don't know how to "sign onto our website and register for housing now!"

Why?

Now, you're getting into culture and how we distribute resources and education, and how we help or don't help each other, and how we respond to need by hiding the problem and pushing it out of our backyard into someone else's, instead of fixing what's wrong.

The Toyota Way really emphasizes that problems need to be brought to the surface, and made visible, so they don't fester and result in bad results later. Here's a view out of the window of where I'm currently writing this. Can you spot a "hiding" place and see what's happening here?


A huge pile of trash has built up just around the corner and out of sight of the main road.

In any Toyota plant, or anywhere near it, you would not find such a thing. They find they get better results if they deal with problems as they arise, instead of letting them stack up until the total pile becomes so overwhelming that no one wants to even think about it anymore.

Well, I hear a reply, that's because everyone is overwhelmed and stressed-out these days and no one has TIME to deal with "other people's problems."

Why?

This is actually a puzzling problem, related to multi-level depression or something. The "poor" in this country are poor at $10,000 a year, versus $200/year in India or China, if that. I think the figure is that something like a billion people earn less than $1 per day on this planet.

Why?

What's the most intriguing to me is that people in the US seem so fragmented and often unwilling to help each other out, or be helped, even when there are many really good-hearted people who are trying to help.

Or, even when the problem becomes desperate. A family about to lose their home because the mortgage payment just doubled on their fancy new loan would rather lose the home than try to have a second family move in and share the space and share the mortgage payment.

Why?

Because people just don't know how to get along with each other and things always turn bad.

Why?

After easily 5,000 years of written history, why is it that people haven't yet figured out how to get along with each other? If this is a big deal, here, in poverty, in Iraq, why isn't THAT what we study in school, from kindergarten through PhD level work, instead of algebra and physics?

"Because we need all this science and technology to save us from the mess we've made of things here."

Umm... Isn't the dependence or science and technology and the rejection of "learning how to get along" precisely the reason WHY we just spent $1,000,000,000,000 on the post-9/11 "homeland security" and war? That would have bought a lot of houses. Isn't the failure of management and labor to talk one of the big reasons GM lost its lead in the auto business and had to layoff hundreds of thousands of workers?

Well, for "cultural reasons" learning to get along is not a high priority.

Why?

In my book, it keeps coming back to this. We have what appear to be "technical" or "production" or "cost effectiveness" or "safety" problems, and they appear to be intractable, unsolvable by anything we can do. Then we find that "anything we can do" excludes the one thing that seems like it WOULD help, namely, putting a lot of resources into understanding how people should work together, relate, overcome conflict, and fix each other's roofs.

Why?

And that is precisely the point of the "Health, Behavior, and Society" focus on the role that "culture" and "distal factors" play on the visible immediate problems in front of us.

Don't look at the smoke. Go find the fire. Put the fire out, and the smoke will stop.

One last thought - some people argue that this kind of reasoning is no good because it doesn't involve mathematics. They've somehow deified the idea that there is such a thing as rigorous qualitative reasoning. I'm against sloppy thinking, sure.

But I've had more math than most people in this discussion. I've had 6 years of calculus, quantum mechanics, general relativity, statistical thermodynamics, etc. I taught financial modeling to MBA's.

Too often, the request for more math is an effort to avoid doing something that you already know you should be doing. We know enough now, with no more math at all, to know that a root cause of most of the mess we're in is that we don't know how to live with each other and work together. If we could solve that single problem, most of the rest would just dissolve, like a pearl necklace with the thread pulled out.

But, for those who insist on math, and are so deeply rooted in the culture of worship of "hard sciences", be of good cheer. I'll give you the math and you can be happy. You just may need to "come to the mountain" a little and learn about feedback control loops and all the rest of the non-linear, loop-based mathematics that YOU, dear you know who I mean, have been avoiding hoping that everything would fall neatly into linear causality, open paths with clear starts and finishes, and the General Linear Model and its grip on research.

And, in fact, with a little Laplace Transform wizardry, even those dreaded loops will flatten out and you can use your existing math and solve the problems with STATA -- even though the basic assumptions about unbiased estimators won't be met. Who ever checks those anyway?

So, enough. I'm off to breakfast.