When I first heard the famous parable about “The River,” I was at a national cardiovascular convening in 2003 held at Mountain Lake Lodge in Virginia (made famous by Dirty Dancing). The presenter told the story: you and a friend are having a picnic by the side of a river. All of a sudden, your friend looks in the river and points to a baby drowning in the river. Of course, you and everyone else around jump into the river to save the baby, but unfortunately, more keep coming. At first, it is manageable, but then they start coming faster. Out of breath, everyone tries hard to keep up, but some are saved and others are not. Finally, you look around and see your friend leaving the river and walking away. You ask, “Where are you going?” Your friend answers with disgust, “I’m going upstream to find out who is throwing babies into the river and try to stop it.” 

Of course, I remember the story, but I also remember the room falling silent after we heard it. In the early 2000s, we were at a pivotal point in cardiovascular care – many lives had been saved through advances in cardiac treatment, but the numbers were also increasing steadily due to a number of societal factors. It was a landmark moment that ultimately led leaders in statewide and national cardiovascular care, including myself, to shift many resources to prevention. Because of this parable and the mental shift it inspired in me, I was forever changed. I went back to the national office of the American Heart Association and began my social intrapreneurship work to champion adult and childhood obesity prevention efforts. 
Health care advocates had a reckoning and began to focus not only on “downstream” work (e.g., treating the problems), but also on the “upstream” work (e.g., preventing the source of the problem). Social entrepreneurs – who also got their start at the same time – adopted this same logical strategy using a number of tools to tackle long-standing social issues (e.g., education, homelessness). The idea was to shift the power dynamic by looking at the problem systemically and advancing programs, services and policies that promoted proactive solutions. Now, these ideas have become connected to system change, which we covered in our annual blog post in 2016, and equity, which we discussed in our annual post in 2019. To help illustrate the relationship between upstream and downstream issues and work, we have developed the following graphic over the past year with help from our public health/healthcare clients:
It is important to note that upstream work is not meant to replace downstream work, which is still sorely needed. This concept instead helps us understand the bigger picture in which we operate. It’s important to note that there have also been some cautionary tales associated with upstream work, specifically in public health, and how to ensure it is centered in equity. For more on this topic, don’t miss a brilliant piece of work by the Racial Equity Institute called “The Groundwater Approach.” 
This year, we applied our 2021 word shifts to the idea of upstream work and how to shift our thinking to include it in our programs, services and policies. We’ve also included ideas on how to help nonprofit staff embrace this mindset:

Synergy vs. Silos: There is growing recognition that true social change – whether it is improving health, combating climate change or creating wealth – will not happen within a single system. We know that when we have solved big societal problems (e.g., traffic fatalities, smoking), it has happened when multiple sectors came together toward a common vision and used all the tools at their disposal (e.g., social marketing, policy changes, education). In order to model this approach, we work with clients on leveraging design thinking to create “user personas” to walk in the shoes of those they serve. Through this process, you can simulate all the influences that impact clients’ decisions and prioritize those for collaboration.  

Solution Orientation vs. Problem Orientation: As I often tell my students, one of the hallmarks of upstream work is to “fall in love with the problem.” It is about flipping our mindset from jumping to a solution before we truly understand the nature of the problem. For organizations, this means always collecting and sifting through data to better understand the problem, talking to those you serve about their pain points and ideas, and mapping the entire ecosystem to understand where and how the system may be getting stuck. 

Accountability vs. Responsibility: At first glance, these words may mean the same thing to you. Both are task-oriented, but they differ in their outcome. Responsibility is about completion. Accountability is about results. Many of us walk through our to-do list the same way – checking the box. But too often we stop there without ever discovering the results of that work. Did it create the intended outcome? Have conditions changed and, if so, what do we need to do to ensure that we continue achieving results? As my good friend and colleague, Ashwina Kirpalani, of The Commit Partnership, aptly said to my students, “Are you a person who checks the box or makes the box?” In order to shift this mindset, organizations have to move to an “ownership” mentality. For more tips on how to make this shift, see our recent post on employee ownership.  

Impact Measurement vs. Evaluation: Nothing strikes fear into the heart of a nonprofit employee more than the word “evaluation.” It has led us down a path where the social sector worries about measuring everything – for fear of being wrong or being perceived as critical. And, it has led to a less-than-desirable result – we only share the “good data” about our programs and not our struggles or pain points, so we never evolve as a sector. We keep reinventing the wheel unsuccessfully. In past posts, we have shared remedies to this mentality – adopting a lean startup approach, embracing failure as a norm and adopting an impact culture. We encourage you to plot your organization on our Impact Culture Checklist to see how you are doing and uncover opportunities for growth in 2021.

Creator/Challenger/Coach vs. Victim/Persecutor/Rescuer: I love superhero movies, but they have influenced our ethos enough that many people believe that you can solve complex social issues with a “silver bullet.” It has also created what we call a “superhero complex.” One of the best reads on this dynamic is TED (The Empowerment Dynamic), a quick read on the dreaded drama triangle (DDT) and how to shift it. We have used this book often with executive teams and clients because it sets the right tone for upstream thinking – both in the office and with those we serve to ensure the right power dynamic. 

We are excited that upstream thinking got a big boost this year with the amazing new book by Dan Heath (a fellow Dukie) called Upstream. As with all his books (e.g., Switch, Made to Stick), he boils down all the research and thinking around upstream work into engaging social sector stories and action-oriented next steps. It is an enjoyable read that is perfect for staff book clubs, executive teams and board retreats. 
If you have a friend or colleague who enjoys learning about trends, please share this blog post with them. And, if you missed our past annual word shift posts that plot the trends from year to year, please check them out below. 
As always, we welcome your feedback on these and other shifts you are seeing in your communities.


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