Meet the first beginnings

"He who excels at resolving difficulties does so before they arise.He who excels in conquering his enemies triumphs before threats materialize."

Sun Tzu The Art of War


Like most active people, I occasionally get injured. Over the years I've banged myself up pretty good, but I've also gotten adept at managing my various aches and pains, using my favorite rehab modalities or simply by waiting for nature to take its course. Most of the time I'm pain-free, but sometimes things get a little out of hand and I go in search of a specialist. That's when things start to get interesting.

One particular instance stands out in my mind. I'd been suffering with a nagging pain in my shoulder, so I made an appointment with the local bone carpenter, an orthopod. The good doc ran me through a basic physical exam and took the afflicted limb through all the standard tests. He checked my range of motion and did a host of biomechanical assessments. And because he was either detail-oriented or living in fear of litigation, he sent me down the hall for X-rays and an MRI.

When the results came back, we reviewed the images in his office. "Well," he said, taking on his best bedside manner, "It doesn't look like much. You've got a bit of an arthritic change in the joint, but it's pretty subtle. You've got basic function and you can mange your pain with NSAIDs. Beyond that, there's really not much I can do for you at this point. I'd recommend that you wait until it gets really bad and then come back and see me. Then I'll be able to help you." With that, he fired off a prescription for an over-the-counter NSAID and disappeared.

I am not making this up.

This story, strange as it may seem, speaks volumes about the underlying orientation of modern medicine. Here was a highly-trained professional, working at a top-flight medical institution in a first-rate American city. He'd been trained at a major medical school and had been mentored by the profession's finest minds. And yet, here he was, counseling me explicitly to take no action for better health. Not a word about upstream solutions. Not a word about movement modifications, diet, postural work, activity levels or other preemptive strategies. Instead of teaching me how to help myself, he actually suggested that I let my condition deteriorate until I could get into the system. Then, he could apply an expensive, heroic procedure to help me. And for that, I would, supposedly, be eternally grateful.

To my way of thinking, this episode symbolizes everything that's wrong, not only with the medical and health care system, but with so many other systems in the modern world, from education to agriculture to economics to international relations. That is, we apply the majority of our attention and resources to late-stage downstream problems while ignoring what's happening upstream, at the source. Across a wide range of professional and social programs, we practice a strange and troubling variation of the Hippocratic oath. Instead of "First, do no harm," our strategy now appears to  be "First, do nothing. Wait until the problem is monstrous in scale and scope, then implement some desperate counter-measures." These counter-measures may or may not work, but they sure are lucrative.


the upstream origins of downstream thinking

So what are the origins of this downstream orientation, this habitual foot dragging, this bias against prevention? Can we trace it to its source? Perhaps there's an influential force in intellectual history that gave rise to our "wait-till-the-last-minute" orientation. Or maybe it's just a quirk of the human mind, a malfunction in our brain wiring that inclines us towards cognitive laziness and procrastination.

In all probability, it's our evolutionary psychology at work: our brains are wired to maximize survival in the present moment. Staying alive is the prime directive; the future is an abstraction that may not even come to pass. Only with the invention of agriculture and industry did people have the opportunity to think of abstract upstream causes and future downstream consequences. When you're living on the wild grassland, you hunt, gather and scavenge, and let the consequences fall where they may. If you're still alive in the morning, you've succeeded.

Of course, it's also a matter of circumstance and environment. In our perpetually-panicked, stressed-out noisy world, going upstream now seems like an impossible luxury. We are maxed out, right here and right now, just trying to keep our lives from flying off into chaos. I have bills to pay, you know, so don't go telling me that I need to go back to the Big Bang of my predicament and make everything right. If I can catch a moment of free time, I'm going to have a nap, or a beer, and catch my breath. And besides, don't we pay people to go upstream and figure these things out? Isn't that what the non-profits are for?

Over time, stress eats away at our psychophysical margins and in turn, biases us towards immediate survival in the here and now. If the threat is acute and physical, as in a predator attack, that is as it should be. But as a chronic orientation, stress leads us towards downstream "solutions" and an increasingly problematic fate. More stress leads to less upstream attention, which creates more downstream problems and so on, right into a vicious cycle and a desperate lunge for quick solutions.

Whatever the origins, today's incentives are fundamentally perverse. There can be no getting around the fact that our prevailing downstream orientation keeps profits high. In fact, it keeps entire industries and professions afloat. Why should my doctor teach me how to keep my shoulder healthy when doing so would only hurt his bottom line? Even more to the point, why should medical and health insurance companies lift a finger to promote healthy living when doing so would destroy their gravy train of obesity, diabetes, heart disease and other lifestyle diseases? If we really started getting serious about upstream health and education, a lot of people would find their cash cows drying up; the profit party would be over.

It's an old story of course, this tragedy of the commons. Like the village grazing pasture or the local river, the future is a commons, a very handy dumping ground for today's challenges and inconveniences. Just as we casually dump carbon into the atmosphere and plastics into the oceans, so too do we dump today's difficulties into the days, years and decades of our futures. This "solution" ultimately fails of course, as it leads to vicious cycles of embedded problems, desperate action, frantic fixes, half measures and escalating chaos. Procrastination, whether personal, professional or institutional, is a recipe for disaster.


going upstream for health

Of course, some people do recognize the importance of upstream action and fight the good fight to get to the source. Health care upstreamers fall into a couple of camps: The most conservative put their money on simple measures like seat belts, bicycle helmets and vaccinations (probably the most effective upstream health measure ever undertaken in human history). Others realize that the real upstream challenge has much to do with our style of living and relating to the world. These upstreamers emphasize exercise, good food and community as the true source of health. In the world of athletic training, upstreamers talk about prehabilitation, the early-season development of strength and skill to prevent injuries later in the year.

It's all good, but there's another layer to this, one that is just now coming to the surface. As it turns out, some of our most notorious public health problems are traceable to the combined effects of social inequality and prenatal stress. When Mom is beaten down by social inequality and impossible economics, her stress hormones actually set her child on a life-span trajectory towards stress-related disease: obesity, diabetes, depression and attention problems. And in this sense, the ultimate upstream health measures don't look like health and fitness measures at all: they look like social and economic justice measures. For more: see the recent piece in the March 21 issue of The New Yorker: "Does Poverty Make You Sick?"


today is the upstream of tomorrow

Of course, going upstream in today's world, even thinking upstream, is damn hard work. There are powerful social currents driving us relentlessly towards the ocean, or the sewer, depending on how you see the metaphor. Fighting this tide is bound to feel completely overwhelming. If you try to swim upstream, people will fight you all the way. Critics will call you a radical. Nay-sayers will accuse you of being unrealistic and call your efforts "utopian." Fighting your way against the current will require strength, endurance, resilience and courage, not to mention friends, money and resources. It's an epic quest.

But upstream action isn't all about fighting a heroic battle against the forces of procrastination and apathy. If we simply turn around and change our perspective of time, we find another opportunity, one with immense potential. In this sense, we don't have to fight our way upstream because we already are upstream. The present moment is the upstream of the future; tomorrow is the downstream of today. And in this way, we are always generating downstream effects; everything we say, do or create has huge downstream potential.

To the casual observer, a present-moment upstream action may not look like much. It might be something subtle, something having to do with attention, awareness or seemingly minor choices. It might be a simple change of language, a new choice of words. It might be a new orientation towards the body, with a fresh physical challenge. It might be eating, a little more real food and a little less refined carbohydrates. It might be spending a little more time with friends and family.

No matter the specifics, a small upstream action today has the potential to cascade and ripple into the future with immense consequences. Just as procrastination generates vicious circles of chaos, so too do positive acts set in motion virtuous circles of health and rapport. The beauty of upstream efforts is that they can have profound multiplier effects, far beyond the scope of the original change or effort. For better and for worse, we are all incredibly powerful.

full circle

Oh and by the way, that pain in my shoulder went away just fine. I did some research into functional movement and rotator cuff mechanics, readjusted my training just a bit, and after a few weeks I was as good as new. The upstream approach really does work.As Shakespeare put it:

"Meet the first beginnings. Look to the budding mischief before it has time to ripen to maturity."

All you have to do is do it.