Chris Simms: Brexit and the vengeance of unintended consequences

Chris_simsDecades before the advent of complexity science, H L Mencken wrote that “For every complex problem there is a solution which is clear, simple, and wrong.” These solutions typically complicate existing problems while creating new ones.

Local and global health communities likely have lessons to offer political leaders at risk of opting for these kinds of solutions, which have been influenced by inadequate information, weak analysis, perverse incentives, cognitive or emotional biases, or a focus on the short rather than long term.

Such decisions usually have negative unintended consequences and, when they represent a doubling down on past “do nothing” policies or non-decisions, accidental decisions, or what might be termed “slouching towards a decision,” they may signal a serious threat to overall population wellbeing. They also may be relevant to the calamity confronting Britain as it now attempts to deal with Brexit.

Two examples of unintended consequences are global warming and antibiotic resistance: the first the result of unrestrained economic growth, and the second the result of unchecked use of antibiotics. They are so called “long wave events” that evolve over a protracted period, foment a culture of their own, create self-supporting structures and processes, and desensitise decision makers and blunt their sense of urgency—thus pushing further out the probability of an effective response.

Scientists advocating for change will sometimes seek to address their long wave aspect by presenting decades of change in data visualisations (see infographics), time lapse videos, or event animation to spark a sense of urgency and underscore the need for action.

For instance, a two minute time lapse video by Harvard researchers shows the beautiful and terrifying  manoeuvres of bacteria (over a two week period) as the cells adapt to graduated levels of antibiotics. The video captures “evolution at work” and explains how, enabled by poor antibiotics stewardship, antibiotics have transitioned from a 20th century medical miracle to a 21st century public health crisis. In a similar fashion, scientists have sought to capture the progress of CO2 build-up and the effects of global warming on the environment. NASA’s animated time lapse video of Arctic ice loss (1984-2016) shows the 90% depletion of “old ice”; other animation effectively depicts global temperature change between 1850 and 2016.

Although a time lapse video to capture the sequelae of Brexit is years or decades out (if it happens at all), it’s nevertheless interesting that many observers evoke the time element in the opposite direction, repeatedly citing Brexit as “a slow motion car crash”—the point of which is to stress the inevitable. Early signs of this “calamity” include doubling down on a largely accidental decision, little or no expressed remorse for the results, and no acknowledgement of a swiftly moving chain reaction (the causes of causes and results of results). For example, Prime Minister David Cameron’s escalating commitment to a referendum he never wanted followed by his claim in its aftermath that he had no regrets are consistent with his successor’s (Prime Minister Theresa May) ambivalence about Brexit followed by her subsequent claim that she had “no regrets” about calling an election meant to strengthen her position to negotiate Brexit, which in fact did the opposite.

As this unfolds, dozens of experts are warning of the detrimental effects Brexit will have throughout all sectors of the British economy over the short and long term. Predictions made by the British Medical Association say that it will have huge negative implications for the medical professions, and not just by compromising the workforce—patient safety, public health, and medical training standards all stand to lose out too. According to the Royal Society, 29% of the UK academic workforce (and more than 50% of PhD students) are from overseas. In addition, the number of nurses from the EU registering to work in the UK fell from 1116 in May 2016 to 85 in May 2017.

Many also expect that it will negatively impact research funding, medical innovation, and the pharmaceutical sectors. Furthermore, few would deny that Britain will lose influence as an actor in global health—an area that it has led over the past two decades.

H L Mencken warned of the perils of ill conceived problem solving, and now complexity science provides the details of how this is a trap that governments and those creating public policy must be particularly wary of. Yet clinicians confront complexity and the risks of unintended consequences daily—whether it relates to new (or old) drugs or procedures, electronic records, trying to balance efficiency with equity, or, indeed, the risk that clinical practice guidelines might inadvertently stifle innovation or obfuscate local context. They therefore might reasonably expect some semblance of the same from their political leaders. For surely politicians must also abide by a modicum of good stewardship and some form of “do no harm.”

Dr Chris Simms teaches at Dalhousie University, School of Health Administration, Halifax, Canada; he spent many years living and working in Africa’s health sector.

Competing interests: None declared.