The Ouroboros Effect:  The Revenge Effects of Unintended Consequences a compilation by  David X. Swenson Ph.D.

The origin of the Ouroboros symbol (serpent devouring its own tail) can be traced to ancient Egypt and China, Norse mythology, Medieval Europe, and into modern times. It has been interpreted in a variety of ways, but here represents the cyclic and interactive nature of events. More specifically, it reflects how some of our best attempts to solve problems comes back to bite us!

Solutions to problems are usually intended as final fixes, but more often than not, while solving one problem, they generate more problems. In some cases the new problems from the intended solution are bigger, worse, or more complicated than the original problem; in other cases, the intended solution feedsback into the original problem and simply exacerbates it. The German word, verschlimmbessern, can be interpreted as "to fix something more broken," or to worsen through attempts to make better. These unintended consequences have been called "revenge effects" and are largely a function of limited scope in problem strategy conceptualization: most problem solving deals only with the problem (as defined) at hand, and does not consider the long term effects, ripple and spin-off effects (contingencies), or feedback effects in a larger system. The examples I have collected below present a variety of revenge effects that might have been prevented by taking a more systemic view of the situation.

Examples of Systemic Backfires

• In the Okavango delta in southern Africa an attempt to combat hunger resulted in unintended eventual effects. The tsetse fly had, for decades, devastated the cattle herds of the native people, often resulting in depleted herds, starvation, and subsistence level survival. Consultants acted to suppress the tsetse fly and replace the local cattle with beef cattle. The increased cattle populations soon overgrazed leaving the land desertified and uninhabitable (Kleyn & Jozefowicz, 1985). In an attempt to better understand how such an unintended error could occur, a computer simulation was devised and presented to planning professionals from several disciplines. Each time, the professionals made the same error: they solved the problem only for the immediate situation, not considering the systemic implications of the intervention for long term survival. For example, like the real situation in the Okavango delta, the tsetse flies were suppressed, the few shallow watering holes were replaced by more and deeper wells; this enabled cattle to proliferate, grain to grow, and for farmers to actually store excess grain for market. For several years (computer time) the standard of living rose. Then, as the small aquafers became depleted, additional and deeper wells were drilled to compensate, with the effect of quickly consuming all available water. The wells dried up, as did the grains, then the cattle died--and then the people (Dorner, 1989).

• The 1981 Family Adoption Act was passed with the intention of keeping families together following dysfunctional problems such as child abuse. It required states receiving federal funds (all of them) to take extraordinary measures to maintain children in families. This meant that they would have to conduct a detailed assessment of risk, give families extended opportunities to make changes (e.g., through parenting skill training, family therapy, etc.), and avoid damaging the child by separating them from a family where they had bonded. There are numerous examples of extremely dysfunctional families kept together for several years, during which time even severely abused children bonded to parents. By the time it was clear that the parents were not responsive to intervention, the children were bonded and it would be disadvantaged by separating them.

• A similar problem solving error occurred in Hawaii involving the attempted eradication of an invasive weed, the Lantana camara. Unintentionally introduced birds from other countries, like the mynah and turtle dove, quickly flourished as they fed on the berries of the plant and spread the seeds throughout the island. The logical approach to curbing the invasion of this weed was to introduce the agromyzid fly to lay eggs in the berries and destroy the seeds to stop the spread. The problem arose when the planners forgot to consider the other systemic connections with other important links in the environment. For years, the grasslands and sugar cane plantations had been ravaged by army worms that the brids had held in check. The agromyzid fly was so successful in destroying the lantana that the mynah and turtle dove populations were also decimated, leaving the army worms to flourish. The result was extensive damage to crops due to the unchecked worms, and the niche left empty by the lantana was replaced by an even more invasive plant (Keeney, 1983).

• In the early 1990's President Clinton became concerned about the increasing numbers of refugees attempting to sail from Cuba to Florida. He increased the number of US Coast Guard patrols and moved them closer to Cuba, hoping to scare off would-be sailors with their presence. Few Cubans owned large and stable enough craft to sail the 90 miles to freedom, but they knew that the patrol boats would intercept them and take them to Florida where they would be placed in a refugee camp for disposition. As a result, the numbers of attempts increased from a few hundred to several thousand.

• The plight of many impoverished and psychologically disabled families has led many states to promote "wrap around" programs in which multiple human service agencies provide comprehensive and continuous services to them. A central component of many of these is Intensive In-Home Treatment in which teams of therapists may spend several hours each day working with families on parenting skills, conflict resolution, and other interventions. Although this is an impressive organization of community resources, someone forgot to consider the effect of this mass of external pressure brought to bear-- the result in many cases is that it keeps the family dependent on external sources for motivation and execution of plans. For far too many of these families, when the wrap-around pulls out because of exhaustion of treatment plan extensions, retreat to about where they were before all of this began.

• In England, lifestock that contracted "mad cow " disease during the mid-1990s led many farmers to sell their livestock before it demonstrated symptoms. In the cattle food production business, cattle parts are often ground up, dried, and added to livestock feed for protein. Unfortunately, the disease is passed on in the cattle protein and the disease was spread widely to previously uninfected cattle.

• Organizations conscientiously cut costs whereever possible--including toilet paper. Thick, soft and more expensive toilet paper is often replaced with paper of much lower quality. Paradoxically, many users find the cheap paper unreliable and therefore use twice as much. The high volume use not only counteracts the intended savings, but the mass can clog drains, users are annoyed, and rolls must be changed more often.

• Recent concerns about food contamination with salmonella and e.coli has led many homemakers to conscientiously use dish cloths, towels and sponges more often to wipe up spots and wet areas. It has been established that the kitchen is more of a hotbed of bacteria than the bathroom! While frequently the counter sounds like a good idea, it more often refreshes and spreads bacteria that grows in the cloths (and especially sponges). Paradoxically, some of the "cleanest" homes are the dirtiest.

• A South American country was deeply concerned that desperate thieves who were robbing tourists at gunpoint of their ATM cards would adversely affect tourism. The risk was so high that they arranged to have tourists replace their ATM cards with thumbprints so the cards could not be taken. This actually escalated the problem--the thieves continued to assault the cardless tourists, this time by cutting their thumbs off and using them to access the accounts on the ATM's.

• The American Forest Service was concerned about the destructive nature of forest fires and set about to suppress them as quickly as possible. Developments in new fire retardant chemicals and rapid deployment of fire fighters enables many fires to be quickly extinguished. As a result of the overprotection, accumulating thickets climbed into the understory of trees. In other cases, clear cutting left large amounts of branches and needles on the forest floor. When fires eventually erupted, the firest spread faster through the trees and burned hotter on the floors, raging out of control and causing even more destruction to forests and communities (Little, 1993).

• The reduction of usable freshwater has lead many communities to revise their building codes to restrict the types of toilets that can be installed. Increasingly they have required (in some cases by law) the installation of "water saving" units that use only 1.5 gallons of water per flush rather than the older 3 gallon model. Unfortunately, many of the new models do not flush well--they often clog with waste and require unplugging with some device. To avoid the flush problem, most users flush twice--defeating the purpose of the new design, as well as imposing some degree of inconvenience and annoyance.

• A community mental health center had been losing staff due to low morale and experienced lower billable contact hours with clients. In a reorganizational effort the administrators "empowered" the treatment staff and involved them in administrative decision making. As a result, the staff had even less time for clients, staff-administration conflict increased, and more of them left due to the unexpected pressures of seeing the larger picture of the problem.

• In recent years there has been heightened concern over the increase of contaminated meat. In an attempt to curb the problem, the agriculture department placed more inspectors on duty and required them to be more aggressive in their inspections. Consequently, meat was out of meat coolers longer giving bacteria an increased chance of surviving, and the more aggressive trimming tended to spread it over more of the carcasses.

• In Madison, Wisconsin the plight and high visibility of the poor and homeless troubled the community, so they provided safe and comfortable shelter for these unfortunate people. As the word spread about the kind efforts of the city, the numbers of homeless swelled as more of them moved from other states to Madison to take advantage of the generous conditions.

• The development and use of antibiotics has made immense impact on the treatment of injuries and infectious diseases. Yet the overuse of these medicines has also produced strains of bacteria that are nearly impervious to any medication, and are more virulent than before. Tuberculosis, after having nearly been defeated, has now erupted in at least 42 states as an antibiotic resistent strain.

• Medical insurance companies are always searching for ways to contain costs of medical care. Traditional gall bladder surgery was costly, risky, uncomfortable, and required a stay in bed. Newer laparoscopic surgery involved only a small incision, caused less discomfort, required fewer days of care, and enabled people to return to work more quickly. It was so attractive and embraced by HMS's that the rate of gall bladder surgery increased by 50% in one HMO, unexpectedly raising total costs on gall bladder care by 11% (Legorreta, et al., 1993). In addition, the number of errors increased due to poor resolution on TV's guiding miniaturized instruments.

• Sir William Osler described a paradox in his 1935 medical textbook in which he noted that most patients at the time died not of a primary illness, but a secondary terminal infection. With the advent of sulfa and other antibiotics during the 1930's and postwar period, innumerable patients were saved after they were weakened by an incurable disease. He observed that, instead of improving general health, the medicines were increasing the prevalence of disability and chronic illness (Gruenberg, 1977). A more recent version of this is the increasingly effective health maintenance of Alzheimers patients who may live twice as long as they did a few years ago. The result is a prolonging of the devastating effects on the patient's family and savings, and overall health care costs.

• The use of computers in the workplace was touted to be a time saving device, promoter of efficiency, and beginning of the "paperless" office. There are some users and businesses who feel, in contrast, that the cost of system purchase, learning curve for staff, dependency on a fragile system, backlog during downtimes, and quadrupling use of paper may not be what was promised. In addition, the incidence of repetitive stress injuries has increased many-fold, with a corresponding cost of worker's compensation costs to the employer.

• When a project is behind schedule, in desperation most project managers add more people to the task. While it seems intuitively correct to add more workers it usually slows the process down even more due to training time, errors, working at cross purposes, duplication of effort, and confusion of current roles and instructions.

• Traffic engineers and mathematicians have discovered that expanding old routes and adding new ones may actually make traffic slower, not faster. Called Braess's Paradox, an attempt to reduce traffic bottlenecks on two roads by making a third, more direct road, often has the effect of creating even slower traffic due to merging. During merging, cars drive closer to each other and therefore slow down; huge traffic jams can appear miles from the actual merge (Arnott & Small, 1994). The positive aspects of this is that it increases safety, the negative side-- idling engines produce as much as 300 times as much carbon monoxide as cars driving freely.

• A similar catch called Brook's Law applies to the idea of adding manpower to a software project. The good intention by project coordinators is to make the project go faster by distributing the work among more people, thereby getting it done faster. The revenge effect is that the added complexity and communication from more people interacting and attempting to merge their work into a final product more often complicates and unexpectedly delays the task.

• Early American boxing was considered too bloody and barbaric, so boxing gloves were introduced to decrease injuries. Protecting the hands from injury as well as three minute rounds with resting between allowed the fighters to fight much harder for much longer. In addition, the gloves also enabled harder round-house blows to the head. The result of the protective innovation was to dramatically increase the number of long term eye and brain injuries that seldom occurred from the old bare-knuckle contests (Dillner, 1993).

• Modern health consciousness has led to many household inventions that promote cleanliness, such as floor sweepers. The high power engines that drive vacuums are so strong, that much of the dust, dander, bacteria, and dust mites that are embedded deep within carpets are sucked out and spewed through the air to aggravate asthma, as well as settle on drapes and other furniture (Tenner, 1997).

• The microprocessor was hailed as one of the major solutions to the energy problem-- after all, the 8086 chip was as powerful as an IBM mainframe but used an incredibly small amount of electricity. Now computers have hundreds of microprocessors and millions of people have computers. The 20 billion processors or so out there make the chip one of the world's hungriest power consumers.

• Before the internet there were specific entry barriers to be overcome before a business could be started. Considerable capital was needed to fund product development, manufacturing, and delivery. Although it has been the dream of many people to start their own businesses, typically 2 of 3 fail within about the first two years. With the ease of starting one's own dot.com business, inexperienced entrepreneurs surged, gaining the trusted investments of enthused consumers. However, when it's easy to start a business, anyone ca do it and the inexperienced execs more often than not failed, leaving their investors in the lurch.

• Related to the above, our immune systems have a substance IgE or immunoglobin E that produces antibodies protecting us from a host of bacteria and parasitic invaders. With improved health conditions this militant protector has run out of work and turned to defending the body against less dangerous substances like plant pollens, animal dander, and dust mites in our pillows. The resulting antigen-antibody reactions produce allergic reactions such as hay fever and asthma that has doubled in the last 20 years, causing one-third of child visits to emergency rooms (Lowenstein, 1997).

• DDT was once considered a miracle insecticide. In the 1930s the South American fire ant stowed away on cargo ships bound for the US. The stinging ant not only was dangerous to farmers and lifestock, but often destroyed electrical insulation. For nearly three decades the government sprayed DDT on the insects-- with no effect on them. From overuse, many other pests developed immunities to it, and at the same time it often killed off the natural enemies of such pests. As a result, the pesky insects were more plentiful and resistant than ever, beneficial ones were depleted, and the accumulation of DDT in humans was related to a variety of health problems (Tenner, 1997).

• The gypsy moth was brought to Massachusetts in 1868 by scientist Etienne Trouvalot to interbreed with other moths to produce a new strain of silk- producing caterpillars. The ingenious experiment failed and several of the species eventually escaped to the countryside to reproduce. The moth feeds on over 600 species of trees and is one of the most defoliating insects in the US, costing millions of dollars in damage each year.

• Life in third world countries has become more competitive, populations have grown, and many farmers desire the standard of living that other countries have. In the Amazon rainforests, subsistance farmers eke out a tenuous life by clearing dense jungle, planting gardens and grazing cattle on fragile few inches of topsoil. Within a few years the close grazing and intense planting exhausts the earth of nutrients, increases erosion of whatever topsoil remains, and the farmers must move on. The result is a reduction of productive land available, pollution of rivers and destruction of fishing from runoff, and exposure to new viruses as they make deeper incursions into the rain forest.

• The development of automobile airbags was in response to many drivers and passengers being injured because they refused to voluntarily wear safety belts. These "passive protection devices" could be deployed without any effort on the part of the driver (other than hitting something) and cushion the impact. The bags were primarily designed for adults and were touted as potentially saving 9000 lives a year. The enthusiasm for the devices was so great that several studies that clearly indicated that children might be injured by the bags was overlooked or disregarded. As the injury and death count of children mounted, it was determined that nearly twice as many children might be injured by the bag as might be saved from the crash. In addition, even for adults, the bag only works well when the driver/rider is also belted in (Norton, 1996).

• Communication "dispatch" centers are notorious for hiring people at low wages to perform coordination of numerous emergency calls in the community. The stress and heavy workload results in reltively high levels of absenteeism and turnover (often within two years). With limited funding and resources most administrators have considered that hiring additional full time staff is more expensive (due to benefit payments) than is paying time-and-a-half overtime to current workers. The result is that the overtime they work results in more burnout, absenteeism and turnover, and the hidden costs of worker replacement often exceed the benefits costs.

• Dispatch centers, because they are so central to emergency communications--as the line of thinking goes-- are often located in highly secure areas of public buildings--such as the basements. It is more likely that they have the low end of the budget and are placed there in spite of their importance. As a result, they often have no source of outside or natural lighting. In addition, the computer consoles are difficult to look at for 12-16 hour stretches (they put in a lot of overtime), and darkening the room makes them more visible. Dispatchers also work round the clock and in shiftwork settings this usually means that they have difficulty adjusting their biological clock or circadian rhythm to the changing schedule. The dimly lit room becomes a cue to the brain to elicit sleep just at the time they need to be more alert. The lack of bright light further confuses the body clock which often creates serious shiftwork adjustment disorders, leading as many as 20 percent of workers to leave the field.

• The invention of rubber and its application to auto tires was a marvelous development, except that there is limited use for the old tires after they wear out. As a result, they often sit for long periods and collect water, many of which are shipped from foreign ports to become recycled tires. The downside is that the tiger mosquito traveled with the tires from Southeast Asia and now enjoys an extended breeding season in the southern US where extremely painful dengue or "break bone" fever is increasing rapidly.

• The Russians have been more open to experiment with using radiation for destroying bacteria on meat than have Americans. The method reportedly works well and leaves no unpleasant or dangerous effects. However, after the Chernobyl nuclear accident in 1986, the counter reaction to irradiation and negative attitude toward anything related to radiation led to a destruction of the then growing Lapp reindeer-meat economy.

• The purpose of the French Revolution was to rid France of the corruption and injustice of the old regime. To this goal Dr. Joseph Ignace Guillotine expanded on the plans for a new form of merciful execution using a large falling blade (the machine bearing his name), and even went to Louis XVI (who loved riddles and problems) for suggestions on the proper angle of the blade (which Louis later became intimately acquainted with). The device was promoted by Robespierre whose Jacobite committee dominated the new regime. His cold-hearted methods and new laws led to numerous beheadings--his included--as French crowds became caught up in rampant accusations, impulsive convictions, and summary executions. It was later estimated that a severed head retained consciousness for as long as 15 seconds--not so quick a death. The intent of a merciful execution had unexpectedly fostered over two years of public butchery and cost an estimated 13,800 lives.

• Kudzu, one of the most invasive and problematic plants of southern states did not start that way. It was recognized by government agricultural experts that the fast growing kudzu plant had many useful qualities: in Japan it was a starchy food item, in the early US it was a popular ornamental shade tree, prevented soil erosion, restored soil nutrients, and made passable pasturage and hay. The Soil and Water Conservation Service even sent 73 million seedlings to farmers with encouragement to plant it. Its proliferation, however, led to an awareness that it overgrows and kills large trees, overheats power transformers and pulls down wires, obliterates traffic signs, and slickens train tracks. It is resistant to mechanical eradication, and the few chemicals that destroy it also severely damage the soil for up to a year, thereby renewing the erosion that kudzu was introduced to prevent.

• C. L. Sholes, the inventor of the typewriter keyboard (QWERTY key sequence) developed it in response to the problem that fast typists often jammed the keys together. He designed the key layout to intentionally slow down the typists and thereby increase their typing efficiency on the old manual typewriters. With the advent of electric typewriters and particularly computers there was no need for the old keyboard, but tradition had been set. In spite of numerous alternate keyboards that provide improved speed and reduced risk of repetitive stress, the old keyboard lives on.

• Brazilian honey bees had a disappointing level of honey production, and many North American bees were not much better, in addition to being decimated by bee mites and infections. More robust African bees were interbred to create an Africanized hybrid that was much more productive: the bee moved Brazil from 47th place in world production of honey to 7th! However, the more aggressive hybrid began driving out more docile domestic bees, causing serious human and livestock damage, and was even so aggressive as to discourage beekeeping in many areas.

• In the mid-1870s, Spencer Baird, a fisheries commissioner, was concerned about the future food supply of America. After some study he was convinced that the German carp had the qualities necessary to become a revolutionary new food source: it was a hardy, fast growing, nutritious, vigorous, firm-fleshed fish. Working with Rudolph Hessel, a German fish culturalist, they imported the fish to the US where they projected it would cost only half as much to produce as chicken, and could be raised in areas unfit for other kinds of production. Millions were sold. However, the fish did not behave as expected in its new environment. Unless raised in clear water, they had a bad taste; when fed routinely they became lazy and the flesh lost firmness; they expanded their original grounds as voracious feeders and destroyed wild celery, wild rice, and pond weeds that supported waterfowl; and were prolific (each producing hundreds of thousands of eggs) driving out other fish species.

• Many industries that involve lifting have serious problems with worker compensation claims for back injuries. To the rescue--the back brace to add support for lifting. Human resource managers nation-wide rushed to secure these wide-belt and harness contraptions that would be bound around the waist, straighten the lower back, and give support to lifting. It promised such protection that many industries mandated the device. However, the FDA ruled it was an orthopedic device and could only be prescribed by a physician, which placed the HRM's in an interesting position because they were still mandated to have workers wear it. Within a year the promise faded, as reports welled in about the device causing more injuries due to spinal  nerve compression, or forcing natural lumbar back curvature into a straightness that was unnatural and painful.

• The Minnesota Department of Natural Resources and Northern Minnesota residents were concerned about porcupines seriously damaging local trees. The porky's tend to eat bark in a circle around a tree, thereby lethally girdling it. In a stroke of ingenuity DRN considered that pine martins (a large member of the weasel family) were natural predators of porcupines and might be used to control the expanding population. The martins were so successful in eradicating the porcupines that few porky's are seen by residents today, and the lower prey population has led martins to create a new CATastrophic problem--in alarming numbers domestic cats are taken right off the porches of houses by the martins as a new food source (story provided by Mary Perala).

• Not to be outdone by Minnesota (see above), Hawaii recognized that the proliferation of rats on the exotic isles was creating problems by damage to crops and risk of spreading disease. To control the critters, the voracious mongoose was imported, which apparently has a fine taste for rats. Having done its job quite well, but out of a food supply, the resourceful mongooses began predating on exotic Hawaiin birds, poultry, and their eggs. The mongoose is attributed to have killed nearly all of the birds known as Ao or Newell’s Shearwater on the islands of Hawaii, Maui, and Molokai. I wonder what the predators of mongooses are?

• Another marvel of agricultural planning was the introduction of the cane toad from Hawaii into coastal Queensland, Australia in 1935. The toad was expected to eat the scarab or cane beetles that were attacking the sugar cane roots. Unfortunately the beetles spent much of their time underground and beyond the predation of the toads. Having a prodigious appetite, the toad began feeding on all sorts of other small life forms including honey bees, small snakes, native frogs, and small mammals. In addition, its toxic composition at all stages of development resulted in poisoning a variety of predatory fish, snakes, turtles, birds, and mammals. The toad has established itself throughout important rivers and wetlands of northern Australia.

 
• In the latter part of the 1800s European travelers introduced pigs as part of their staple diet in Hawaii. As one would expect, some pigs escaped and became feral, eking out their existence doing what pigs do– rooting, wallowing, and eating anything and everything. The latter was the problem. One sow can produce five offspring per year, and with 100 sows the 500 per year can grow to over 21,000 in only four years– especially with no predators for pigs on the islands. Their tusks, snouts, and hooves essentially rototill the roots of plants and they devastate huge areas of land, killing rainforest, plants and eating ground mammals as well.

• Another mongoose story--this time in Okinawa. "The Indian mongoose was introduced here in 1910 to control the rat and habu snake population, which threatened sugar cane workers. Unfortunately, the mongoose is a daytime hunter and the habu snakes are night owls. So both species thrived and it seems the only time the two meet are in staged habu-mongoose fights at several parks on the island. Now it is feared the mongoose, which has no natural predator, is a threat to several endangered specieis of birds and small mammals in the wilds of Okinawa's northern jungles" (personal communication--provided by David Allen, Okinawa Bureau Chief for Pacific Stars & Stripes)

• A doctor was abhorred with the incredible loss of life in warfare due to firearms. He vowed to develop a weapon that would be so powerful and horrendous that it would end war. He reasoned that if an invention made it unnecessary for more men to take the field, then lives would be spared. He bound six gun barrels to a central rotating shaft that would automatically load bullets. In 1864 the US Army ordered 100 of the new firearms that could shoot 350 rounds a minute. Although never used during the Civil War, unfortunately, Dr. Richard Gattling's gun (the Gattling Machine Gun) led to even greater carnage and escalation in armaments during the the Spanish American War and later.

• In Europe, it was not uncommon for an entire family to enter a single business-- like manufacturing munitions. The brother of a young chemist in a Swedish family was killed by nitroglycerin which led the chemist on a crusade to improve the unstable product. His inventiveness stabilized the product al right-- stable enough to be used in warfare as TNT or dynamite. Alfred Nobel felt so guilty about the use of his invention that he willed $9 million for an annual award for science, literature and world peace.

• The high costs of maintaining welfare recipients led the state of Wisconsin to revise its service policy, now known as the "Welfare to Work" or "Wisconsin Works" project started in 1997. It was hugely successful--initially--with a client load of 100,000 families in 1987, now reduced to 9000! Yet the hidden costs began to emerge. For the mothers who were unwilling or unable to work, they lost their benefits. Many were evicted and slum landlords lost their tenants and incomes, daycare centers lost their customers, and homeless shelters ran out of beds. Some of the disenfranchized turned to crime, such as stealing, selling drugs, and prostitution--with many of these contracting diseases or ending up in jail. The children of these unfortunate women were most often sent to grandmothers for care. This in turn resulted in excessive financial strain on older single women on a fixed income, requiring transfers of money for their added support.

• The United States and most of the industrialized countries have fairly long life spans--owing primarily to the development of antibiotics defeating serious bacteria borne diseases. The success and resulting proliferation of these products has grown incredibly over the years: more than 50 million pounds of antibiotics are produced in the US each year, and about 40% of it is given wholesale to animals, mostly to promote growth. These miracle drugs are creating a potent problem--the bugs are developing resistance to them! Widespread pathogens such as streptococcus, staphlococcus, and pneumococcus (causing ear, nose and throat infections, scarlet fever, meningitis, and pneumonia) are incvreasingly resistant. An estimated 2 million people become ill after entering the hospital in the US, and about 90,000 die. As many as 70% are infected by a drug resistant bacteria, and cost for treatment is about $5 billion a year, with an overall cost of $30 billion. In the future, catching a cold may be nothing to sneeze at.

• With an aging population growing in size lawmakers have eagerly approved the concept of home health care. The intention was to make visits to ill persons in their own homes and thereby save large costs to insurance companies, Medicare, and the patients themselves. Instead of saving money, many health care facilities now rely on the service as a strong source of revenue and therefore encourage more visits. In 1998 the average home health care patient received 80 visits per year--nearly four times as many visits as 10 years ago. In 1995 Medicare spent $16 billion on home health care. (Daft, R. 2000. Management. Orlando, FL: Dryden).

• Metropolitan congestion and the attractiveness of nature has led millions to build homes close to the ocean. Such construction has removed sand dunes that provided a natural barrier to erosion. Without the dunes, hurricanes, storms, and wave action  steadily erodes thousands of miles of beachfront and jeopardizes residential and commercial structures. Shore protection engineers have come to the rescue with "groins" (rocky outcroppings that reduce sand backwash), breakwaters, and sea walls designed to prevent the sea from further eroding beaches. Unfortunately (a frequently used word on this "Revenge" page), while the groins build up sand on the updrift side, they increase sand erosion on the downdrift side. The sea walls unexpectedly reflect the wave action with a blunt deflection that actually increases the wave energy, so that it carries back even more sand into the ocean than it would have without the barrier (Discovery News, 9-4-99).

• The increase in terrorism has led the federal government to increase its surveillance and testing of people and luggage in airports. Part of the training involves using bomb-sniffing dogs to sniff out such items in luggage compartments and in passenger areas. To train the dogs properly, the animals must be exposed to a variety of planes so they do not become accustomed to just the smells of a single test plane. As a result, bomb materials are often planted on a large number of planes on which the dogs can practice. When Flight 800 went down off Long Island in 1996 under mysterious circumstances, dogs were again brought in to sniff whether a bomb had been used. Unfortunately, the plane that went down was one of those that had been used as a training plane, and it was impossible for the dogs to determine whether a new bomb was introduced after training. The very attempts to prevent or enable discernment of explosive materials, in this case, prevented such determination.

• "Just don't think about it!" The problem is that when we are admonished to suppress a thought it has just the opposite effect-- it tends to make people fixate on the idea. Likewise, when people are told to disregard or ignore information, or that what they have been told has been false, they tend to consider it anyway. Efforts to avoid thought may lead to later preoccupation with them (Wegner, et al., 1987).

• Ain't technology wonderful-- except when it ain't? Building contractors have mixed feelings about this when automated structured actually cause more problems than they were designed to solve. A study from Building Services Journal found that automated windows, blinds and  occupancy-sensed lighting more often increased inconvenience for users, added a work burden to managers for monitoring these systems, and inability for users to regulate the mechanisms and therefore more complaints

• Malaria is endemic in parts of Africa, so it isn't surprising that evolution has found some clever solutions to the high risk that people suffer with the disease. The sickle cell (cresent shaped red blood cell) is not affected by malaria-- except that when both parents have sickle cell as a protection, the offspring contract sickle cell anemia that is life threatening.

• For over a decade the frog population around the world has been increasingly  flagging. Since the early 1900s, environmentally conscious Australians have been attempting to bolster the decimated frog population by reintroducing tadpoles into streams and ponds. The depopulation has been largely due to the chytrid fungus which attacks the keratin in the frog's skin, interfering with respiration. While tadpoles do not have keratin in their skin, they do have hundreds of tiny teeth that can carry the fungus, so that following metamorphosis, the infection develops. The well-intentioned environmentalists are actively spreading the infection to previously unaffected frogs by their zealous attempt to increase the population.

• People go to the hospital to be treated and recover from injuries and illnesses, not to get worse or to acquire even more serious conditions. However, iatrogenic conditions are a considerable likelihood according to a report from the Institute of Medicine (IOM) of the National Academies. Medical errors are estimated to kill between 44,000-98,000 people each year--more people than die each year from   highway accidents, breast cancer, or AIDS. About 7,000 of these deaths are from medication errors--these accidents exceed even workplace injuries. (Report: Preventing death, 1999).

• NPR Senior News Analyst Daniel Schorr reported that the CIA, eager to engage the Russians in a Viet Nam-like war in the Middle East, trained Afghani Muja Hadin guerillas in bomb making and other terrorist techniques. At the time the Afghanis were separated into about a dozen diverse factions, some as hateful of the US as Russia. However, CIA Director William Casey convinced President Reagan to authorize training for all factions. It seems that no one considered what the factions might do after the Russians were defeated. Many of the trained terrorists decided to go after the Great Satan of the West--the US. The bombers of the World Trade Center, US Destroyer Cole, and numerous other terrorist strikes against western countries were all trained by US specialists.

• The automation of libraries was  (and still is to a large extent) considered a boon to both librarians and users who should be able to locate more comprehensive information more quickly than older filing methods. However, reliance on this technology has posed some unexpected problems. Now, when the online system goes down, one can't simply go to another card file since paper filing have been completely replaced--the whole system is down and inaccessible. In addition, a higher level of skills is required for both librarians and patrons, software skills are often not protable between libraries that use different systems, software procedures are more complicated for circulation personnel, and these systems require software specialists on staff or on call. Whatever happened to the good old card file? (Barnett, 1999).

• During the British Colonial Period indentured servants became popular after slavery was outlawed, and between 1830-50, hundreds of thousands of East Indians were shipped by the British to relatively uninhabited, beautiful islands. Although the intention was to exploit these laborers, these Hindu workers settled down, raised families, and eventually took over Guyana (British Guiana) and the islands of Mauritius, Fiji, and Trinidad--not exactly what the British had in mind (Arumugaswami, 1997)

• In the late 1980's the Big Lake Golf Club in Cloquet, Minnesota was concerned about the disruptive effect that the large mosquito population had on its patrons, as well as the impact that army worms had on the surrounding attractive foliage. After discovering that black flies were predators of mosquito larvae and army worms, in a stroke of genius they imported large numbers of black fly eggs to the golf course. The eggs hatched and successfully reduced the numbers of targeted bugs. Then, like so many other successful predators who exhaust their prey, they turned to larger and juicier victims--the golfers, who were often driven off the courses in clouds of blackflies (thanks to Ross Korpela, 2001).

• Although tennis officials have been quite strict regarding rules, nets, and wardrobe, they have been somewhat more lax on the regulations for tennis rackets, especially during the 1970s. Leaving the dimensions up to the players and manufacturers, rackets were open for experimentation. In 1974 Howard Head developed a newer and larger racket-- its 130 square inches were nearly twice the surface area of the traditional racket. Designed with a larger "sweet spot" for less skilled players, the racket caught on. While popular, the rackets posed several problems. The larger area made it possible for the racket to twist more and transfer more shock thereby causing strain injuries. The new designs allowed up to 30% greater speeds, sometimes resulting in speeds of 125 mph. Consequently the usual game of volley and counter-volley was reduced to terrific serves and points, thereby boring the audiences (Tenner, 1997).

• In Rudy Nadler-Nir's short article (Feb 3, 2001) he complains that "the e-postman never rings." Lamenting the fact that the promise of the paperless office has never quite developed, he describes the revenge effects of e-mail that was intended to make communication easier. Perhaps the problem has become too easy-- it is estimated by a marketing firm that by 2005 the number of e-mails exchanged daily will number 35 billion! One won't even have to go to the office to do it, with an estimated 1 billion mobile internet access devices in the hands of eager communicators by 2003, according to the Yankee Group. For those lucky people who subscribe to even one of the more than 90,000 listservers (online discussion forums), it is not uncommon to receive scores or even a hundred e-mails a day (unless they are digested) from people compelled to share their ideas with everyone else. For a time-saving idea, it sure is time demanding.

• Bags filled with sand have been used for makeshift dikes throughout the world to protect against raging floods. The bags are often hard to remove after high water since they are often heavier due to absorbing water and silt. As a result, some communities have left the bags in place or piled nearby for long periods. This saving device has become a serious health hazard because the bags also absorb dead fish and waste products, promoting contagious bacterial cultures.

• In this safety-conscious age, home security devices are touted as the best way to protect your home and valuables while two-career families earn their daily bread. The proliferation of such security systems, especially when they became inexpensive, led to numerous false alarms, still requiring law enforcement to respond. In philadelphia, for example, only 3,000 of 157,000 calls were legitimate--which diverted the equivalent of 58 full-time police officers from the real criminals.

• Early in the Afghan War the US wanted to show its beneficience toward the Afghani people by sending needed food and supplies. Air transports dropped small yellow food packets to the people below who were desperately in need of supplies. Unfortunately (this is a common word in revenge effects...), the yellow packets looked quite a bit like the yellow cluster bombs that were also about the size of a large coke can. No report of injuries due to mistaken identify have yet been published.

• Congress has proposed that the Corporate Average Fuel Economy (CAFE) standards for the US auto fleet should be raised and broadened, especially regarding SUV's. Purportedly, this will require higher standards of greater fuel economy and eventually save gas and money. An unexpected effect of this is to downsize the passenger fleet since bigger and heavier cars require more gas. However, smaller, lighter cars are more dangerous in crashes, and the policy may have been indirectly responsible for 2600 such fatalities. Smaller cars have less space to absorb crashes that people must absorb. Weight and size reductions have been linked to 46,000 auto deaths from 1975 to 1998 (Death by decree, 2001).

• The new Volkswagon Beetle was designed with numerous customer conveniences built in-- their key system was intended to be one of the best in the industry. With auto theft on the rise the ignition key contains a highly specialized computer chip (for only $35), and no one can steal the car without one. Unfortunately, if the owner happens to misplace or lose the key, they become just as immobilzed as the thief. A VW owner in Duluth, MN slipped on ice, and in falling, threw the key into deep snow where it could not be found. Although the owner's manual says the owner can independetly reprogram the key, this information is inaccurate and only a dealership can reprogram it. In addition, the key can spontaneously lose its program. The replacement key in this case came from a dealer 150 miles away in Minneapolis-- overnight by FedEx. Since the key was lost and might be found by an unscrupulous person, to reprogram the car and new key also required a 300 miles round trip to the dealership. Fortunately the driver lived in the town where it was lost or she would have incurred taxi, motel, and meal expenses in addition while waiting for the FedEx to arrive. This makes one wonder whether auto theft or misplacing keys happens more often.

• In response to the germ-conscious, plastic loving Americans, several kitchen supply manufacturers started producing plastic cutting boards as germ free aids. The boards are attractive, come in a variety of sizes and shapes, and are easy to wash off. The only problem is that wood boards are more germ-free than the plastic ones. While wood seems to absorb and destroy bacteria within a few hours, microbes stay quite healthy on plastic surfaces. If they remain too long on the plastic they can even form a biofilm that is resistant to normal washing and require a second hand scrubbing with detergent and steel wool.

• Used to be that students rushed to their lockers between classes to exchange textbooks for the next class. Then in the 1980s backpacks became fashionable, durable, and enabled students to carry their loads with them everywhere, foregoing the locker trip. It is rare to see students without the convenient backloaders these days. Convenient, yes, but perhaps more of a burden than expected. The packs often carry 20-30 pounds, sometimes up to 50 pounds resulting in shoulder and back strain, especially when consistently carried on the same shoulder. Few students carry the weight on both shoulders, and even fewer use waist supports-- doesn't look cool. A 1999 study presented at the American Academy of Orthopedic Surgeons showed that 60 percent of orthopedists had young patients with shoulder and back pain. Fifty-five percent carry loads over the recommended 15 percent of body weight,  nearly half of youth experience one low back pain episode by the end of their teen years, and the Consumer Product Dafety Commission estimates nearly 5,000 emergency room visits each year from book and bag carriers. Concern is that what was an effective solution for overloaded books during youth may come back to bite them in 30 years when they may be unable to carry much at all.

• Although the overthrow of the Taliban in Afghanistan was intended to decrease the risk of terrorism, it may have unwittingly contributed to another war-- the drug war. Afghanistan is the major world producer of heroin from their primary agricultural product of poppies; 4,000 tons of opium in 2000, about 75% of the global crop. Prior to the war, the US government provided $43 million to the Afghans in drought aid after the Taliban began its severe religious crackdown on poppy farmers. To care for a family, a farmer needs about $1800 a year-- a level most don't achieve. By selling opium these dirt-poor farmers can attain an income of about $6000 a year. In addition, the ban led some families to sell off their young daughters in early marriage to pay debts. Replacement crops such as wheat don;t even come close in comparison to what the farmers can raise in opium. Now, with the Taliban gone, the farmers can resume their poppy production.

• Gardeners of exotic plants have become enthralled with a  plant from the Caucasus region of central Asia. The Giant Hogweed is an impressive plant, growing up to 15 feet tall on four inch stems with colorful purple splotches, decorative leaves five feet across, and sporting large umbrella-shaped flowers. While this would make an impressive addition to any gardeners collection, the large seeds are also attractive to birds and are spread by them. It is an invasive plant, and even after cutting off the stem and leaves the roots can spread and send up new shoots each year. The problem?-- the sap is highly caustic and can cause skin irritation, blisters and swelling, and if contacted by the eyes can cause temporary or even permanent blindness. In spite of this many ardeners continue to propagate and distribute the plant because of its attractiveness. (http://www.umass.edu/newsoffice/archive/2002/072402weed.html)

• In the interest of conserving on costs, legislative groups have brought pharmaceutical companies under scrutiny for their high prices on medicines. In some cases caps have been placed on medication costs for certain medical conditions. While this cap provides evidence to constituents that legsilators are acting to protect the public from expensive pharmaceuticals for the short term, over the long term some disturbing hidden costs emerge. For example, AIDS medication costs about $11,000 per year to maintain a patient-- a high cost, but only a tenth of the $100,000 in annual hospital bills until they die should they forego proper medication. Likewise prevention of stroke can cost about $1700 per year, vs. the $6000 cost of treatment following stroke. New Hampshire capped medication for schizophrenia at $57, while off-medication patient costs in the emergency room and mental health system then rise to $1500. (Robert Ingram, COO of Glaxo-Smith-Kline, National Press Club, Minnesota Public Radio, 7-23-02)

• Metropolitan highways have been designed to accomodate high levels of traffic and have built in safety mechanisms. For example, when traffic gets too heavy, motorists slow down thereby reducing risk of high speed accidents. While this feature contributes to collision prevention, the slower traffic (called a "breakdown" by traffic engineers) increase pollution levels. When a car covers 10 miles over a 30 minute period, it produces 3.5 times the hydrocarbon emissions of an 11 minute trip in nonrush traffic. Idling engines in slow traffic can produce 300 times as much carbon monoxide as cars running freely-- all being inhaled by the drivers over many minutes in "safer" slow traffic.

• Enthusiasm about childhood vaccinations may be misplaced. Since 1995 chicken pox cases in the US has declined rapidly and there is a risk it can be eradicated from childhood. In that case, there would be no further need to vaccinate children against this usually mild condition. However, the varicella zoster virus that causes chicken pox in children is also the cause of painful and often debilitating shingles in adults. Without exposure to and immunity against chicken pox in childhood, the risk of adult contraction to shingles increases. It has been estimated that the eradication of chicken pox could result in as many as 9 million more cases of shingles over the next 50 years. (Winters, J. (2003). It's good to be around sick kids. Discovery Magazine, 24(1).

 

 

In summary, the problems and crises described above were approached with the best intentions and highly skilled people, but the effect the approach to problem solving had devastating effects. In most cases, problems occur because the "problem" was too narrowly defined and the spin-off consequences and systemic reactions to change were not fully anticipated. In other cases, the system has become so complex that it is very difficult to consider the outcome of various parts interacting to produce unexpected consequences. To minimize these problems, consider the following:

• After you define the initial scope of the immediate problem, define the larger scope: who are other stakeholders, where are new nodes (decision or contingency points), etc.?
• What are the long term series of connections, and what are their likelihood of occuring?
• Are there "butterfly" effects (small events that produce change accelerating, large scale, unintended effects)?
• What are are the problems that will be created by the intended solution? What will the "solution after next" require? Is the treatment worse than the disease--is the solution and its spinoffs worse than the original problem?
• Follow the connections, especially looking for feedback loops to the original problem. Will the intended solution make the original situation worse?
• Who is willing to assume responsibility, not only for the immediate solution, but for the eventual spinoffs generated by the solution? Moreover, is it ethical to make an intervention without considering the negative long-term consequences that may be initiated by short-term good intentions?

Links

• Unanticipated consequences of technology--
• The future fights back--
• Review of Tenner's Why Things Bite Back--
• Tenner's testimony on technology to Congress--
• Tennis & the revenge of technological revolution (Tenner)--
• Complexification--a source of the problem?--
• Revenge of the machine--
• Consider QWERTY--
• Murphy's Laws and Corollaries-- Murphy was an optimist...

References

Arnott, R., & Small, K. (September-October, 1994). The economics of traffic congestion. American Scientist, 82(5), 446-455.

Arumugaswami, T. (April, 1997). Oops: Unintended consequences. Hinduism Today, URL: http://www.hinduismtoday.com/1997/4/#gen361

Barnett, A. (7-25-99). Why library technology bites back. One Librarian's Opinion, URL: http://www.geocities.com/SoHo/Nook/8823/bitesback.html

Death by decree, (2001, Sept.). Consumer Research, 84(9), 10-13.

Dilner, L. (1993). Boxing should be counted out, says BMA Report, British Medical Journal, 306(6892), 1561-1562.

Dorner, D. (1989). The logic of failure. New York: Henry Holt.

Gruenberg, E. M. (Winter, 1977). The failures of success. Milbank Memorial Fund Quarterly: Health and Society, 55(1), 3-24.

Keeney, B. (1983). The aesthetics of change. New York: Guilford

Kleyn, T., & Jozefowicz, J. (December 28-29, 1985). Wasteland created by human hands. Hamburg Evening News.

Legorreta, A. P., et al., (1993). Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. Journal of the American Medical Association, 270(12), 1429-1432.

Little, C. (May-June, 1993). Smokey's revenge, American Forests, 99(5-6), 24-25, 58-60.

Nadler-Nir, R. (February 3, 2001). The e-postman never rings. The Media Toolbox. URL: http://www.mediatoolbox.co.za/new/aspen_viewartaspen.dll?Aid=634&temp=12

Norton, R. (August 19, 1996). Why airbags are killing kids. Fortune.

Nowak, R. (September 2, 2000). Leave well alone: Misguided amateurs are driving frogs to extinction. New Scientist. URL: http://www.newscientist.com/news/news.jsp?id=ns225442

Radetsky, P. (1998, November). Last days of the wonder drugs. Discover, 19(11).

Report: Preventing Death And Injury From Medical Errors Requires Dramatic, System-Wide Changes (12-1-99). Institute of Medicine, http://www.iom.edu

Tenner, E. (1997). Why things bite back: Technology and the revenge of unintended consequences.

Wegner, D. M., & Schneider, D. J., Carter, S.R.III, & White, T.L., Paradoxical Effects of Thought
Suppression, JPSP, 1987, 53, 636-647.