The Ouroboros Effect:
The Revenge Effects of
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
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
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
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
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
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
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
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,
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
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
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
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
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?
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of traffic congestion. American Scientist, 82(5), 446-455.
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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
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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,
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.
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T.L., Paradoxical Effects of Thought
Suppression, JPSP, 1987, 53, 636-647.
last updated 1-1-02
David X. Swenson Ph.D.