Chris​ Simms: Path dependency—Trump, Brexit, and the future Europe

Chris_simsBarbara Tuchman begins her seminal work The March of Folly by observing that a “phenomenon noticeable through history regardless of place or period is the pursuit by governments of policies contrary to their own interests.” The phenomenon seems relevant to the election of Donald Trump, the Brexit vote, and perhaps to upcoming European national elections that begin in December—all of which are related to the rise of populism, protectionism, and nationalism.

These trends present obvious risks to the finance and delivery of local and global health and, inevitably, health outcomes, and are a concern of healthcare providers. In the United States, for example, Obamacare and reproductive and sexual health are under threat, as well as public health and safety—through a pro-gun policy stance and a rise in racial and ethnic violence. The risks to Britain’s already underfunded NHS, its health workforce, research, and Britain’s global health leadership are already apparent in the wake of Brexit and may threaten other European countries that become fellow travellers down this political path.

One means of gaining insight into the rise of populism is by applying the concept of path dependency, which suggests that at a critical point in time, a set of policies may be adopted by a government (from an array of alternatives) that then persist unchanged over time. This occurs through a series of self-reinforcing mechanisms that shape stakeholder attitudes and values, and which create and bolster structures so that switching paths becomes increasingly too costly.

In the 1970s, with globalization as the driving force, a set of neoliberal policies emerged, which included cuts to government services, privatization, free trade, deregulation, free flow of capital, and explicit refusal to deal with inequalities. These policies grew and strengthened and locked in over time with detrimental effects.

Recent analysis of the rise of populism and “the rage against the machine” felt by many in rich countries says it is the result of two sets of factors—economic and cultural backlash—that began a generation ago.

Firstly, real incomes have stagnated or declined except for the wealthiest 10% (especially the top 1%). This wealthy elite have influenced a set of policies that have made them the beneficiaries of automation, outsourcing, globalization, mobility of capital and labor, the erosion of blue collar labor unions, and neo-liberal austerity policies. Framed within path dependency, these policies have limited the capacity of democratic governments to regulate the private sector.

Secondly is the cultural backlash against self-expression values championed by younger and better educated voters; these values focused on environmental issues, gender and racial equality, LGBT, and a tolerance of different cultures and religions—drawing energy away from redistribution of wealth. Less educated, older citizens (especially white men) resent being told to be politically correct while they are simultaneously becoming marginalized. When immigration concerns emerged over the past three years, this was the tipping point.

Academic journals and medical and public health associations have also recognized the increasingly high levels of inequalities across the world; a prevailing sense of loss, disenfranchisement, and unfairness; and, most importantly, that few public policies have sought to right the injustices. Editorials in this journal, for example, have noted that there is “anger at the collective failure of successive governments to notice, let alone try to tackle the UK’s deepening social divide”; of the immigrant and refugee crisis it noted: “It isn’t a new crisis. Nor was it difficult for politicians to anticipate.”

A way forward: It’s often observed that “voters are rarely wise but are usually sensible”—meaning that they know their needs, but not how to have them addressed. A recent Washington Post headline, for example, reads, “If you voted for Trump because he’s ‘anti-establishment,’ guess what, you’ve been conned.” Similarly, within hours of the Brexit vote Nigel Farage reversed the Leave Campaign’s commitment of £350 million of EU funds being redistributed to the NHS, claiming it was a mistake. Theresa May followed suit by declaring that there would be no extra funds, despite explicit promises by her senior ministers.

Unlike the US, Britain still has the opportunity to reverse paths through a parliamentary vote on Brexit—this time informed by broken promises, its own anxiety, the tragedy of David Cameron’s escalating commitment to a referendum he never wanted, and by Theresa May’s own ambivalence about choices of which she was uncertain. Farage’s jarring boasts “I am the catalyst” and Trump’s jaw dropping populist views recorded on video (evoking the darkest days of 20th century Europe, even as European voters prepare to go to the polls from 4 December) characterize a rapidly changing context that should give cause to pause.

To qualify as folly, says Tuchman, the decision must be made by a group, be perceived as counterproductive in its own time, alternatives must have been available, and its consequences must persist beyond a political lifetime. Only by addressing the last criterion by Parliamentary vote will the sadness and anger of folly be avoided—such a decision might lead to better health for all.

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

Competing interests: None declared.