{"id":37880,"date":"2016-11-25T17:59:21","date_gmt":"2016-11-25T16:59:21","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=37880"},"modified":"2016-11-25T21:16:20","modified_gmt":"2016-11-25T20:16:20","slug":"chris%e2%80%8b-simms-path-dependency-trump-brexit-and-the-future-europe","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2016\/11\/25\/chris%e2%80%8b-simms-path-dependency-trump-brexit-and-the-future-europe\/","title":{"rendered":"Chris\u200b Simms: Path dependency\u2014Trump, Brexit, and the future Europe"},"content":{"rendered":"

\"Chris_sims\"<\/a>Barbara Tuchman begins her seminal work The March of Folly<\/a><\/em> by observing that a \u201cphenomenon noticeable through history regardless of place or period is the pursuit by governments of policies contrary to their own interests.\u201d The phenomenon seems relevant to the election of Donald\u00a0Trump, the Brexit vote, and perhaps to upcoming European national elections that begin in December\u2014all of which are related to the rise of populism, protectionism, and nationalism.<\/p>\n

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<\/a>,\u00a0for example, Obamacare and reproductive and sexual health are under threat, as well as public health and safety\u2014through a pro-gun policy stance and a rise in racial and ethnic violence. The risks to Britain\u2019s already underfunded NHS, its health workforce<\/a>, research, and Britain\u2019s global health<\/a> leadership are already apparent in the wake of Brexit and may threaten other European countries that become fellow travellers down this political path.<\/p>\n

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<\/a> mechanisms that shape stakeholder attitudes and values, and which create and bolster structures so that switching paths becomes increasingly too costly.<\/p>\n

In the 1970s, with globalization as the driving force, a set of neoliberal policies emerged, which included cuts to\u00a0government 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.<\/p>\n

Recent analysis<\/a> of the rise of populism and \u201cthe rage against the machine\u201d felt by many in rich countries says it is the result of two sets of factors\u2014economic and cultural backlash\u2014that began a generation ago.<\/p>\n

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.<\/p>\n

Secondly<\/a> 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\u2014drawing 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\u00a0emerged over the past three years, this was the tipping point.<\/p>\n

Academic journals and medical and public health associations have also recognized the increasingly high levels of inequalities across the world; a prevailing\u00a0sense of loss, disenfranchisement, and unfairness; and, most importantly, that few public policies have sought to right the injustices. Editorials<\/a>\u00a0in this journal, for example, have noted that there is \u201canger at the collective failure of successive governments to notice, let alone try to tackle the UK\u2019s deepening social divide\u201d; of the immigrant and refugee<\/a> crisis it noted: \u201cIt isn\u2019t a new crisis. Nor was it difficult for politicians to anticipate.\u201d<\/p>\n

A way forward: <\/strong>It\u2019s often observed<\/a> that \u201cvoters are rarely wise but are usually sensible\u201d\u2014meaning that they know their needs, but not how to have them addressed. A recent Washington Post<\/em> headline, for example, reads, \u201cIf you voted for Trump because he\u2019s \u2018anti-establishment,\u2019 guess what, you\u2019ve been conned<\/a>.\u201d Similarly, within hours of the Brexit vote Nigel\u00a0Farage reversed<\/a> the Leave Campaign\u2019s commitment of \u00a3350 million of EU funds being redistributed to\u00a0the NHS, claiming it was a mistake. Theresa May followed suit by declaring that there would be no extra funds<\/a>, despite explicit promises by her senior ministers.<\/p>\n

Unlike the US, Britain still has the opportunity to reverse paths through a parliamentary vote on Brexit\u2014this time informed by broken promises<\/a>, its own anxiety<\/a>, the tragedy<\/a> of David\u00a0Cameron\u2019s escalating commitment<\/a> to a referendum he never wanted, and by Theresa May\u2019s own ambivalence<\/a> about choices of which she was uncertain. Farage\u2019s jarring boasts \u201cI am the catalyst\u201d and Trump\u2019s jaw dropping populist views recorded on video<\/a>\u00a0(evoking the darkest days of 20th<\/sup> 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.<\/p>\n

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<\/a> of folly be avoided\u2014such a decision might lead to better health for all.<\/p>\n

Dr Chris Simms<\/strong>\u00a0teaches at Dalhousie University, School of Health Administration, Halifax, Canada; he spent many years living and working in Africa\u2019s health sector.<\/em><\/p>\n

Competing interests:<\/strong>\u00a0None declared.<\/p>\n","protected":false},"excerpt":{"rendered":"

Barbara Tuchman begins her seminal work The March of Folly by observing that a \u201cphenomenon noticeable through history regardless of place or period is the pursuit by governments of policies […]<\/p>\n

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