Reformers have been active for a long time now, and have achieved many successes. Yet the number of reforms needed remains as great as ever, and may even be increasing. This suggests some built-in source for our continuing difficulties, and here we ask whether they may not arise, at least in part, from the solution of previous problems. (The Germans have a word Schlimmbesserung – worsening by improvement.)
Lucretius remarked that savages die of starvation, the civilized of indigestion, and the suggestion that each solution may be two-sided in its effects, raising new problems as it disposes of an old one, gains weight when we encounter titles like The Disaster of Aid, The Crime of Punishment, The Sickness of Medicine. A piece in IC63, ‘The Progress of Conservation,’ brought forward some of the problems arising from successful establishment of conservationist organisations; here we give other examples, on an even larger scale, and go on to look at the principle.
The invention of the modern nation state came as a solution to the problem of the oppressive, warring empires. From the French Revolution on through the 19th Century and beyond, the self-determination of peoples (later rephrased as national self-determination) served as one of the great causes rallying progressives. This looked like the way to peace and freedom, but it has not produced the expected results. Since the 1960s, with the empires virtually gone, the nation-states have been showing with increasing clarity and vigour just what they are capable of; in 1993 twenty-nine wars were being fought, most of them between nation-states or groups aspiring to that status.
Medicine has long had its own term for the problems it causes directly, ‘iatrogenic’ illnesses being those due to medical treatment. Down through the centuries these have remained relatively unimportant, but with the growing effectiveness of drugs their unwanted effects have also grown, until the risk of ‘side-effects’ worries every sufferer offered a course of treatment. Until about 1900 medicine could offer little help to most patients; they probably did better for themselves by staying away from doctors and hospitals. In the course of this century the profession has, deservedly, attained the status of a major institution. It now affects most of us from birth till death, enabling many to survive conditions formerly fatal, and this obliges us to face a new range of q questions.
With medicine able to extend life beyond its former span, although often at great cost, we have to face a problem never known before: What proportion of social resources should be devoted to this purpose? Is any version of ‘triage’ to be applied, any selection of patients to be treated while others are left to suffer and die? This comes with a range of smaller ones: How far should doctors dominate the patients? Must a surgical operation have the patient’s permission if it is not to rank as an assault and, if so, can a medically unqualified patient give valid consent? On a deeper level lie all the difficulties of the very concept of disease. Should the doctors retain their power to define health and sickness, including mental health and sickness, with all the consequences these carry? Do health and sickness exist so to speak independently, or are they social constructs, intimately linked with concepts of class, race, gender, scapegoating, deviance and control? Overriding even this impenetrable tangle loom the problems presented by the greatest of the triumphs that medicine and public health have achieved; although it may be practicable to support a population many times larger than the present one, to do so will result in conditions many may find intolerable. Should we accept them? Medicine has also presented us with a solution to the problems of increasing population, and in doing so has raised all the social, political, moral and religious problems that come with cheap, effective contraception. To steal a phrase from Roy Porter: ‘Medicine’s finest hour becomes the dawn of its dilemmas.’ 
Success in defending ourselves from the natural world leads to problems of damage to the ecology: ‘In our dealings with the natural world our species should be less controlling and more scientific and insightful.’  People huddled in a brushwood shelter, with the lion-roar coming closer, do not have to worry about the damage their control of the ecology may be causing.
In 1901 less than 5% reached the second age of dependence (call it 65). In 1994 the figure is 16%, and for 2050 the prediction gives 25% of the population too old to support themselves.  How big a burden are the younger people prepared to carry?
Without the motorcar and its ability to conquer distance, we would not have the same number of traffic accidents, the cost of roads, or the noise and pollution caused by diesel and petrol engines. Without police, and the greater security they bring, no bent coppers. Without sophisticated chemistry, overcoming many limitations of natural materials, no crack, cocaine or heroin. Overriding and embracing all of these stands our greatest triumph and the source of our greatest difficulties. Civilisation solves many of the problems encountered by the human being in direct contact with raw nature, but at the cost of raising all the problems we have glanced at and many more besides.
Solutions entail changes, and since social affairs form an integrated system, any change in one affects others in unpredictable ways. Almost inevitably, some of these effects go against the wishes of the people affected, raising new problems. The solution of these in turn produces other undesired effects, and so on indefinitely.
We can hardly ignore problems, if only because the human being is a problem-solving animal. But we shall encounter less disappointment if we stop expecting solutions to provide final satisfaction. While at it, we might also accept that additional problems are not always the worst possible outcome. Since the introduction of airbags in cars, increasing numbers of crash victims have had to face the problems of living with severe injuries; formerly, they would have died in the crash, and the dead have no problems at all.
 TLS January 14.
 E. M. Thomas, NYR March 24.
 Sunday Times 17 April.
from Ideological Commentary 64, June 1994.