While the Cat's Away, the Mice Come Out to Play: Canadian Listeriosis Outbreak is a Hard Lesson in Leadership Governance

Learning teacheth more in one year than experience in 20, and learning teacheth safely, when experience maketh more miserable than wise…it is costly wisdom that is bought by experience.

--- Roger Ascham (1515-1568) in The Street Master

The listeriosis outbreak traced to one Maple Leaf Foods plant in northern Toronto glaringly shines a light on the ethical and moral dilemmas underlying leadership. With 11 people dead so far and many more ill, the impact of the assumptions and beliefs of leaders within the food security system is tragic and economically costly. Only a full inquiry will unearth where the system went wrong. It’s a hard lesson in system governance and one which we will likely find was entirely preventable.

The movie Beautiful Mind gives us some clues as to the dilemmas inherent in any system and the principled solutions which are possible. Princeton University professor John F. Nash Jr. shared a 1994 Nobel Prize with three others for his research on “games theory” or the science of strategy in conflict situations. In 2005, two more researchers were awarded the Nobel for their games theory work. Clearly, the phenomenon has struck a chord in our increasingly complex society.

In layperson’s terms, Nash and other researchers have demonstrated that outcomes depend on not just your own decisions but also on what others do as in driving through an intersection. The particular scene in the movie illustrating Nash’s “ah ha” is a university bar where men and women are meeting and greeting and clearly influenced by each others’ actions. Taken further, Nash and other mathematicians demonstrated that co-operation in most instances trumps butting heads. It explains why some groups or individuals, organizations and countries succeed in promoting co-operation while others suffer from conflict. It has been used to explain economic conflicts such as price and trade wars, the workings of the stock market and why some communities are more successful (economically) than others in managing common resources. However, it won’t work without trust. That’s’ where things get “dicey”.

A clash of cultures (assumptions, beliefs and values) within the system can wreak havoc with making the right decisions. A public safety system such as food security requires many redundant checks and balances. Who does what when remains the repeatable big question as lessons are learned. There are hints in the press that government loosened the reins a little on the shop floor, giving more control to industry to police itself. Maybe that didn’t happen. If it did it would have stirred the “pot” of leadership assumptions and beliefs. What now is going to govern preventing serious food-related bacterial outbreaks in the general population?

A family story that has animated our history for 77 years provides some direction. I never understood while I was growing up why my mother Margaret would often bring up the subject of her sister Adelaide. To me it was history. To her, it was and still is painful, “what if?” history.

In my adult years, I’ve come to understand the senseless tragedy of Adelaide’s death—being at the wrong place at the wrong time when the system could do little to help her. At the same time, I have a strong appreciation of the advances that have been made to protect other young children from the same fate.

My grandmother on my mother’s side liked to travel and she yearned for her homeland. In early 1931, she embarked, with her two little girls Margaret, 5 years old and Adelaide 8, on a voyage across the Atlantic to Liverpool. Little did she know they were heading straight into a diphtheria epidemic! Within days of landing, both young girls became seriously ill and were hospitalized. Only my mother made the trip back. Why she survived and Adelaide did not remains a mystery.

In those days, although a successful vaccine had been developed, it was not widely available. It took the discovery and development of sulfa drugs following WW 11 to open up protection for the general population. Regular vaccinations for infants, children and boosters for adults are routine in developed countries.

What does this say about governance now? Since we know what prevents senseless deaths, the values and beliefs of a leader then and now no longer drive the ethics of decision-making. Instead, it’s the evidence of what works. Inotherwords, when in doubt wherever you are as a leader in the system, default to the evidence.

A just released World Health Organization (WHO) report on the determinants of health reinforces this principle. The blue-ribbon panel of International experts concluded that “social injustice is killing people on a grand scale.”

The evidence, according to the panel, is clear and irrefutable: societies, like the Nordic countries, are healthier because they spend generously on universal social programs, reduce income equalities, and regulate important health determinants such as food, housing and labour markets. In the spirit of “games theory”, the economies of these countries do not suffer. They thrive as expected. Sweden, for example, continues to do a credible job at balancing and re-balancing the needs of the free market (private enterprise) with the quality of life needs of the population, as a whole. These findings hold for rich and poor countries alike.

In light of the current food security scare in Canada, the WHO report is timely. For those leaders who wrestle with competing interests to make ethical decisions, the WHO findings “lead the way”. You might think that these findings have nothing to do with you in your organization. You might not like the WHO’s findings because of the kind of business you are in. Alternatively, the findings might be “bang on” for you. In reality, there are lessons to be learned no matter what your leadership challenges are and in what part of the system you work.

The WHO report speaks of the lack of political leadership and moral courage as key barriers. In every organization, not just government, these factors are relevant and play a role in influencing important outcomes. The food security problem in Canada, at the moment, is a symbol of the co-operative tensions in any complex system and that serious collateral damage can occur if the cat’s away.