Imajine scenario response – Gail Carson, Centre for Tropical Medicine & Global Health, University of Oxford

Imajine scenarios response - Gail Carson FB

In this discussion, Dr Gail Carson from the Nuffield Department of Medicine, Centre for Tropical Medicine & Global Health, University of Oxford, offers some thoughts in a personal capacity on what might happen within the IMAJINE scenarios in the year 2048, in terms of infectious diseases and the response from the health sector.

What were your first thoughts on reading the IMAJINE scenario set?

Certain issues leapt out at me: the impact of climate change, the urban vs rural dynamic, plus the impacts of political policymaking on infectious diseases and our response to them.

I was intrigued by the presentation of a contrast between focus on economic prosperity and focus on wellbeing, thinking about how those two are related: to what extent do you need to focus on economic prosperity to delivering wellbeing? To what extent can you focus on wellbeing as part of ultimately securing a lasting economic prosperity?

The axes alone provoked a lot of debate. COVID really shaped the decision to use that axis, which highlights the contrast between focussing on traditional prosperity metrics such as GDP and alternative measures such as those proposed in the WHO’s policy brief, “Valuing Health for All”.

During the pandemic we’ve seen governments make trade-offs between measures that protected citizen health & wellbeing and the impacts of such measures on economic activity.

Can you say more about political policy impacts and COVID-19?

We’ve seen throughout the pandemic that scientists can give whatever advice they want to give, but if politicians choose not to follow that – or if scientists give the wrong advice, and politicians choose to follow that – then you might see outcomes that are not what’s best for the community.

The issue of trust between society and government, but also trust between people, is key. If you look at the Blavatnik School’s COVID policy tracker, they’ve found that interpersonal trust, one citizen to another, is a major factor — which I think is relevant to all four scenarios.

PATCHWORK RAINBOW sees a breakdown in agreement on common social and cultural values between regions, and as a result by 2048 Europe has fragmented. The EU remains as the ‘last talking shop’ of communities who can barely agree on fundamentals. And yet levels of trust within a community or within a single region might be very high.

There will be issues of competition and conflict, or the risk of conflict, between regions in this scenario – and there are huge spatial inequalities. This could be potentially a backwards step in the fight against infectious diseases, with the return of diseases of poverty. You might see, for example, a next-generation tuberculosis, which we’re unlikely to fully eradicate without ending poverty.

Sexual health would also be a major issue. You could imagine a rise in trafficking and an increase in sex work. Would sex workers have the support of local health systems, depending on where they were?

If trust went from being widespread to deeply local and the connections between nations and regions broke apart, or at least relaxed to a looser framework, it might be difficult to summon the will for a coordinated response to diseases which don’t respect jurisdictions.

The institutions which currently coordinate European infectious disease responses would potentially have their authority challenged and might also not receive information early enough to make effective interventions. Outbreaks could also become out of control through porous borders, tension and miscommunication between regions – especially as in Europe, each country shares multiple borders with its neighbours.

Are there any analogous situations in the world today, where infectious diseases must be dealt with in the context of fragmented jurisdictions and groups that don’t communicate well with each other?

Any outbreak control in conflict: Yemen, Sudan and South Sudan, Ebola in DRC. Unfortunately, there are numerous outbreaks that have to be dealt with under such circumstances. I’m even reminded of trouble in northern Nigeria, where terrorist activity had the potential to disrupt or impede outbreak management, or in Uganda, where there were active forces of the Lord’s Resistance Army and health workers had to operate under curfew.

We haven’t seen such outbreaks in Ukraine yet, but it is something we are preparing for, working up vaccine programmes and trying to mitigate against the possibility of diseases thriving in this broken society where people are having to live in difficult conditions.

It’s interesting also to think about people migrating from the north to the south in this scenario. Potentially what diseases might they be taking from the Europe of 2048 to North Africa? Again, I think of sexually transmitted diseases, which may have developed antibiotic resistance. Resistance will be an issue across many kinds of bacterial infections, especially those which are already a concern in 2022. If we haven’t dealt with that or made progress on it between now and 2048, we’ll be in real dire straits over not having enough antibiotics in our armoury. The more impoverished parts of PATCHWORK RAINBOW’s Europe might see people dying of bacterial infections which aren’t fatal in 2022.

It sounds like part of the EU’s role in this scenario – “the last talking shop for a patchwork Europe” – would inevitably involve some health coordination – though that could be difficult if regions held radically different notions of science, health, medicine, or trustworthy knowledge. Given that some parts of the patchwork have “sponsorship” from other parts of the world, new dynamics might arise, including Europe as aid recipient.

Even during the COVID-19 pandemic, there were arguments that “the West”, or “the developed world’ should have been learning from other areas of the planet which had recent experience dealing with significant infectious disease outbreaks.

I can certainly imagine Europe’s epidemiologists and clinicians picking up the phone – or whatever the communications device of 2048 is! – to communicate with people from outside Europe who have seen some of these diseases in the past, including diseases of poverty and diseases which Europe thought it had eradicated.

Retaining knowledge is already difficult for us. Medical textbooks have given way to evidence-based articles. Especially in the context of PATCHWORK RAINBOW’s attitude to information, values, and trust, how will science have developed over the next thirty years?

The science journalist Annalee Newitz has talked about this, the idea that science might be ultimately replaced in the long term by other practices, disciplines, and institutions that fulfil some of the same roles that science currently plays in our societies.

How will data be communicated and analysed? How will knowledge be passed on? It’s a key question for each scenario. When I was at medical school, we were taught about syphilis, but we were also told we’d probably never see it in our lifetime, because it can be treated with penicillin. Move forward seven or eight years, and we saw a syphilis epidemic, and all the four stages of this disease that we had thought we’d never see outside the classroom. We had to remind ourselves: how does this present at each stage? What are the treatment plans? Can we learn from other parts of the world that have already gone through this resurgence?

By 2048, we can’t presume that the knowledge we have today will be retained and be useful then. Nor can we make assumptions about how progress will play out – either for Europe or for the many countries of the African continent which make up PATCHWORK RAINBOW’s “Silicon Savannah”. Had some world leaders spoken to the DRC about how they rolled out the Ebola vaccine programme in the middle of a war, there may have been useful lessons for our COVID response – but now we’ll never know.

There’s an interesting counterfactual to consider… Let’s move on to SILICON SCAFFOLD, where social and economic life has migrated to privately-owned “clouds”, and European regions are privatised hybrid entities; people have allegiance to corporate identities rather than traditional jurisdictions.

If these corporate spaces are heavy with surveillance, the question becomes what is done with that data and how easily it is shared?

It’s easy to imagine that the corporations of this world would have an immense amount of data on their employee-citizens, but having the data alone is not enough, it’s what you do with it. Data for public health might not be shared, or only be shared slowly, once any opportunity to extract advantage has been taken.

The EU in this scenario manages the elements of infrastructure which have to spill across corporate jurisdictions, like the power grid. They keep the lights on and the data flowing. It sounds like health might have to become part of that work, at least when it comes to infectious disease.

Usually, infectious disease is one of the issues which you don’t pay for within a health system, because it has effects on the wider population, and you’re not seen as being at fault for picking up an infection. So, there’s a question of choice there: who is made to pay for the cost of dealing with infectious diseases?

Within such a society, you’d also see people who slipped between the cracks, and jobs which couldn’t be migrated to the cloud. You would still potentially have diseases of poverty, members of society who don’t have access to paid-for healthcare, and there would potentially be blind spots in the health system.

I’m thinking of the way that Singapore’s COVID response was affected by the failure to protect migrant workers. Their living conditions were overlooked. People doing well in SILICON SCAFFOLD could be merrily off in the clouds, not seeing how the have-nots in their society are suffering.

Poverty’s just one of the social determinants of health, probably the most important one, but other determinants might come into play depending on how society was structured in this scenario and others.

IMAJINE scenarios
IMAJINE scenarios

Another respondent, Saskia Van Uffelen, talked about this society as one where there is pretty much complete access to other citizens’ resume, education history, skills and aptitudes – to help ensure the most efficient use of human resources. It sounds like health would be included with that.

Potentially health data and the equivalent of the European Health Insurance Card would be rolled into your digital identity. The exercise of healthcare rights and permissions might be automated.

You might also see a proportion of people in SILICON SCAFFOLD resisting that sharing of their data, either on privacy grounds or again to hide data which might be detrimental to their fortunes within society.

So a healthcare black market, or the possibility of corruption in the management of health data. If I can avoid getting something with stigma put on my health record, then I might try to do that by licit or illicit means.

People would be looking for ways to get their health needs met. That might include leaving for another jurisdiction which didn’t have this highly privatised health system, or some kind of arrangement arising to fill the unmet need.

This highlights one of the most important things across all four scenarios: who are the most vulnerable people in each future? What can we do to avoid that vulnerability arising, or to mitigate against it?

We’ve seen how H1N1 flu hit the Indigenous population in Canada, how the living conditions of Singaporean migrant workers increased the spread of SARS-COV-2 among them, how society is sometimes blind to these vulnerable communities. One of the benefits of this scenario-based approach is anticipating vulnerability and shining light on the places where insufficient attention might be being paid. Who is seen as being of less worth in each scenario? Who is hard to reach, and therefore vulnerable?

That’s not just about poverty; for example, religious communities who are somewhat withdrawn from society might thrive under some circumstances and then be severely disadvantaged in others.

I think of that argument from the disaster studies community that there are no natural disasters, only events which impact on different societies and communities. Depending on how that society or community is set up, and how it copes with the event, that determines if what happens is a disaster.

Give thought to who the vulnerable population would be across these scenarios, and what could be done to ensure that they were cared for, or to head off that vulnerability developing in the first place. Because those vulnerabilities ultimately benefit no-one. However much healthcare improves by 2048, we’re unlikely to escape comorbidities and chronic ill health. They may not be caused by cigarettes or alcohol, but there will be other health challenges arising from how we live.

SILVER CITADEL sees Europe as a single expanded bloc, with a new social model, strict border control, and a strong focus on achieving economic parity between regions, with economic management supported by artificial intelligence. What might that mean for your area of expertise?

Two things come to mind: the first is about “aggressively heading off migration from climate refugees”, as the scenario document says. But what about within Europe? If southern Europe grows warmer and drier, if we begin to see diseases which we didn’t previously see at those latitudes, that will create an internal inequality that has to be addressed.

We already see the encroachment of mosquito species we never saw before in France and Italy, bringing diseases like dengue and Zika. Tick-based illnesses might also spread; the fluctuation you see in the tick population can also be climate-dependent.

Southern Europe itself might see an increase in vector-borne diseases, which might lead to people migrating away from those regions, increasing pressure on more northern cities.

One of the things SILVER CITADEL has already highlighted is the discontent some regions may feel when they perceive themselves to be net donors rather than net recipients in this kind of “levelling up” in pursuit of economic equality. That discontent might be exacerbated by internal migration within Europe, driven by climate change and disease.

It sounds like also there would be political machinations around public health reporting. Maybe those southern regions, already perceived as being more prone to disease, would be shaped in their health response and attitudes by the shifting power dynamics within Europe.

The other question is around the sporadic conflict on Europe’s eastern border in the SILVER CITADEL scenario. Russia has different infectious disease challenges to the EU, issues with tuberculosis and Crimean-Congo haemorrhagic fever, for example. No data will be shared across that border if there is conflict. And, although the conflict is described as highly automated, you already see today how chronic conflict leads to intermittent outbreaks of infectious disease associated with poor hygiene in the field, rodent-based and airborne infections, issues around clean water supply, the cramped close quarters in which soldiers may have to live. So, the conflict itself might give rise to new infectious disease threats. This goes all the way back to 1918, and influenza tearing through the military barracks a century ago.

That data sharing issue is interesting. To what extent is data sharing happening between Europe and its competitors in this scenario?

Data might be delayed or obstructed, certainly. This also applies to the internal issue between European regions which you described above: the person at the front line may be reluctant to report because they know that there can be negative consequences, including to their career, for raising the alarm. As a result, outbreaks can grow beyond a relatively controllable one or two cases before they’re reported. But again, that comes back to issues of trust between healthcare workers and decision makers, as well as trust at a wider level, including institutions and the whole of society.

Finally, we come to GREEN GUARDIAN, where there is a great deal of solidarity in policymaking and a focus on new wellbeing metrics over traditional economic measures.

At first, this sounds quite promising, but as you dig deeper, there are issues to explore. The flipping of the urban-rural balance sounds promising from an infectious disease perspective as the population density will be less and there’s more opportunity for physical or social distancing during outbreaks. But it does depend on where people end up rurally: again tick-borne diseases are prevalent in some parts of rural mainland Europe.

There’s also an issue around food. Given the focus on sustainability, and the use of “bioregioning” to make the food chain more resilient and more local, there will be new risks and vulnerabilities. This also applies in GREEN GUARDIAN’s all-but-abandoned cities, where the disadvantaged are also trying to sustain themselves through backyard farming and will be living much closer to their poultry and livestock. Zoonoses are a key issue here. There’s only so much you can do to stop diseases spreading to poultry via migrant birds, for example, and influenza spreads very easily from pigs to humans.

A “One Health” approach integrating human and animal health would be really important here. It occurs to me that agricultural terrorism might also be a greater issue. If one wanted to gain some form of control or disrupt a system in GREEN GUARDIAN, agriculture would be a significant vulnerability.

Even with improved telehealth in the year 2048, there’s the chance that people in this new rural Europe will be farther from healthcare facilities, so they may take longer to self-present. This will particularly be an issue for time-critical treatments. Are we going to completely do away with heart attacks and strokes by 2048? Even if we’re eating healthily and exercising plenty, our genes are still our genes when it comes to certain things.

So it raises the question for us in 2022, in this scenario just as all the others: what are the mitigations? Vulnerable populations are not just the poor ones; vulnerability includes poverty, but it doesn’t equate to it.

The hit of the pandemic showed up all the weaknesses of the system, and then everyone was at risk of suffering from that, because it kept the pandemic going. Especially in futures where we see an ageing population, they will naturally be at greater risk as their immune systems grow more vulnerable. Looking at these scenarios can identify systemic weaknesses before we have to endure the next hit; doing that work of identification and early intervention would be an honourable thing to do with these scenarios.