We are in the pandemic now, but what happens next? Being a futurist, I am among those who have thought about that for a long time. I think in terms of decades. That means I generally don’t predict specific developments. Instead, I envision — analyzing and projecting trends based on the forces of disruption that are already known and some that are unknown. In the futurist playbook it is called working with scenarios.
In January, I saw was about to unfold: a pandemic of unprecedented proportions in contemporary society. Almost in a vision, that’s how it felt, although it was based on hundreds of readings, I quickly charted five scenarios on my paintable wall: Borderless world, Nation state renewal, Two worlds apart, Hobbesian chaos, and Status Quo. I instantly knew I had an important book to write and threw away all other plans. Not that I had many other attractive options since I after a few weeks of writing, I took my own medicine and put my family into self-imposed quarantine and a month after that, Governor Baker put in place a stay-at-home order making it official.
Four hundred and fifty pages later, I’ve got a very clear picture of where we are heading: towards unprecedented chaos. Again, I’m not predicting, I’m offering foresight based on studying the forces of disruption I have worked on for years: sci-tech, policy and regulation, business models, and social dynamics. The challenge for our times is that on all the issues that were so much discussed over the past four months, I see trouble ahead: vaccines, superspreaders, social distancing, public health, the economy, geopolitics, innovation, you name it. Some people call it the new normal. They are clearly not futurists. This is not going to be normal. Not under any circumstances.
Let me try not to sound alarmist. Many things will stay the same. The world will still be recognizable over the next decade. Maybe. In fact, it all depends. Not on some external force, or a set of government leaders, or which random events happen throughout the decade. Those will, however, throw us some curveballs that we will need to deal with. Others may throw us unexpected lifelines which we will need to hold on to.
Trond Arne Undheim, futurist, author of Pandemic Aftermath (2020)
The government planning fallacy
As a former public servant, I am generally upbeat on behalf of government. I grew up in Norway where many public officials are still the best and the brightest, even judging from the quality of their decision making during COVID-19.
The problem lies elsewhere. The individuals may be smart, but the public health system itself is not smart and it does not evolve at the pace of society’s requirements; not in Norway and not in any country where I have lived, or any country I studied for their response to Pandemic Aftermath. Let me be quite specific because this is not a general criticism of government as such. I went through each of the pandemic scenario exercises that governments have undertaken over the past two decades. Just for the sake of completeness, let me list a few of them:
- United Kingdom: OSI (2006), Exercise Cygnus (2016)
- Japan: ASEF-ASAP (2011-13)
- USA: Dark Winter (2001), Atlantic Storm (2005), Pandemic Influenza Plan (2006), SPARS Pandemic (2017), Clade X (2018), CSIS (2019), Event 201 (2019), Crimson Contagion (2019)
- Germany: MODI-SARS (2012)
- EU Parliament: Economic Impact of Epidemics and Pandemics (2020)
- WHO: Disease X – the R&D blueprint (2018)
- GPMB (2019) – desk report on the global pandemic threat
Generally, each of these 15 exercises left a lot to be desired. They failed to include the relevant stakeholders, failed to get media coverage, and failed to inform the public. However, what this means is that the much-used media phrase “the pandemic was a crisis foretold” is incorrect in several aspects. These were small, isolated and expert based scenario exercises without widespread discussion or the required realism. None of them were followed up appropriately even if some of the conclusions were sound and downright scary.
Notably, the scenarios mostly involved influenza (although the German MODI-SARS exercise was close to 2020’s coronavirus). The flu is still dangerous, but is an entirely different challenge because the parameters and disease characteristics and even our history with it is relatively long. There is also typically a vaccine at this point. None of these scenarios were terribly imaginative, which may sound like literary criticism, but it is more serious than that. If you fail to imagine how people would react, the scenario itself fails. There were a number of other issues with these scenarios. For specifics, please refer to chapter 3: “Foresight Failures by Futurists, Government, Media and Innovation” of Pandemic Aftermath.
The vaccine fallacy
Very briefly, in three out of five scenarios, the vaccine either fails, sees technical problems in its implementation, is much delayed compared to current expectations of 1-2 years, or is hampered by a significant increase of antivaxxer sentiment in the overall population. It’s not a secret that antivaccination sentiment is gaining ground in the population. Not only among the uninformed, or in extremist camps, but among the highly educated as well, even among the elite. A recent online survey of more than 2,000 U.S. adults, conducted by The Harris Poll on behalf of the American Osteopathic Association, revealed that more than 2 in 5 American adults (45 percent) say something has caused them to doubt vaccine safety, according to Infection Control Today (2019). If it is realistic to expect that up to half of the population needs some kind of convincing to take a vaccine from a disease that has threatened their livelihoods, way of life, and killed their parents and friends, and will kill hundreds of thousands of people around the world in less than a year, we have to realize that we are dealing with more than simply a communication challenge.
For some it is a freedom thing, or mistrust in experts, in big pharma, or in government. For others it’s a concern with side effects and health risks. A new concern with the mRNA vaccines (such as Moderna’s and BioNTech/Pfizer’s vaccine candidates among many others) is that they have a risk of permanently changing a person’s DNA. These are vaccine types that have never previously been approved. Yet, Moderna was allowed to skip over the animal testing step before testing it on humans, which is unprecedented in the US. All in all, the antivaxxer arguments are many and easy to mobilize around.
Let me be clear: I’m NOT an antivaxxer. If a coronavirus succeeds, I’d be the first to applaud, and I’m going to be among the first in line to get it, I owe it to my kids and I generally believe in vaccines and in the government’s checks and balances to make them safe and efficient–and that applies to governments around the world. I’m simply seeing that their argument is gaining ground and I worry about it, because I think their arguments, enthusiasm and worry should not be taken lightly.
Misplaced aggression towards big organizations (which is only a partly related matter) is mixed in with legitimate concerns about uncertainty and trade-offs in public health interventions. In fact, the entire field of public health has been caught a bit with the pants down as a field with slower innovation that would have been ideal for a changing and globalizing world. If you think of most major public health intervention strategies: quarantine, vaccines and hygiene, for instance, they each represent legacy science (apart from the mRNA vaccine which, in a way, is the opposite–it is so new that it is quite striking that it’s being fast tracked). But the regulatory regime around public health, as with the system around clinical trials, needs to be looked at. It’s expensive (around a billion dollars per vaccine on average), unnecessarily slow (unless it’s too fast–which is also worrisome), and it only suits particular pharmaceutical business models that are supported by enormous preexisting investments or big venture rounds. In contrast, it should be a field where innovative financing is widely available. We should half the time it takes to issue vaccines from 10 to 5 years on average (that would be an enormous achievement), and in emergencies, we should be able to get them out in one year. But the economic side is only one aspect (see AAMC’s article Here’s why we can’t rush a COVID-19 vaccine).
Public health desperately needs innovation
Social distancing is mentioned in the Bible and dates back to the 5th century BC. As we have seen, it’s now a misnomer (what was meant is physical distancing, but since technology didn’t yet exist at that time, they were one and the same). The analysis of superspreaders hasn’t evolved much since historical autocrats from the Byzantine era and beyond blamed disadvantaged groups for spreading disease. We still have not pinned down the risk factors to individual characteristics so continue to blame specific social groups or indeed we may just not understand the phenomenon at all yet.
Quarantines were invented in Italy in the 14th century to curb coastal cities from the Black Death contagion from arriving ships. They represented an innovation of 10 days from Trentina, the the previous practice. Again, not mindnumbing innovation here either. In the US, governors even had to reinvent a word, stay-at-home order which I believe came from the Californian Governor Newsom, instead of the unfitting shelter-in-place regulations that refer to hurricanes and terrorism incidents. In many countries, most forms of lockdowns were even unconstitutional, and had to be introduced as emergency legislation or weren’t introduced at all, instead depending on voluntary compliance. Not really the way public health should be run, if you ask me.
Vaccines started in England in 1796 with Edward Jenner’s smallpox vaccine and live vaccines improved with Louis Pasteur’s efforts in France in the 1870s. Since then, not much has happened until a united field of biomedicine rather suddenly decided to apply lessons from DNA research to vaccines and regulators suddenly decided to agree to get this done now as opposed to over the next decade. The urgency is understandable, but the risks are also there. We may be lucky and we may not. Let’s see.
Hygiene practices have varied throughout history, although each great civilization have had their own approaches for millennia but were changed forever with John Snow’s intervention to clean a shared water pump handle in a 1854’s London ravaged by cholera (although they didn’t fully understand why until previously mentioned Pasteur discovered germ theory). Semmelweis (1847) introduced the first medically sound approach of disinfecting oneself in hospitals using a good chlorinated lime hand wash. The modern flushing toilet was invented in 1861 although it has not yet spread to every household which is a story of the need to find a business model for public health that can work for the whole world.
Lysol, the disinfectant currently sold by Reckitt Benckiser, of recent fame due to President Trump’s unfortunate suggestion to ingest it for use as internal body cleansing of coronavirus, has a history used as a genital disinfectant since 1920 and as a somewhat inefficient, painful, and dangerous form of birth control from the 1930s until 1960s. All in all, we need new tools in the toolkit.
I’ve also taken another point into account: the discrepancy between people’s expectations and the realities. Given the fact that the speed of innovation is much higher now, we also expect innovations to literally change the course of the current pandemic. In some cases, that expectation is overblown. Vaccines take years, and the 12–18 months that have been indicated by presidents, prime ministers, and even by some public health officials is dangerously optimistic given the 10+-years average for introducing a new vaccine. In fact, a relatively recent scientific review found that each vaccine has a 6% chance of success and on average takes 10.7 years to develop (Pronker et al., 2013).
In addition, sometimes vaccines never succeed. The HIV virus was identified in 1984, but four decades and 32 million deaths later, there is no HIV vaccine. Also, who gets the vaccine(s) if they arrive? How will they be distributed? Will they be as effective as we hope? The point is this: under no circumstance can we assume that vaccines will work. In fact, the more prudent approach would be to plan as if it is NOT going to work very well.
Note that if vaccines do not pan out, it won’t just be because of a sci-tech failure. In fact, it may just as likely be a policy or regulation issue, delay or premature approval, or lack of a credible distribution strategy. It could also be that the business model around the vaccine(s) fail. Or, it could be social dynamics, since it is not enough to buy enough doses, you have to administer them strategically, well timed, in the right places, at the right price—and—you need to convince people to take them.
For a few decades now, innovation in public health has meant discussing inserting technology and private sector partnerships into the mix. These are nice ingredients, but the real game changing approaches have yet to appear. We need to think deeper. We need systems change. We need to create better incentives for good solutions to emerge. Basically, we need the public to mobilize and help make it a priority. Then, we need to take the time to implement all good ideas and we need some patience. Public health might be one of the most complicated domains to change. It involves each of the forces of disruption I’ve outlined above. It cost massive amounts of money. It is heavily entrenched with industrial players profiting from the existing system. In short, it is a Sisyphean task.
The public health misinformation fallacy
The paperback edition of Pandemic Aftermath (for instance, see Amazon.com’s version here) was published two days ago after a minor delay where it was censored by two of the world’s biggest book distributors. I am not going to name names. I bring this up because this kind of censorship shocked me to the bone. A banned book created by a writer on American soil in 2020 is almost inconceivable. Only coronavirus and three years of relentless fake news rhetoric from a President could have created it. I was slightly dumbfounded. Until I found out why. The whole world of media is being blamed for misinformation. There is obviously a big debate on where the responsibility lies for speech published on social media and in other publications. There has also been an uptake in electronic (and paperback) publishing by authors previously not getting through the traditional publisher’s filters. I happen to know a bit about quality control in publishing since I wrote my MA thesis about it a while back. Before technology, it was mostly based on a gut feeling. Now, it is outsourced to machines and to staff with little historical awareness of their role in the defense of free speech and in upholding public debate.
Anyhow, the distributors must have made some sort of calculation that the indie publishers would not have enough political power to a sizable uproar. So, the censorship appeared to only apply to indie publishers, not to traditional publishers. I’m not sure if they realized there also was a grey zone until I confronted them. In my case, I publish with traditional and indie publishers depending on what the case may be. What I do worry about is that whilst my book got through, I’m sure the principles of (A) “our industry’s need for content integrity” and (B) “we are referring customers to official sources for health information about the virus” lives on, not sure for how long. I cannot believe it will survive beyond this spring, anything beyond that would be extremely surprising. I can understand it as some sort of last resort emergency knee-jerk reaction to information overload and lack of editorial capacity. As a policy of any publisher or distributor it is not consistent with operating in a free, democratic society.
The irony here is that there has never in history been so much misinformation from credentialed public health officials as well as public health personnel, including doctors and infectious disease specialists, as in the first 100 days of the coronavirus pandemic. In January, I counted dozens of press clips with statements from experts indicating the news from China were little to worry about. Some of them were explicit about how their opinion was formed based on some kind of expertise on this disease. Most of them were speaking based on their expertise on treating influenza. Very few of them, to my knowledge, had done research on coronavirus specifically. For the sake of those who made these highly optimistic claims, I’ll refrain from quoting them here. The point is this, the media often picks “experts” based on availability and a superficial glance at affiliations. In the first 100 days, it seemed like being a physician and having a hostpital affiliation was the only salient background to comment on the emerging pandemic. What a shame! In the case of public health, understanding spread of a disease is equally about understanding network effects, demographics, business, culture and social science. You should ask an infectious disease doctor about how to treat an individual patient or how to avoid infection, not about whether a disease will spread across the world and how fast. That’s an entirely different question.
Despite having grown up in Norway, a relatively innocent fairy tale land up North, I am quite familiar with censorship. My first book, Leadership From Below (2008), was self-published via Lulu Press on the one day I didn’t have an employer. I was working for the EU in Belgium at the time. My boss at the European Commission had made it abundantly clear that if I published a book, I would be terminated (or something of that sort). My new boss at Oracle corporation had not been that direct, but I understood enough about the culture at that company to know that seeking approval to publish would not be easy for a first-year employee.
The ebook is now trailing at #15 on the Amazon Kindle Bestseller charts for Epidemiology and the paperback at #32 on the Amazon Bestseller charts in the category of Public Health Administration . What to make of the demand? I am not quite sure. But I know this. If less than millions of people read my scenarios, and voice their opinion as to which of them they want to avoid the most, we are headed for big trouble, unless scenario planning for pandemics suddenly miraculously appears elsewhere. Historically, nobody has done the job well. We need a groundswell of awareness about what is about to happen, which is the disintegration of the world order as we have been used to for the last fifty years. To some, that’s a good thing. To others, it is a catastrophe.
Do I think there is such a thing as public health misinformation or disinformation. Sure. There might be. But even that information deserves to be out there. We should just be better about pointing out strengths and weaknesses in various publishing models, brands, and media operating procedures. There is no perfect medium. There is no perfect newspaper, publisher, author or journalist. We are all just fallible humans. But we cannot close off the public sphere to a particular subset of editorially endorsed voices. That does not mean we cannot curate cleverly. More that that but I’m deeply passionate about that quest. In fact, I’ve dedicated the good part of the past three years to thinking about this near intractable problem.
If my review of the 15+ government pandemic exercises briefly reviewed above have taught me anything, it is that the discussion about the future of humanity is not one for policy makers alone. Citizens need to get involved. We need to hear more than the polarized sides of the story. This is a time for a renewed commitment to the important nuances of civilized public debate. As a human being, I’m concerned about our kids’ brave new world. Because it will be brave—or the future world will not exist as we know it. But bravery always has a cost. It is time we discuss what that cost is and whether we are willing to pay. The moral toll will be the highest and likely far higher than the economical toll. The experts have, in some ways, said enough. It is time to open up for more voices to make their way to this discussion. How to do that? We could start by letting people publish their opinions.
Five scenarios for the next decade (2020-2030)
All of this brings me to the specifics of the five scenarios, and I’ll reveal enough to give a sense of what I’m getting at.
In Borderless world, an expert-led world federal state where leaders are able to fully implement globalization and strategies to fix health systems. Yet, the cost is a synthetic world, where nature and the elderly, are both abandoned.
In Nation state renewal, with enormous virus death tolls, borders close down and people stop traveling huge distances. This is the decade of intermittency, cycles of opening up society are followed by cycles of closing down, repeatedly and physical distancing is needed throughout the decade. China, Scandinavia, Singapore, Qatar and Germany thrive, whilst formerly “great” nations like US, UK, Russia, Brazil, and India struggle.
In Two worlds apart, with a failed vaccine the top 0.1% of population separates from the 99.9% in entire new walled-off financial districts plus a set of islands purposefully constructed to avoid contagion, filled with the world’s most expensive real estate, governed by their own laws.
In Hobbesian chaos, all vaccines fail, no protective state lasts beyond a year, rule of law ceases to exist, and terrorist groups (Boko Haram, the Mafia, al Qaeda), clans and ideological movements sweep through the earth with constant struggle and fight for scarce resources as a result.
In Status Quo, the vaccine works, the world is still a tri-polar order (US, China, Russia rule in each hemisphere) and after a period of readjustment, society and the world economy, on most dimensions, will not be significantly altered by this pandemic experience, although remote work is now a real thing.
Conclusion
To summarize, three fallacies underpin the changes set to now occur in the next decade. They relate to (1) legacy government planning (and infrastructure), (2) dynamics around the possible vaccine and to (3) misguided efforts to quell public health misinformation which results in censorship, which have each accelerated during conditions of intense globalization. Not to brag too much, but I said as much six years ago, in my 2014 Fortune article on Ebola: The dark side of globalization. Additionally, the forces of disruption we are experiencing, notably, sci-tech, policy and regulation, business models, and social dynamics, as well as the environmental context that connects us in both fortunate and unfortunate ways to the natural world and sometimes to zoonotic pandemics.
To make sense of these five scenarios, you are going to have to read the book. I recommend it, in fact I will insist on it. There is no time to lose. Our children’s world depends on it, perhaps even ours, as history’s span has suddenly potentially contracted dramatically—in only 100 days.