The corona crisis and the need for public health foresight studies

One thing that the Coronavirus outbreak has shown is that we hardly had a clue what a global pandemic would be like and how it could affect daily life. Its speed of spreading, the direct and indirect impacts it has on our health and quality of life, and even its domination of the media given opportunity to a legion of all kinds of experts, could hardly been foreseen. Having only 50% of the knowledge, but having to take 100% of the decisions is a quote from the Dutch Prime Minister that reflects the uncertain situation that we are currently in. Dealing with uncertainty is one of key elements of foresight methodology, also known as scenario studies or future outlooks, terms that can be considered as mutually exchangeable. This methodology addresses uncertainty which is unmistakably attached to future trends.

For centuries people have been engaged in thinking about the future. Especially in the period after the Second World War, these explorations of the future became more systematic with some notable examples by Kahn and the Shell scenarios (see ref.¹). Where in the field of (global) environmental change and economy scenario studies have built up a long history, applications within the field of public health have been limited. Only few countries have done a public health foresight study (PHFS), with the Netherlands as one of the frontrunners with 25 years of their Dutch PHFS.² International studies have been even more limited, though some environmental scenario studies include health impacts. The EUPHA is one of the few international Public Health organizations to address foresight in its strategy and is initiating a Public Foresight Section.³ Explanations for the limited number of public health foresight studies are difficult to substantiate but might have to do with the multi-causal nature, the important role of human behaviour in health outcomes and limited knowledge of underlying mechanisms. However, a scenario approach could suitable to address these uncertainties.

Uncertainty comes in many forms. Where trends in the near future might be forecasted with a relatively low level of uncertainty, looking into the further future introduces more uncertainty. Future developments are subject to limited knowledge regarding the underlying trends driving these developments. For example, economic growth, climate change, the population ageing and technological progress are important factors for health, but they all bring along various degrees of uncertainty. These uncertainties are referred to as cognitive uncertainties and are often used to explore a possible range of how the future might enfold in scenario studies by selecting the ones that are likely to occur and may have important impacts. One particular uncertainty should be mentioned here, namely those uncertainties with a very low likeliness and a disproportionally big impact, the black swans.⁴ Given their unlikeliness, they are not often included in future studies. And now we are facing one of the black swans, the corona pandemic.

In addition to cognitive uncertainties, normative uncertainties can be distinguished which capture the different perspectives that exist about deviating desirable futures. Also in the field of public health, these normative uncertainties play a role.⁵ Setting priorities in public health policies highly depends on what people value more. Will it be controlling the growth of health expenditures, tackling health inequalities, aiming at the highest quality care? Also this dimension of uncertainty plays an a relevant, sometimes not too visible, role in the corona crisis, especially now that the first stage of controlling the crisis is hopefully behind us and we have to think of what normal life looks like. What is considered to be normal, and who will have to pay and who will benefit is highly value loaded.

‘Could we have been better prepared’ will be one of the important questions in the aftermath of this crisis. No scenario study aims at predicting the future; they normally aim at exploring possible futures and to raise awareness and improve preparedness for these possible futures. It is often that foresight studies described a future that might never come true, simply because they are meant to stimulate policy makers to developed policies bend unfavourable trends. What Antoine de Saint-Exupéry said: ‘As for the future, your task is not to foresee it but to enable it’, is particularly applicable to policy makers. Public health policy makers try to influence future trends to attain a more desirable future than it would have been without these policies. Public health foresight studies will help to explore possible futures and stimulate thinking about what a desirable future might look like, accounting for diversity of thinking in what desirable is. Black swans are a valuable element of foresight studies to think about the unthinkable, and to build robustness against possible negative events while maintaining positive impacts. Maybe we are then better prepared for future outbreaks.

Conflicts of interest: None declared.