ECDC Foresight Programme

‘Drivers of change’ are issues, topics, trends and other developments that effect change, for example on disease epidemiology, burden or response. The drivers of change most relevant to ECDC’s mission and operations were identified together with a large diversity of experts and combining several foresight methods, using the global megatrends of the European Commission’s Joint Research Centre (JRC) as a starting point. Drivers of change with the highest uncertainties and highest likely impact on future disease prevention and control in the EU/EEA were identified as:

• Inequalities in access to healthcare
• International migration and travel
• Climate change
• New distribution of wealth and influence
• New modes of learning and communication
• Impacts of ageing populations
• Data collection, security, analysis and A.I.
• Urbanisation globally and in the EU
• Pressure on natural resources and ecologies
• Antimicrobial resistance

Several alternative development trajectories that are possible towards 2040 were defined for each of the key drivers of change. These possible future trajectories can already be used to assess the likely implications and challenges for disease prevention and control. However, systemic complexity is fundamental to the shaping of future outcomes, and drivers of change do not affect change in isolation. A mapping of driver trajectory interactions shows a very high level of interconnectivity, where the future trajectory of a driver is in part determined by developments in other areas. This highlights the complexity of the operational environment of public health institutions dealing with infectious diseases.

The future conditions in which ECDC and its partners are required to operate are highly uncertain and complex. To be able to navigate these uncertainties more holistically, a suite of six future threat scenarios was developed that covers the full range of driver trajectories. A ‘scenario’ is an image of a possible future to be used as an instrument to explore critical uncertainties; they are not written or intended as predictions. The context of each scenario is provided by a coherent, interrelated network of future development trajectories, encompassing all key drivers of change. Context-dependent implications on the threat landscape of infectious diseases, the operational conditions for public health institutions, and relevant governing systems were integrated into the scenarios. Assessments of potential technological and scientific development were also taken into account, where relevant. The resulting six scenario narratives broaden the scope of possible futures under consideration to help the European public health system bolster its resilience and preparedness for future threats:

1. A United EU in a Polycrisis World 

“In a world defined by systemic, socioeconomic and environmental crises, the EU draws closer together to forge forward in a disorganised world.”

Main characteristics: EU autonomy and solidarity in the face of multiple crises; lack of global governance with blocs having disjointed strategies and uncoordinated actions.

Potential challenges for infectious disease prevention and control in scenario I:

• Changing human-animal interfaces and interactions because of climate change effects
• Increased vulnerability in populations in post-disaster conditions
• Higher incidence of food-borne diseases due to production and supply chain issues
• Increased risk of water-borne diseases due to floods/droughts and water system disruptions
• More use of antimicrobials to combat diseases and increase food-yield
• High pressure on and shortages in healthcare personnel
• Unintended effects of geoengineering
• Late detection of (illegally) imported contaminated food, disease vectors, migratory animal disease reservoirs, etc. from outside the EU
• Lack of data availability of cross-border health threats
• Disrupted global supply chains impacts development, production and supply of medicines
• Complexity due to the diversity in crisis conditions requires more tailoring (e.g., communication)

2. Building Back Nature

“A global movement to align human activities with planetary health is underway, but there are emergent challenges, and the EU is more follower than leader.”

Main characteristics: complex socio-ecological transformation towards sustainability and sufficiency; global decision-making power outside the EU.

Potential challenges for infectious disease prevention and control in scenario II:

• Increased human-animal contact with livestock, peri-domesticated animals and wildlife
• Novel pathogen emergence and disease reservoirs (due to e.g., rewilding, wildlife reintroduction)
• Possible spread of infectious disease vectors due to city greening and rewilding
• Possible increased risk for food- and waterborne diseases 
• Nature-based focus could lead to ‘synthetic’ vaccine and medicine hesitancy
• Consequences of changes in economic model for EU/local public health financing
• Anti-globalisation could lead to medicine, vaccine and antibody production and supply issues

3. Divide and Prejudice

“As societies continue to polarise and fragment, trust and accountability evaporate. Can public health operate if the public is so shattered?”

Main characteristics: increasing authoritarian and nationalistic tendencies; lack of international cooperation and solidarity.

Potential challenges for infectious disease prevention and control in scenario III:

• Polarisation and mistrust impeding health information, risk communication and healthcare access
• Weakening EU institutions facing more complex coordination challenges
• Poor quality and limited availability of health data
• Staff shortages across all levels of healthcare systems
• Inequality and poverty deteriorate health in population
• Increasing health risks and vulnerabilities due to unabated climate change 
• Increased risk for food safety and AMR issues

4. Public Health in Private Hands

“The private sector is dominating decisions, services and data, with a mainly privatised healthcare sector and market forces in control, but on whose behalf do they optimise?”

Main characteristics: private actors and market forces are increasingly directing policies and controlling data and information; high inequality.

Potential challenges for infectious disease prevention and control in scenario IV:

• Risk of losing access to key data for surveillance and monitoring
• Expansion of the digital divide, also between the private sector and public institutions
• Widening inequalities create more vulnerabilities in (sub)populations
• Unequal and profit-based access to healthcare impacts diagnosis, treatment, and prevention activities
• Increased contact and mobility for commerce and trade increases transmission rates
• Encroachment increases pathogen (re)emergence and spill-over
• Market failures impact R&D for e.g., paediatric medicine, rare diseases, antibiotics
• Human resources shortages in less profitable healthcare sectors
• Late or undetected threats due to free cross-border movement of goods and people
• Unethical use of Artificial Intelligence tools

5. Urban Dominion and Digital Society

“People find refuge in the engineered safety and security of cities, where a global youth-driven and high-tech culture thrives, but not all can keep up.”

Main characteristics: technological advanced, highly digitalised and urbanised societies; power lies with cities and younger parts of populations.

Challenges for infectious disease prevention and control in scenario V:

• Higher transmission rates due to higher density and mobility of people
• Antimicrobial resistance due to high pressure on urban healthcare centres and food-production
• Urban sprawling and greening increases human-animal contact (vectors, pests, zoonoses)
• Access to healthcare issues due to hospital-associated and acquired infections and AMR
• Higher population vulnerabilities due to lower physical activity
• Tech-solutions like telemedicine, e-health, remote work, etc. are not accessible to all
• Possible increasing interactions between wild and (peri-)domesticated animals
• Unintended consequences of gene editing (e.g., of gene-drive, gene therapy, species hybrids)

6. A Patchwork Society

“Exhausted and intimidated by creeping governance, many try to break free and create their own isolated utopias, but can so many diverse self-organised communities thrive?”

Main characteristics: many self-organised communities with high diversity; societal trust in central national and international authorities is low.

Challenges for infectious disease prevention and control in scenario VI:

• Access to healthcare is highly differentiated, affecting disease risks and vulnerabilities
• Fragmented/absent disease surveillance and monitoring activities across and within sub-communities
• Difficulties in prevention and treatment of diseases with disjointed approaches and isolated groups
• High diversity in values and beliefs impede collaboration, consensus, trust and governance
• Low accountability and coordination during outbreaks or other serious events

_{Disclaimer: Both external experts and ECDC staff contributed to this process, providing their individual expert views, rather than those of their respective country, organisation, or other affiliated entity. The threat scenarios are meant as a tool to explore a wide range of relevant changes: they are not meant as predictions and do not reflect preferred directions or an official position of ECDC otherwise. The statements and views expressed in the scenarios and analyses do not necessarily reflect those of ECDC.}

The threat scenarios are a tool to inform anticipatory actions and strategic considerations to ensure better preparedness and resilience of public health systems. For each scenario, the challenges for infectious disease prevention and control were assessed. Moreover, various expert groups defined what future attributes ECDC should have to still be effective in achieving its mission under the conditions of each scenario, covering among others: activities, resources, structures, partnerships, impact, and workforce. ‘Backcasting’ from these future attributes to the present revealed a web of steps to take to attain the future attributes, as well as their barriers and enablers. Robust strategic actions were identified that could be undertaken to contribute to these steps, address an obstacle, or enable an opportunity, across the wide range of possible future conditions elaborated in the six scenarios for 2040. To further assure the robustness of actions, processes and policies in a dynamic operating environment, these are reviewed against different scenario conditions in ‘wind-tunnelling’ exercises. The main focus areas that have been identified in this foresight process for future-ready strategic actions are:

1. One Health and climate change
2. Health services and risk mitigation
3. Demographics and social determinants of health
4. Data, digitalisation, and new technologies
5. Governance and collaborations

A report describing this part of the ECDC Foresight Programme in detail is expected by the end of 2024, which will include the full descriptions of the threat scenarios and action areas.

_{Disclaimer: Both external experts and ECDC staff contributed to this process, providing their individual expert views, rather than those of their respective country, organisation, or other affiliated entity. The threat scenarios are meant as a tool to explore a wide range of relevant changes: they are not meant as predictions and do not reflect preferred directions or an official position of ECDC otherwise. The statements and views expressed in the scenarios and analyses do not necessarily reflect those of ECDC.}