Think Tank W.I.R.E. (Hg.): Slow Pandemics. Reshaping everyday life in the upcoming age of illness

FUTURE SOCIETY ASSOCIATION

Stephan Sigrist

SLOW PANDEMICS

Reshaping everyday life in the upcoming age of illness

FUTURE SOCIETY ASSOCIATION Think Tank W.I.R.E.

The end of healthcare as we know it

Why everyday life defines health Outlook on the new normalcy of everyday life

Health in the age of illness

Initialise

THE END OF HEALTHCARE AS WE KNOW IT

Despite great advances in modern medicine, our health is under more pressure than ever before. Paradoxically, the reason for this is precisely the progress of the modern lifestyle, which is designed to make our lives easier and promises more and more rewards.

Low-cost food and stimulating luxuries, such as alcohol or tobacco, widespread mobility and ever more convenience are on the one hand the result of progress in civilisation. On the other hand, they are responsible for a growing number of illnesses such as type 2 diabetes, cardiovascular problems and mental illnesses. On closer inspection, the new possibilities of digital life also reveal a dark side in the form of digital dependencies which, in addition to lack of exercise, lead to psychological suffering that can have detrimental effects for the global population, especially for young people. The rise of these slow pandemics is largely defined by the choices we make – individually and collectively. They are threatening the current structures of public health in a dimension far beyond a virus-triggered pandemic. These everyday-based health risks are fundamentally challenging the current healthcare system with its foundation in specialised and self-contained centres. Looking ahead, we need a new focus on everyday life and a change in behaviour instead of traditional medical treatments. In the big picture, they demand a re-evaluation of the underlying concepts of enjoyment, pleasure and, in general, quality of life, in order to develop a "life care system" that addresses the needs and challenges of the 21st century.

As we entered the second decade of the 21st century, fiction merged with reality. Countless books, studies and panels have chosen the enchanting appeal of 2020 as a starting point for visionary utopian or dystopian outlooks. They narrate a future full of technological scenarios, in which autonomous vehicles or intelligent humanoid robots support or replace humans, in which food or organs are artificially produced or where humans make journeys to other planets of our solar system.

The year 2020 did indeed mark the beginning of a new reality. However, rather than being brought about by digital technologies, intelligent materials, or sustainable energy sources, it was a global pandemic, triggered by an insidious virus which catapulted humanity into an unexpected new reality. Despite the scientific evidence and public figures that had pointed at this kind of pandemic threat, the fast spreading and transforming coronavirus caught healthcare systems, companies, and political leaders off guard.

Looking to the future, however, what matters is not so much who was to blame, but rather to identify the mechanisms that led to this situation. Moreover, the measures that truly helped to deal with the virus trade-off between public and individual health, respect the principles of a liberal democracy and ensure economic growth. In this spirit, our obligation is to learn from experience and use them to prepare for future challenges. On the one hand, we need to learn how to prevent future pandemics of infectious diseases, which potentially could be far more dangerous than the coronavirus. On the other hand, other, possibly even more far-reaching threats to our health are already part of our reality. This threat is defined by "slow pandemics", namely those that are not characterised by communicable pathogens such as viruses but by a changing lifestyle and living environment. For decades, these "non-communicable diseases" (NCDs) have been responsible for a large proportion of deaths – without many headlines in newspapers, without public debate on talk shows, and without paralysing entire industries because of the risks. Due to the systemic nature of NCDs, a large number of people are chronically ill without knowing it. In Switzerland, a country with a high-quality healthcare system, currently roughly 2 million people (from a total population of 8.5 million) that have at least a mild form of chronic NCDs. Worldwide, the WHO estimates 41 million deaths every

year attributed to NCDs – 71 percent of all deaths globally, 15 million between the ages of 30 and 69.1

The main reason for this lack of attention and readiness to act –for both communicable and non-communicable diseases – is that no acute danger is felt, only rather abstract forecasts without any relevance to everyday life and without a description of possible consequences for our society and the economy. Before 2020, in the case of a viral pandemic, the warnings from risk experts and even celebrities such as Bill Gates were seen as a purely hypothetical threat, even though there had been several viral outbreaks not too long ago with the SARS epidemic in 2003 and swine flu in 2009. In the case of NCDs, despite the very different nature of viral infections and lifestyle-related diseases, there is one similarity: they are based on a lethargic and almost silent increase in attention. They are overshadowed by the many critical issues and crises that constantly occupy our attention span.

Meanwhile, the consequences of NCDs are becoming ever more obvious, for example, in the form of increasing numbers of children and adolescents suffering from diabetes mellitus or the clear correlation between the consumption of addictive substances such as tobacco or alcohol and reduced life expectancy. Still, one of the key challenges with this type of "pandemic" is that they do not lead to short-term statistical peaks – and do not contribute to high click rates on social media yet, even though the associated health and economic risks exceed the Covid-19 virus many times over. Therefore, a first critical lesson is to start focusing on future risks, even if they are not yet visible in our everyday life.

Towards a new landscape of healthcare

Given the changing conditions of our daily lives, considering the increasing amount of time we spend online, with less physical activity, more psychological pressure (including in the wake of the pandemic), and the prospect of moving into the immersive spaces of the metaverse, to name just a few challenges, there is a clear need to address NCDs before they affect an even larger portion of the world's population. There are already indicators that show progress: on the one hand, the awareness of a healthy lifestyle has increased significantly in recent years, especially in industrialised countries. On the other hand, the possibilities of modern

diagnostics lead to a higher quantification of potential risks – and to an expansion of health risks in our everyday life.

Hardly a day goes by without warnings about the negative health effects of how we live. Health experts raise concerns over everything from processed foods to insufficient sleep. And for good reason. The behavioural and environmental features of modern life have a decisive impact on individual health. Despite the Paleo diets, standing desks and mindfulness retreats, they represent the central determinants of our life expectancy and the status of global public health.

The facts are clear: the choices we make – as individuals and as a society – represent the greatest preventable cause of diseases. As a consequence of stress, high cholesterol and drug abuse, American Millennials are now predicted to die earlier than their parents.2 Almost half of all Chinese adults are obese. 3 And air pollution is responsible for more than 8 million premature deaths worldwide.4

Looking into the near and distant future, critical scenarios are emerging: advanced monitoring tools and access to new data sources further expand the number, types, and interconnection of health risks in lifestyles and environments – including everything from red meat to noise pollution. Additionally, new risks are emerging because of a changing living environment. Digitalisation not only transforms social life but also gives rise to new health risks, as social media platforms, designed like slot machines, can induce dependencies and addiction. Smartphones are linked to sleep deprivation, reduced attention span, and increased stress levels by chronically raising levels of cortisol. Besides mental health, technology can also affect physical health by causing vision problems, hearing loss and neck strain. Not to forget the emerging environmental concerns. Urban air pollution has been dubbed “the new tobacco”, whereas the health risk of microplastics and 5G radiation are clouded in uncertainty and function as a trigger for public unrest and polarisation.

From cure to control

Currently, effective solutions for the rather well-known lifestyle diseases are typically lacking, let alone for the new risk factors. The challenges in dealing with traditional behavioural and environmental health risks exist on several levels: first of all, many of the clinical pictures

resulting from lifestyle-related diseases are complex and characterised by "multimorbidity". NCD patients often suffer from several interacting clinical pictures, which in many cases cannot be treated with individual measures. Another challenge is their slow development, which can take years, thus reducing the incentive for a patient or consumer to change their behaviour. The recent pandemic provides yet another example of how such synergies explain disease development and risk. People who suffer from NCDs have shown to be more vulnerable to severe Covid-19 or mortality. In comparison with people of a healthy weight, those who are overweight have a higher chance of developing severe Covid-19 and a 48 percent higher likelihood of dying. 5 Consequently, a systemic understanding of certain diseases is becoming increasingly important. Furthermore, the basic principle of traditional medicine, which is based on a diagnosis and the application of a specific therapy, falls short. Although high blood pressure or diabetes can be efficiently and successfully combated with the help of drugs, they attack symptoms, not the root causes. As a result, healthcare costs continue to rise and the medicalisation of broad sections of the population increases. Furthermore, patients are affected by long-term side effects of years or decades of drug consumption. The central aim here is to define the "culture" of healing more broadly, beyond a reparative approach. A broken leg can be treated and even a tumour removed with a visit to a doctor or a stay in hospital, but the effective fight against NCDs is a component of everyday life. Consequently, in order to address lifestyle-related diseases such as NCDs, the "treatment" must increasingly focus on a change in behaviour. And so, the circle is completed. The mechanisms and solutions that are applied to limit the spread of viruses are the same as those to tackle non-communicable diseases: behavioural change. Given the difficulties in finding effective, sustainable vaccines, which are not available for several diseases, such as HIV, ebola and hepatitis, this is the key to strengthening our health in the long term.

Looking at this challenge, effective answers are lacking. Addressing behavioural risk factors is characteristically hindered by a public reluctance to restrict individual choices. In the case of digital addictions, in autumn 2021 China decided to restrict the gaming time of under 18 years olds to one hour per day. Although decisions about drastic measures like these (could) have a positive effect, they are not

easy to make. This is partly because decisions about media consumption, for example, are interwoven with notions of enjoyment and quality of life and are thus deeply anchored in culture. Environmental risk factors on the other hand typically ask for large-scale and international reforms that are difficult to coordinate or implement.

Health in the age of disease

Health becomes a component of more and more decisions in everyday life. But how can we live a healthy life in a world where everything can potentially make us ill? How do we define health and who is responsible for it? Moreover, who should bear the rising financial burden that comes along with it? In the United Kingdom, smokers and overweight patients have been denied surgery – such as hip and knee replacement – until they can prove they have made substantial changes to their lifestyle. Should treatment be conditional upon behavioural change? Or should we redefine the quality of life and get rid of the idea of life extension at all costs?

The far-reaching interventions in response to the coronavirus could increase the acceptance of more extensive surveillance in everyday life, thus also creating a new basis – both technically and culturally –to address the risks of slow pandemics. At the same time, there are farreaching issues regarding privacy and the technical and organisational feasibility of building up a functioning real-time database of the health status of the population. In either case, it has also become clear that an overarching internationally aligned strategy is fundamental –notwithstanding a primary and immediate response that focuses on national and regional solutions.

Digital technologies – from consumer healthcare to behavioural analysis or incentive schemes – are providing an important building block for a more differentiated, preventive, and personalised approach to health risks in the 21st century. This makes it especially relevant to focus on the resulting innovations in medicine, consumer goods and public policy; all the more so to establish the appropriate social and technological foundations that will enable us to control health in a way that preserves and strengthens individual dignity and autonomy.

From a broader perspective, the focus is not merely on the means and measures to avert health risks. The underlying question is concerned

with finding an adequate balance between freedom and security; to conceptualise quality of life in a manner that allows health and pleasure to be understood as coexisting, rather than conflicting values. In essence, it is about nothing less than the transformation of the healthcare system from the 20th century into the 21st century and the creation of a sustainable foundation for innovation that starts in people's everyday lives.

This publication aims to contribute to the launch of a long-needed public debate, and initiate an open dialogue among the population, with current and future actors in 21st century healthcare, involving not only hospitals, pharma companies and insurers, but all sectors that impact our everyday life. Furthermore, it serves as a foundation for the development of a future-oriented health care system that is truly a "life care" system.

The first part sketches the issues at stake, now and in the near future. After describing some of the most important health risk factors, the next chapter explores how they will likely change over time and under the influence of societal trends. In the third chapter, scenarios for the near future are developed by extrapolating the consequences of societal trends and sketching out the future landscape of NCDs. The document concludes with recommendations for appropriate responses to the identified changes and challenges ahead that need to be addressed in the next decade. This publication is a project by the Future Society Association (FSA), an initiative launched by the think tank W.I.R.E. to put society at the centre of innovation and strengthen the holistic responsibility of private and public actors as part of long-term and sustainable economic growth. For this reason, we would like to thank the FSA partners for their support in finally addressing slow pandemics as one of the key challenges for society in the 21st century. We further want to thank Josseline Ross for her contribution to the development and realisation of this publication.

Healthy reading! And don’t forget to occasionally stretch your back and drink sufficient water to keep your brain functioning, but don’t cut out all potentially unhealthy rewards. As a long-distance runner with a high life expectancy, you deserve the occasional emotional indulgence.

Understand

WHY EVERYDAY LIFE DEFINES HEALTH

Our health is determined by a complex web of interactions between genetic, behavioural, and environmental factors. Abstracting from the (still very limited) possibilities of making genetic modifications, opportunities to improve health lie primarily in the first two spheres. Behavioural risk factors involve a broad spectrum of determinants including over- and malnutrition, physical (in)activity, cigarettes, psychoactive drugs, addictive gadgets, bad posture, and insufficient sleep. Environmental risk factors include the exposure to toxic chemicals and air, light, or noise pollution. Collectively, these behavioural and environmental risk factors are the dominant causes of the growing prevalence of NCDs, including cardiovascular and respiratory diseases, obesity, cancer, diabetes, mental diseases, musculoskeletal diseases, allergies, neurodegenerative and devolutionary diseases. All in all, diseases that develop over long periods of time, but with documented, detrimental effects on individual and public health.

HOW INDIVIDUAL CHOICES ARE SHAPING OUR HEALTH

A microwave meal or a quinoa salad, taking the stairs or the lift, but also the quality of our sleep and the amount of screen time or time spent outdoors: our choices have a defining influence on our health. Their effects – positive or negative – accumulate over time and typically become visible only in a distant future. With each decision, an imaginary abacus calculates the effects on our health and – ultimately – our longevity.

Enjoying an occasional cigarette or the convenience of on-thego refrigerated food containing high levels of salt, sugar, and saturated fats? Up go the odds of dying from heart disease or cancer. Regularly exercising on the other hand means a hurray for longevity. Health risks as a direct consequence of individual behaviour can be summed up in eleven categories: over- and malnutrition, physical (in)activity, cigarettes, psychoactive drugs, digital devices, virtual addiction, indoor life, vaping, bad posture, insufficient sleep and loneliness.

A word of caution is required: to identify health risks as rooted in individual behaviour is not the same as claiming their responsibility lies exclusively with the individual person. Individual behaviour is embedded in larger cultural, societal and economic structures, hindered by lack of access due to poverty, cultural codes or addiction and a range of other psychological or biologically defined mechanisms.

The first four categories are responsible for most of the health burden from individual risk factors. For example, around one third of all cancers are linked to diet, whereas 80 to 90 percent of all lung cancers are caused by cigarette smoking.1 Next, the health consequences of everyday choices are discussed in greater detail by looking at the individual effects of nutrition, physical activity, smoking, psychoactive drugs, digital devices, virtual media and indoor life.

OVER- AND MALNUTRITION

The combined effects of what we eat represent the greatest opportunity to influence individual health. Unhealthy diets are estimated to be responsible for more deaths than any other health risk globally, including tobacco smoking. The majority of global diet-related diseases and early deaths can be attributed to a combination of just three factors: high intake of sodium, low intake of whole grains and low intake of fruit and vegetables. The other side of the coin is that healthy diets can actively reduce the risk of developing cancer, diabetes, and cardiovascular diseases.

What is considered healthy today is influenced by individual conditions; the appropriate caloric intake depends on factors such as body size, the level of physical activity, and age.

ONE BITE AT A TIME: HEALTH EFFECTS ACCUMULATE OVER TIME

Health effects of nutrition are established by one’s overall food patterns over longer periods of time. Whereas policy measures tend to concentrate on reducing the intake of specific components (sugar or salt), sufficient intake of other components (whole grains, vegetables) is equally important to improve a person's nutritional quality.

THE PRICE OF CONVENIENCE: THE CONSEQUENCES OF PROCESSED FOODS

A demanding everyday life and the need for convenience explain the growth in take-away and readymade types of nutrition such as processed foods. The latter contain little to no whole foods and are produced through industrial means (salting, sugaring, frying, etc.) and the use of preservatives and chemical additives. Processed foods are typically engineered to override dietary self-control and promote over-consumption.

PHYSICAL (IN) ACTIVITY

A lack of physical activity is identified as the fourth leading risk factor for mortality worldwide. According to estimates, more than a third of adults worldwide are physically inactive, accounting for nine percent of premature mortality.2 Physical inactivity is defined as “doing no or very little physical activity at work, at home, for transport or in discretionary time”. 3 Not moving for extended periods of time reduces blood circulation, lowers blood sugar levels, and is associated with increased mortality risks, independent of what physical activity is performed in addition.

In addition to cardiovascular diseases, physical inactivity increases the risk of developing diabetes, obesity, cancer, and depression.

CATCHING THE EYE: THE EFFECTS OF SCREEN TIME ON A SEDENTARY LIFESTYLE

The consumption of digital entertainment – TV series, games –tends to contribute to lower levels of physical activity. At the same time, digital tools are used to promote physical activity; for example, through Augmented Reality (AR)based games or monitoring and incentivising physical activity levels.

IN THE LONG RUN: WHY GOING TO THE GYM WON’T SUFFICE

Contrary to popular belief, daily exercise cannot offset the negative consequences of overall physical inactivity – such as reduced blood circulation – for prolonged periods of time. To do so, we need to be physically active at regular and continuous intervals during the day.

SMOKING AND NEW ALTERNATIVES

More than eight million people globally and 9,500 in Switzerland die each year because of smoking, making cigarettes the second leading behavioural risk factor for early death and disability worldwide.4 Cigarettes are the most important cause of lung cancer and an important cause of heart diseases and chronic respiratory diseases. In addition to directly consuming tobacco, exposure to secondhand or environmental tobacco smoke is associated with increased risk of cancer and heart disease, among other deleterious health effects.

UP IN SMOKE: ADDICTION AND ATTACHMENT INTERTWINE

Besides the pharmacologic foundations of nicotine addiction, smoking tobacco delivers additional reinforcing effects. Over time, nicotine becomes associated with emotional comfort and enjoyment, thereby enhancing the pleasure that is derived from other activities as well.

VAPING PRODUCTS: LESS RISK, SAME ADDICTIVENESS

Recent years have seen the introduction of several new products, most notably heated tobacco products and electronic cigarettes, often referred to as vaping products. A comprehensive picture of the health risks will only be available once long-term epidemiological data has been collected. However, independent and governmental studies suggest the aerosols released by these products contains levels of nicotine comparable to traditional cigarettes, suggesting potentially similar effects in terms of addictiveness but with significantly fewer harmful smoke constituents in comparison to cigarette smoke. Therefore, individual risks for a classical smoker are most likely lower than if they continued to smoke cigarettes.

PSYCHOACTIVE DRUGS

The consumption of chemical substances to bring about temporary changes in perception, mood, consciousness, and behaviour is as old as humanity itself. Two of the most common psychoactive drugs are alcohol and cannabis. Drinking too much alcohol over a long period of time is associated with a higher rate of stroke, heart failure and a shorter life expectancy. Alcohol is also associated with the development of various sorts of cancer and liver disease. The consumption of cannabis over long periods of time is associated with a higher risk of liver disease, cardiovascular diseases, and an increased risk of psychosis.

SMOKE WITHOUT FIRE: THE NORMALISATION OF CANNABIS

The recreational and medical usage of cannabis is met with growing social acceptance, reflected in, among other things, increasing political support for legalised consumption in several countries. In response, investment in the industrial production and application of cannabis is growing.

ALL WORK NO PLAY: DECREASING ALCOHOL CONSUMPTION AMONG YOUNG PEOPLE

The consumption of alcohol among young people in many Western countries is decreasing –leading to labels such as the “sober generation”. However, within socially disadvantaged subgroups, consumption is not decreasing –sometimes even increasing in the prevalence of abusive alcohol usage. When alcohol is broken down in the liver, cells are damaged and fat accumulates. Over time, this can lead to a fatty liver and later to jaundice, cirrhosis and liver cancer. Regular alcohol consumption further increases the iron content in the blood, which can also lead to liver damage.

DIGITAL DEVICES

Excessive usage of digital devices such as smartphones, tablets and computers is associated with several mental and physiological health hazards. The latter include neck and shoulder pain due to sustained postures and hand dysfunction due to excessive repetitive movements.

Problematic smartphone usage is linked to elevated levels of cortisol, in return increasing the risk of high blood pressure, obesity, diabetes and cardiovascular diseases. The associated stress is also linked to impairment of the prefrontal cortex, a brain area critical for decision-making, rational thought and self-control. Finally, problematic smartphone usage is linked to sleep deprivation and decreasing levels of sleep quality, possibly due to disrupted circadian rhythms.

CHICKEN OR EGG: THE CONNECTIONS BETWEEN SCREEN TIME AND MENTAL HEALTH

Research on the mental health effects of “screen time” shows weak evidence for a connection with behavioural problems such as anxiety, hyperactivity and inattention, and poor psychosocial health. However, it remains unclear to what extent the two are connected, as psychological factors such as low self-esteem and levels of extraversion have also been identified as predictors of problematic mobile phone usage.

IN A MANNER OF SPEAKING: DIGITAL DEVICES AND SOCIAL INTERACTION

Communication via digital devices raises concerns over how they influence the way we interact with each other. Some argue that a lack of face-to-face communication can reduce people’s capacity for empathy (much like a muscle which requires training to uphold its strength), and others fear that the continuous presence of smartphones harms the quality of interactions through continuous distraction.

ADDICTIVE APPLICATIONS

Social media and entertainment applications are designed to encourage behavioural reinforcement through feedback loops and social rewards. Consequently, users can show signs of addictive behaviour, such as impulse control problems or withdrawal symptoms. Excessive use is also associated with low self-esteem, low levels of physical activity, sleeping problems and impaired decision-making. The severity of such behavioural issues, and whether they should be diagnostically classified as “addiction”, is up for debate.

Rather than an independent mental disorder, social media or gaming addictions could also be understood as part of other underlying mental health issues such as depression and loneliness.

LUDIC LOOPS: THE ADDICTIVE POWER OF ANTICIPATION

Social media and other digital applications are sometimes compared to gambling slot machines for their use of similar techniques to create psychological dependencies. They keep a user’s attention through stimulating a psychological craving for unpredictable rewards (a match, a like or a news update). The continuous offering of potentially new rewards creates a repeating cycle of uncertainty, anticipation, and reward.

TOGETHER ALONE: SOCIAL MEDIA AND LONELINESS

Ever since the introduction of smartphones and social media, concerns have been raised about their negative effects on social interaction and mental well-being –especially for younger generations. Indeed, studies in the US suggest how face-to-face interaction among adolescents has been declining as digital media usage and feelings of loneliness increased since 2011.5 Moreover, experiments limiting social media usage have been associated with declining feelings of loneliness and depression.

INDOOR LIFE

We spend more time indoors and live in less green residential environments, thereby reducing exposure to natural environments and the intake of vitamin D. Recent studies on the topic showed how more than 10 percent of British children have not been to a natural environment in the past 12 months, whereas 74 percent spend less than one hour outside per day – this is less than what UN guidelines suggests for prisoners.6 Exposure to the natural environment (“green space”) is recognised as an independent contributor to health and healthy behaviour, for example through reduced blood pressure and stress levels and increased levels of physical activity.

BLIND SPOT: THE RISE OF SHORTSIGHTEDNESS

Declining levels of time spent outside are understood as an important contributor to the expected growth of people with short-sightedness or myopia. Estimations expect that by 2050, over half of the world’s population will be myopic.7 Spending time outdoors decreases the risk of developing myopia through several factors, most likely through the exposure to brighter light.

ALLERGIC TO NATURE: THE RISE OF FOOD AND SKIN ALLERGIES

A lack of exposure to natural environments is connected to the increased prevalence of hay fever and a range of food and skin allergies. The rise in allergies in recent decades has been particularly noticeable in the West. Food allergies now affect around 7 percent of children in the UK and 9 percent of those in Australia, for example.8