The Near Horizon Quandary: Real-World Evidence, Legitimacy, and the End of Deferred Truth

The Near Horizon Quandary:
Real-World Evidence, Legitimacy, and the End of Deferred Truth in Healthcare

There is a moment before change becomes undeniable.

Not the moment when collapse occurs,
but the quieter one just before it,
when familiar structures still stand,
voices still reassure,
and the language of continuity remains intact,
even as its foundations have already shifted.

This book is written in that moment.
The Near Horizon Quandary does not predict the future.

It describes the present, seen clearly, without the comfort of delay.
It is written for readers who sense that something essential in healthcare, evidence, funding, and legitimacy has already changed, even if the system has not yet found the words to admit it.
For decades, medicine, markets, and public health were governed by distance.
Distance between intervention and outcome.

Distance between payment and proof.

Distance between approval and consequence.
In that distance, stories flourished.

Models substituted for memory.

Persuasion compensated for uncertainty.

Prevention thrived not because it failed, but because it could not yet be fully seen.
That distance is collapsing.
Real-world evidence has turned time itself into a witness.

Artificial intelligence (AI) has not invented truth. Nor has it or will it be something that reinvents it. It is a tool that has revealed it.

Outcomes now persist in daylight, accumulate year by year, and refuse to fade when narratives do.
The near horizon is not a metaphor.

It is the point at which visibility becomes irreversible.
This book is written in verse-like movements rather than arguments, not to obscure meaning, but to slow the reader just enough to feel the weight of what is unfolding.
Each chapter examines a structure that once made sense, prevention, HTA, funding, commercial influence, leadership and asks a single, uncomfortable question:
What happens to this structure once reality can no longer be postponed?
The answers are not offered as polemic or accusation.

They emerge as arithmetic, as observation, as inevitability.
Nothing here is angry.

Nothing here is sensational.
That is what makes it unsettling.
You will not be asked to agree with every conclusion.

But you will be asked to look.
To sit with the idea that legitimacy may no longer be granted in moments, but accumulated over time.

That authority may no longer belong to institutions alone, but to outcomes that persist.

That funding, pricing, and power may be reorganising themselves silently, without permission or announcement.
You may feel resistance.

That is expected.
This book is designed to be uncomfortable, not because it seeks to provoke,
but because comfort is no longer an accurate guide.
By the time you reach the final pages, the discomfort should lift, not because the world has softened, but because its shape has become visible.
What replaces certainty is not despair, but responsibility.

What replaces persuasion is stewardship.

What replaces approval is alignment with reality.
The near horizon does not threaten those who are willing to see.
It clarifies.
This book is an invitation to look into the mirror before silence replaces surprise and to decide, together, what deserves to endure once reality can no longer be unseen.

What follows does not argue this shift.
It watches it appear.