John’s vision 5
EXTRACT CONVIVIALITY
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Health and care industries are growing because people don’t look after each other as much as they used to. We expect governments to provide support services instead. Governments don’t like this. The provision of care costs a lot of money—and besides, the customer is never satisfied. Hence the growing interest among policymakers in ideas of social capital and conviviality. The case for conviviality is that if we were to take more responsibility for our own well-being, we might rely less on care as a service delivered to us by third parties—especially the state. Such a shift in emphasis from delivered care to supported care would enable governments to focus on the supporting infrastructures, collaboration tools, and social software for connected communities needed to enhance dialogue, encounter, and community in our everyday lives.
Confronted by unsustainable rates of growth in expenditure, much of the health industry is looking to automation and technology for ways to reduce costs. Thousands of services connecting our bodies to networks are in development. For Richard Saul Wurman, who runs an influential conference, TedMed (Technology, Entertainment and Design, and Medicine), on the subject, health care and technology are “the next convergence.” TedMed covers everything from computer graphics and imaging of the human body through microlozenges that record their journey through the body, wearables of all kinds, visualization of blood, urine, and DNA, genomics, robotics, and nanotechnology, plus myriad information services designed to assist people in the planning of a healthy life.
Communications technology and simulation are prominent in high-tech scenarios for health. Health care industries already spend the best part of twenty billion dollars a year on ICT, and that figure is set to soar. One of the more extraordinary books I found during research for this volume was the 1,276-page Telemedicine Glossary. This hefty tome lists 13,500 organizations and projects involved with health telematics; a single page lists thirty online journals and magazines. Other pages list six hundred telemedicine research projects with acronyms like KISS (Knowledge-Based Interactive Signal Monitoring System), DILEMMA (Logical Engineering in General Practice, Oncology and Shared-Care), ESTEEM (European Standardized Telemetric Tool to Evaluate EMG Knowledge-Based), CONQUEST (Clinical Oncology Network for Quality Standards of Treatment), WISECARE (Workflow Information Systems for European Nursing Care), PRE-HIP (Predicting Clinical Performance of Cementless HIP Replacements), CLIFF (Cluster Initiative for Flood and Fire Emergencies), and HUMAN (Health Through Telematics for Inmates) as titles. The last of these is about treating prisoners remotely. The mismatch between the innocuous-sounding acronym and its less-than-innocuous meaning is not untypical of the medical research world. Elsewhere, crisp young white people, their gorgeous bodies wrapped in microcircuitry, adorn the website for “New Generation of Wearable Systems for Health: Towards a Revolution of Citizens’ Health and Life Style Management?” a 2003 conference.
This vision of the future features physically immaculate people who don’t look as if they need implantable health systems. These wearables are “to manage people with risk factors and prevent diseases through health status monitoring and life style management,” which sounds fine, except that the almost casual penetration of technology onto and into our bodies is happening without discussion of its consequences. I call this phenomenon “borg drift.” Borg drift is what happens when you add all these tiny, practical, well-meant and individually admirable enhancements together and find that the picture begins to look creepy. As often happens, artists and writers were the first to spot broader consequences of these trends. Donna Haraway, in her celebrated “Cyborg Manifesto,” observed that “late twentieth century machines have made thoroughly ambiguous the difference between natural and artificial, mind and body, self-developing and externally designed. Our machines are disturbingly lively, and we are frighteningly inert.” We are designing a world in which every object, every building—and every body—becomes part of a network service. We did not set out to design such an outcome, but that’s what’s coming.
The pity of it is that spending money on technology like this does not appear to buy better health—or at least, not a longer life. The biggest spenders on health care, North Americans, die earlier than Japanese or Spaniards, who spend far less on health care. Medicine has become a two-trillion-dollar industry, and the world’s three-hundred-billion-dollar pharmaceutical industry turns out thousands of different drugs. But much of the world’s population dies of the same diseases that killed people a thousand years ago: malaria, tuberculosis, and malnutrition.
A growing number of health professionals believe that that medicine, as an institution, undermines health. When Ivan Illich wrote Medical Nemesis in 1976, he was dismissed as a crank for this celebrated polemic:
More and more people are convinced that, if they do not feel right, is it because there is something disordered inside them, and not because they are manifesting a healthy refusal to adapt to an environment or life that are difficult and sometimes intolerable. Adaptation to the misanthropic, genetic, climatic and cultural consequences of growth is now described as health. As sensible creatures we must face the fact that the pursuit of health may be a sickening disorder. There are no scientific or technological solutions to death. There is the daily task of accepting the fragility and contingency of the human condition. People no longer have the need or desire to resolve their problems within the network of their own relationships. Medicine becomes the alibi of a pathogenic society.
Illich warned that technology push in health may itself be a sickening disorder. “When people no longer have the need or desire to resolve their problems within the network of their own relationships, medicine becomes the alibi of a pathogenic society.” Illich concluded that we have thrust the bad things of life—old age, death, pain, and handicap—onto doctors so that families and society would not have to face them.
Illich was not antitechnology. He argued that self-care and the use of modern technology could be mutually supporting. It took thirty years for his ideas to gain mainstream acceptance, but in 2002 the British Medical Journal, a bastion of the medical establishment, called for a turning back of the “medicalisation of everyday life.” The journal, citing Illich and the biologist Rene Dubois as its inspiration, proposed that we redefine good health as “the autonomous personal capacity to master one’s conditions of life, to adapt oneself to accidental modifications of one’s surroundings, and to refuse if necessary environments that are not tolerable.”
Jean-Pierre Dupuy, who has studied the stress and burnout suffered by the medical profession firsthand, says that when doctors are asked to provide the impossible to patients, they do not gain power or control—they suffer: “The ability to cope with a series of profoundly intimate threats that all men face and will face—namely pain, disease and death—comes, in traditional societies, from his culture. The sacred plays a fundamental role in this. The modern world was born on the ruins of these traditional symbolic systems.”
The use of the Internet to find and evaluate health information is booming. Sixty million Americans troll the Net in search of health-related information, and research shows that nearly nine out of ten people want as much information as possible from their doctor—good or bad—so that they can participate in planning their own health care. Medical professionals increasingly involve patients in evidence-based medicine—the conscious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Multidisciplinary teams of statisticians, health economists, academics, and health practitioners work increasingly alongside service users and caregivers to sift through available evidence and disseminate the results to clinicians. As Andrew Moore, editor of Bandolier, one of the most popular evidence-based sites in the United Kingdom, puts it, “There are six million research papers out there and most of them are bollocks. We’re entering a new age of medicine where the doctor and patient forge a therapeutic alliance.”
Other kinds of decentralized care services offer sophisticated monitoring devices, tailored treatment plans, and personalized Web pages that store individuals’ health care data and facilitate regular interaction with health care professionals. These Web-based health services encourage real-time patient feedback, provide online tracking to enhance treatment plans, and facilitate cost-effective patient monitoring. Researchers at Accenture have developed an online medical cabinet that says things like, “Good morning, I have an allergy alert for you.” Not only does the online medicine cabinet know about your allergies, it also monitors other aspects of your health and tracks whether you’re taking the proper medication. It can also order drug refills when supplies run low and pass along details about your blood pressure to your doctor. According to the Accenture website, “By using a camera and face-recognition software, the cabinet can identify different persons in a household, and their special needs. For example, if an individual suffers from allergies or asthma, the Online Medicine Cabinet will provide information such as the day’s pollen count, and remind that person to take their medicine. Sensors on prescription bottle labels allow the cabinet to identify each drug and alert consumers if they have taken the wrong bottle—or if it’s the right bottle at the wrong time. This is vital, because at present, nearly one third of all hospital visits result from consumers not following their doctor’s orders or taking the wrong medication.”
Social fragmentation and personal isolation are among the more damaging consequences of the ways we organize space and time. Social capital and conviviality are also damaged by the ways we design our work. Not so long ago, it looked as we were doing a better job at designing work. During the 1990s, the enticing rhetorics of a new economy promised us a rosy future in which, rather than salaried men and women, or wage slaves, we would be self-employed “portfolio workers.” We would be actors, builders, jugglers, and stage managers of our own lives. There would be no tedium and no drudge. Work and family life would be in balance. Our every working moment would be filled with meaningful projects and boundless creativity. In this paradise, we would live effortlessly as high-tech nomads.
The reality of Net work, for most of us, is turning out to be pretty much the exact opposite of those promises. A huge gulf separates the rhetorics of the information society from the logic, and hence realities, of the way it actually works. We are too busy working to look after one another.
Reality check one: We are not living in an information society but in an information market. In this market, three powerful economic forces—downsizing, globalization, and acceleration—are fragmenting the social fabric in many different ways. Jobs, for one thing, are disappearing; a twenty-year-old today has little chance of selling a hundred thousand working hours to an employer in advance upon joining an organization. As a result, tens of millions of young adults will labor at short-term tasks—“the project”—and change employer or client frequently. This kind of work—work that is marketed and sold as a commodity by intermediaries with names like Manpower—tends to be fragmented and atomized. Suppliers of the commodity languish near the bottom of the economic food chain in “spot markets” for “human resources.” Human beings “count,” in this new economy, in the same way that a sack of cocoa beans “counts”: Free markets treat people as a cost, not as a value. Increased networking, “unbundles” aspects of the employment relationship that once acted as social glue.
Reality check two: “Unbundling” is bad for your health, both physically and psychologically, In a 2000 survey by the European Commission, nearly half of Europe’s workers complained of physical health problems—posture discomfort, headaches, back pain, repetitive strain injury, and so on. Forty percent of all workers said they suffered from feelings of “high pressure, low control.” Two-thirds said they “do not have jobs of high intrinsic quality.” Fifteen percent experienced their work to be precarious, and one-third—in round numbers, a hundred million people—said they suffered from stress. Things are just as bad in the United States. Less than half of all Americans say they are satisfied with their jobs—the highest level of discontent since surveys were first conducted in 1995. The decline in job satisfaction is found among workers of all ages, across all income brackets and regions. All recent studies of working conditions in the world’s most prosperous regions make similar points: New-economy patterns of work lead to ill health and early mortality.
Reality check three: Net work leads to loneliness, disconnection, and a loss of identity. We tend to be judged by what we do, not by who we are—and that question is hard to answer when we’re working on multiple projects and tasks—“spots” that are not connected, do not have a story, have no beginning, and no end. Spot markets for our labor fragment, atomize, and disconnect us from narrative. Singularity replaces connection and flow.
Could we design some kind of online “farm-to-market” barter economy for the time we can and want to spend on care? There are interesting hints of what may indeed be a startling change. One of these is the growth of local exchange and trading systems (LETS). A wide variety of individuals and local businesses are discovering that it makes sense to receive payment in local barter currencies, which get called things like “bobbins,” “acorns,” or “beaks.” What happens is that local people form a club to trade among themselves, using their own system of accounts. They compile a membership directory containing offers and requests—goods, services, or items for hire; these are priced in local credits. Members use the directory to contact one another whenever they wish. They pay for any service or goods by writing a LETS credit note for the agreed amount of local credit. The credit note is sent to the LETS accountant, who adjusts both members’ accounts. Each member receives a personal account statement, directory updates, and a newsletter. From humble beginnings in the small town of Courtenay, Vancouver, LETS have spread to the United States, New Zealand, Australia, and Europe. An estimated thirty thousand people are participating in some four hundred local LETS around the United Kingdom alone; similar networks have been established in sixteen European countries. All this despite the fact that, until recently, LETS have been completely manual, and people would sit for hours in each other’s kitchens filling out ledgers and sorting little bits of paper.
Some policymakers worry that the local tax base will be eroded if too many people start swapping tomatoes for baby-sitting—without recourse to (taxable) money in the transaction. Tax economists are even more worried about what might happen when the manual, grassroots world of LETS takes off on the Internet. The OECD calls this link the “missing network”; its work on the future of money uncovered substantial unmet demand for real-time peer-to-peer virtual payments as an enabling infrastructures for LETS.
In the United States, one LETS-like scheme called Time Dollars is described by its founder, Edgar Cahn, as “a currency for rebuilding the core economy of family, neighborhood and community.” Says Cahn:
The history of the past century or more is the history of the market economy taking over functions previously performed by the family, kinship groups, neighborhoods, and non-market institutions—because of seemingly superior efficiency. We have contracted out as many of the functions of the informal economy, the non-market economy as we can. McDonald’s now provides the meals; Kindercare the day care; public and private schools the education (such as it is); Nintendo the child care and entertainment; Holiday Spa and Gold’s Gym the exercise; insurance companies the protection; Medicare and Medicaid the nursing care—and on and on the list goes.
Systems like LETS and Time Dollars begin to acknowledge and compensate people for the time they invest in care and convivial activities. Margrit Kennedy, a German pioneer, says LETS are “immune from local or international recessions, interest on debts, thefts and money shortages. The world money system can collapse; the dollar or DM [deutsche mark] can lose their value; unemployment may rise; but Time Dollars … still function because they are guaranteed one hundred percent by work and by goods. The advantage of LETS is that it is limited only by the time and energy a person is prepared to invest.” According to Kennedy, between 10 percent and 30 percent of the world trade is barter trade. “Barter and exchange systems, specializing at a local, national or international level, have benefited greatly from the new information technology. The notion of a free exchange of goods and services … is now much easier to implement where information travels fast to any place in the world.”
Noncash economic systems are, for me, where a genuinely new economy is being born. The dot.coms were a distraction from this much more profound transformation. If, as I have argued, a light and therefore sustainable economy means sharing resources more effectively—such as time, skill, software, or food—then economic systems for exchanging nonmarket work have got to be part of the answer. Nonmarket work includes much of the essential activity we have always undertaken to raise and educate our families, get fed, and look after one another. Half of all the labor done in industrialized countries is spent on unpaid work. The fact that this kind of work is not considered to be part of “the economy” is partly a problem for economists to deal with, but partly, too, a service design challenge that we can get our teeth into.
Networked communications and wireless networks can be repurposed as enabling infrastructures to help systems like local and complementary currencies, Ithaca Hours, Time Dollars, LETS, microcredit programs, interest-free banking, and other community-oriented monetary systems scale up.
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