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Letter from London
doi: 10.4103/0970-258X.295969
PMID: 32985452

Letter from London

Anna Ruddock

Corresponding Author:
Published: 23-Sep-2020
How to cite this article:
Ruddock A. Letter from London. Natl Med J India 2019;32:313
Copyright: (C)2019 The National Medical Journal of India

‘Alexa, turn on living room lights.' (A friend, as we enter his flat one evening.)

‘Alexa, set a timer for 40 minutes.' (Another friend, putting potatoes in the oven.)

‘Alexa, play Let it Go.' (A friend’s three-year old daughter and big Frozen fan.)

‘Alexa, how do you treat chicken pox?'

The last of these I have yet to witness. But news of a tie-up between the Department of Health and Amazon suggests it won’t be long.

I am not what they call ‘an early adopter’. I have neither the money nor the innate curiosity to stay up to date with the latest phone; I underexploit the capabilities of my laptop because I’m too reluctant to invest the time in learning about it; the idea of having my inbox contained in a watch strapped to my wrist makes my lungs constrict. I do not monitor my daily steps or my heart rate. However, in the latter case, I fully appreciate the utility of being able to do so. My reluctance stems in part from an objection to the implicit divorcing of individual responsibility from the structural determinants that influence health.

Which brings us back to Alexa. So far, my experience of Alexa and similar technologies has been as a toy, the indulgence of friends who enjoy the novelty of telling a disembodied voice to turn the lights on and off or to play a particular song. In the homes of these friends, it (let’s not indulge the patriarchal determination to refer to this domestic worker as ‘she’) is a form of entertainment.

However, this is not the case for everyone. Alexa, or its equivalent, can now be found in an estimated 5 million UK homes. For some disabled people in these homes, this technology has an enabling function that extends beyond playing a favourite song. Alexa reminds people to take their medication, it can control the heating, and it offers a simple internet search function that does not require a traditional computer.

The British government has seen the potential here too, as demonstrated by the announcement of the health secretary, Matt Hancock, that Alexa users will now be able to ask the device for National Health Service (NHS) advice about common illnesses. There is an immediate and deep ambivalence here.

The utility of technology for enabling greater independence for disabled people and the elderly is to be celebrated in principle. In practice it gets more complicated when a government that has starved the NHS of funds for primary and social care promotes the potential of technology to take the pressure off ‘hardworking GPs’. The narrative is always one of patients demanding too much of doctors, rather than of a healthcare system that has been underfunded to the point that it is no longer able to fulfil its mandate, to the detriment of many who encounter it, whether as patient or employee. Technology’s most uncritically minded evangelists are revealed in these moments; the current health secretary is one example.

With technology, we are told, comes ‘empowerment’. That magical and usually hollow term deployed by the powerful as a means of signalling a concern for equity without any acknowledgement of their complicity in the power structures that marginalize people. Patients will be ‘empowered’, it is implied, by asking a plastic box to tell them whether the pain they are experiencing warrants attention by a human being. They will, no doubt, be in a position to ‘take back control’ (I really tried to avoid a Brexit reference) of their health. This rests on a premise that as potential patients we are an inherent nuisance. So, if we can avoid demanding a few minutes of human attention from a healthcare system that we support through our taxes, then good. How empowering!

One article included a quote from a local council leader about the advantages of using chatbots to replace short social care visits. These visits are usually brief house calls to check, for instance, that a person has taken their pills. If this type of visit could be replaced by an Alexa-type device, the person said, care workers could spend more time on ‘more useful visits’. No one doubts for a second that care workers are overstretched (and underpaid), but what does ‘useful’ mean here? Presumably, this is ‘care’ interpreted in the most utilitarian terms. What does it say about us if our health and social care policies increasingly understand life as an exercise in longevity above all else?

In another piece, someone said that the use of Alexa-type devices by individuals ‘could stop a partner becoming a carer’. What a strange statement. We know that those who usually shoulder disproportionate responsibility for the care of disabled and chronically ill people are their partners and relatives. This work should receive greater recognition and support. But the idea that we should aspire to a situation in which a person’s most intimate relation is entirely liberated from any caring role fundamentally misunderstands the way in which illness and disability are a part of life, a part of people and thus a part of relationships themselves. They do not translate into a discrete set of needs that can be neatly outsourced, and certainly not to an algorithm housed in a box in the kitchen.

In deeply confused Brexit Britain, allegiances are ever more tribal and people feel alienated and fearful. We are told by people paid to have opinions that we need more togetherness, more closeness, more community. On the Guardian website, beside the article about the potential for technology to remove the burden of care from human beings was an article about Britain’s loneliness epidemic. Yet the ultimate potential of technology is to free us from the need to care for each other? What’s going on?

Technology does different things for different people with different motives. It can generate vast revenue for businesses that thrive on our data (a whole other reason for concern about this latest news), it can provide a useful narrative for policymakers who do not have budgets to support a health system, and it can enable greater independence for some people. It can tell you to take your pills, it can switch the heating on when you need it, it can provide information about when your temperature is high enough to worry about. But it cannot stroke your forehead or hold your hand. It cannot soothe. It cannot connect. It cannot care. It may save the NHS a bit of cash, but we risk the incremental loss of medicine’s humanity in the process.

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