COVID-19,digital health technology and the politics of the unprecedented

Abstract

The COVID-19 global pandemic has stretched the capacities of public health institutions and health systems around the world, opening the door to a range of technologically-driven solutions. In this article, we seek to historicize the expanding role of digital health technologies and examine the political-economic context from which they have emerged. Drawing on critical insights from science and technology studies, we maintain that the rise of digital health technologies has been catalyzed by broad shifts in global health governance that have expanded the role of market forces in public health and a unique set of political and economic crises that have accelerated the adoption of digital technologies—often under the guise of appeals to technological innovation to address “unprecedented” crises. These interrelated historical trends, we contend, are critical for understanding current state responses to the pandemic and possibilities for more equitable and democratic applications of technology in public health.

Introduction

Of all the words used to describe the COVID-19 pandemic, “unprecedented” is perhaps the most common. Combatting the novel coronavirus, we are told, requires novel solutions, now a euphemism for technological innovation. The rapid technologization of healthcare predated the pandemic and has already served as fodder for philosophers who have explored a range of issues, from the epistemic limits of Big Data and Artificial intelligence (AI) in medicine to the ethical impact of digital health technologies. While examining epistemic and ethical issues raised by novel technologies is imperative, additional historical analyses situating technological change within broader social, political, and economic processes are needed in order to understand the conditions of emergence of digital health technologies and contextualize their current uses (Leszczynski and Zook, 2020). Amidst the ongoing upheavals associated with the COVID-19 pandemic, such analyses are critical in order to better understand how appeals to technological solutions in the face of “unprecedented” crises often serve to obscure political ideologies and foreclose critical reflections on more democratic alternatives.

In this short essay, we seek to build on epistemological insights from science and technology studies (STS) that knowledge production and technological change are deeply imbricated in their underlying social contexts. We draw on a burgeoning research agenda within the field of STS that seeks to incorporate frameworks from political economy to study “how different political-economic processes, practices and contexts inform technoscience” (Birch, 2013: 51; Mirowski, 2011). As this literature has argued, the ascendance of neoliberalism since the 1980s has profoundly re-configured conditions of scientific knowledge production and public health sectors around the globe. Drawing on these insights, we examine the political and economic conditions in which digital health technologies have emerged over the past several decades, from the rise of the “New Economy” in the 1990s to the growth of Big Data in the aftermath of the 2008 financial crisis. We contend that the increasing incursion of market forces into the realm of public health, often under conditions of perceived crisis and appeals to technological solutions, has long been a formative influence in facilitating the expansion of digital health technologies. Grasping this history, and situating digital health technologies within sociopolitical context, remains crucial to understanding the dynamics of the COVID-19 pandemic and prevailing public health responses. Our brief exposition of the emergence of digital health technologies during the pandemic reinforces a key lesson from STS: that interrogating genealogies of technologies—including attention to their political and economic contexts—is critical to understanding the positions they occupy in the current crisis.

Big tech and the marketization of healthcare

Over the past several decades, a growing body of literature has illustrated how prevailing approaches to healthcare research, financing, and provisioning have increasingly been shaped by market forces (De Vogli, 2011; Keshavjee and Farmer, 2014). Throughout the early 1980s amidst a steep global recession, countries across the Global South, particularly within Latin America and Africa, faced an unfolding debt crisis, which was accompanied by substantial changes in economic and public health policies as heavily indebted countries were compelled to adopt a range of “structural adjustments” to secure loans from financial institutions (Kentikelenis, Stubbs and King, 2016). While the re-configuration of global health governance over the past several decades toward market-led approaches has been widely examined (Benatar, Sanders and Gill, 2018), fewer analyses have probed its relationship with the rise of digital health technologies. Rather than emerging from politically neutral pursuits of technological efficiency, we contend that the rise of digital technology in healthcare emerged alongside the market euphoria and techno-optimism associated with the “New Economy” of the late 1990s and early 2000s. Alongside a series of geopolitical, economic, and public health crises, technological fixes to “novel” and “unprecedented” crises garnered increasing political and popular salience.

While the origins of the information technology sector can be traced back to the Cold War (Levine, 2018), the dramatic rise of the internet and mobile technologies emerged more recently during the late 1990s and early 2000s at the height of financial globalization (Srnicek, 2017). Within the US, following the economic stagnation of the 1980s, the much-vaunted “New Economy” of the 1990s saw an ideological and political embrace of the virtues of market-led development, private-sector innovation, and financialization by both political parties (Henwood, 2003), all of which created fertile conditions for the establishment of the “infrastructural basis” of the digital economy (Srnicek, 2017). As these market-based policy measures were exported across East European, Latin American, and East Asian countries throughout the 1990s and 2000s, a series of US-led international trade agreements laid the foundation for the strengthening of intellectual property rights, securing the position of US multinationals within global technology infrastructure (Kwet, 2019: 11). On the back of a booming stock market in the US, venture capital poured into Silicon Valley throughout the 1990s and early 2000s, inflating the stock market valuations of US start-up firms, particularly in the telecommunications and biotechnology sectors (Srnicek, 2017). While the collapse of the dot-com bubble in 2001 quickly revealed the volatility of the financialized model associated with the rise of digital technology firms, the belief in technological “quick fixes” to social problems was less easily dispelled (Johnston, 2020). Indeed, following the 9/11 attacks in 2001, the ensuing War on Terror’s pervasive atmosphere of securitization and mass surveillance contributed to the political and regulatory permissibility that enabled the rise of Big Tech firms such as Google (Srnicek, 2017; Zuboff 2019), whose business model soon revolved around offering technologically-driven solutions to social issues.

Within this atmosphere of perceived crisis, a growing nexus of data-driven mass surveillance formed between US intelligence agencies and Silicon Valley. Under the guise of “threats” to national security, many of the largest technology firms were effectively shielded from democratic oversight and public regulation (Zuboff, 2019). As Jiménez (2020) argues, it was at the intersection and confluence of these dual political and economic crises—namely, the dot-com bubble burst and post-9/11 securitization—that a mutual development of mass surveillance and internet technology emerged and reinforced one another (323). The post-9/11 environment of the early 2000s not only created the political and regulatory conditions that enabled the ascendance of Big Tech—it also marked the deepening of a social and cultural shift in which calls for technologically-driven solutions to address seemingly pervasive and unprecedented crises garnered renewed appeal, not least in the realm of public health.

As literature in disaster studies has illustrated, it is often in environments of perceived crisis, ranging from natural disasters (Madianou, 2015), to threats of “bio-terrorism” and infectious diseases (Caduff, 2015), that appeals to technologically-driven solutions often gain their ideological salience. Agamben and Attell (2005) describe such crises as “states of exception,” where formal legal and constitutional rights are suspended and the boundaries of acceptable state power are enhanced. The rise of Silicon Valley in the aftermath 2008 financial crises can be understood in similar terms. Following the 2008 Global Financial Crisis, a macroeconomic environment of cheap credit and quantitative easing channelled billions of venture capital into technology firms from investors seeking higher returns, contributing to an unprecedented consolidation of large firms across the digital economy (Srnicek, 2017). The consolidation of Big Tech companies, with business models predicated on the systemic extraction and sale of personal data, served to further reinforce appeals to technological solutions and the application of Big Data to address social problems (Zuboff, 2019).

Techno-solutionism in public health

Morozov (2013) coined the term “solutionism” to describe a prevailing attitude accompanying the ascendance of Big Tech, which he defines as a worldview that recasts “all complex social situations as either neatly defined problems with definite, computable solutions or as transparent and self-evident processes that can be easily optimized” (5). Amidst the information technology revolution of the 1990s and early 2000s, the use of computer-based tools, such as online health assessments, became increasingly prominent in public health (Lupton, 2013). The adoption of these technologies and the rise of e-health was often catalyzed by moments of perceived crisis. An early example of the systemic application of digital health technologies in the US, for example, occurred in the aftermath of Hurricane Katrina, as electronic health records were increasingly adopted with the intention of enhancing resilience within the US healthcare system (DeSalvo and Petrin, 2018).

Over the past decade, however, digital health has expanded dramatically with the introduction of mobile technologies and the rise of Big Data. Techno-solutionist discourses have deeply penetrated healthcare and public health, where the allure of Big Data seemed to offer a means of bypassing technical incapacities and resource constraints facing underfunded public health institutions, which were perceived as vulnerable to growing global threats, from pandemics to natural disasters. Despite the pervasive appeal of Big Data in public health, a growing literature has shown how the application of digital technologies, particularly in conditions of natural or social disasters, can have mixed results, at times detracting from robust public health interventions. The post-2008 period has indeed witnessed a proliferation of products from digital health firms, ranging from consumer wearables to personalized genomics and telehealth consultations (Lupton, 2013), which have increasingly been introduced within austerity-ridden states that lack the capacity to provide large-scale public health interventions.

Indeed, in the face of emerging viruses and growing threats of global pandemics, “Big Data problem solving capacities can appear infinite” (Erikson, 2018); however, past pandemics give reasons to temper our optimism. From the H5N1 Avian Flu to the outbreak of Ebola in West Africa, global pandemics—and public health crises more generally—have captured the attention of national security officials and Big Tech firms alike, and are often used as a “testing ground” for new technologies (Caduff, 2015: 33). Digital and mobile technologies have also been deployed during natural disasters as part of a trend toward “humanitarian technology.” For example, during Typhoon Haiyan in the Philippines in 2013, social media and mobile technologies were heavily relied upon in relief efforts. Despite the enthusiasm for harnessing the capacities of digital technologies, numerous studies have observed how the application of these technologies contributed to worsening digital divides and “second order inequalities” in disaster relief efforts (Madianou, 2015). More recently, Erikson (2018) has examined the role of Big Data in contract tracing efforts during the 2014 to 2016 Ebola outbreak in West Africa, where data from mobile technologies were deployed remotely as “anticipatory technologies” to resolve threats posed by the disease, often with mixed results and to the detriment of local investment in public health and social infrastructure.

The rise of digital health technologies thus long predated the outbreak of the COVID-19 pandemic (Milne and Costa, 2020) and can be seen as continuous with trends in techno-solutionism engendered by the ascendance of Big Tech in the “New Economy.” As our discussion highlights, far from neutral applications of scientific research and embodiments of “laws” of exponential technological progress, the origins of digital health technology are manifold and complex, overlapping with a range of macroeconomic, geopolitical, and social transformations within the global economy and healthcare sectors across the world. From the embrace of neoliberal policies that have seen a secular shift away from public models of health provisioning, to the push for datafication under conditions of perceived crisis, the historical emergence of digital health technologies offers important lessons for understanding the COVID-19 pandemic as well as the range of solutions deployed across various countries.

“Technological solutions” to the pandemic

State responses to the COVID-19 pandemic have varied. While few countries have successfully contained the spread of the virus, the fragmentation of public health responses in liberal capitalist countries has been particularly notable, with persistent challenges in curtailing community transmission, managing hospital capacities, mobilizing centralized contact tracing, increasing personal protective equipment (PPE) provision, and protecting vulnerable populations (Mellish, Luzmore and Shahbaz, 2020). Within the US market-led healthcare model, for example, a fragmented federal response which devolved public health authority to state and local levels (Haffajee and Mello, 2020) and a reluctance to enforce centralized public health measures to temporarily shut down market activity both contributed to devastating effects from the COVID-19 outbreak. Likewise, in the UK, decades of cumulative cuts to national health service (NHS) funding contributed to a lack of pandemic preparedness (Hall and Lister, 2020). By contrast, countries such as South Korea, Vietnam, China, Taiwan, and New Zealand have demonstrated considerably more success in managing and containing COVID-19 outbreaks, which appears to be at least in part associated with greater state capacities (Mellish, Luzmore and Shahbaz, 2020). While the dynamics of the global pandemic are complex and still unfolding, there is growing evidence to suggest that countries most committed to market-led development and public-sector austerity over the past several decades, particularly in healthcare, have demonstrated an acute inability to mobilize public resources in their efforts to contain COVID-19 (Assa and Calderon, 2020).

Not unlike past global crises and conditions of perceived emergency, government officials and corporate executives alike, invoking the unprecedented nature of the COVID-19 pandemic, have called for “technological solutions” to the crisis, creating fertile conditions for Big Tech to fill the void in public health services, and expediting the “viral” diffusion of “data solutionism” across many regions of the world (Leszczynski and Zook, 2020: 2). Offering a unique command over population data and a capacity to service consumers remotely, Big Tech firms have procured lucrative government contracts and posted record-breaking profits throughout the pandemic—in part due to outsourced public health ventures (Paul and Rusche, 2020).

Just as countries have deployed differing public health strategies to address the COVID-19 pandemic with varying degrees of success, there have also been different models for integrating novel technologies in public health. Across the US, UK, Canada, and other liberal Anglophone countries, data-driven approaches throughout the pandemic, consistent with more longstanding trends, have emerged largely from private-sector initiatives, often as substitutes for integrated public health responses. The roll-out of technology-driven disease surveillance measures in these countries has approximated what some commentators have termed “corporate contract tracing,” in which Big Tech multinationals have dominated public health responses through corporate-controlled infrastructure and mobile technology, undermining the power of public health authorities (French, Guta and Gagnon, et al., 2020). Examples include the use of Apple and Google’s contract-tracing app and other consumer wearables and home-based smart appliances for disease surveillance (Maalsen and Dowling, 2020), the outsourcing of PPE procurement, and the sustained rise of private telehealth technologies to provide remote care. In the US, for example, the COVID-19 pandemic has provided new opportunities to utilize data from mobile technologies for surveillance and data sharing between private industry and state and local government (Whitelaw, Mamas and Topol, et al., 2020). In the UK, private outsourcing within the NHS has continued apace, with contracts offered for PPE procurement and health data management to digital giants such as Capita, Serco, and Palantir (Geoghegan, 2020). In contrast, within China, South Korea, Taiwan, and Singapore, digital health technologies have been deployed more centrally and directly integrated into state-led efforts to contain the virus. This has ranged from the centralization of health-related databases, to the collation of security camera footage, facial recognition technology, smartphone, and global positioning system (GPS) data for disease surveillance (Whitelaw, Mamas and Topol, et al., 2020). Alongside widespread testing efforts, the use of these digital technologies has likely contributed to some of the lowest per-capita mortality rates in these countries throughout the COVID-19 pandemic, albeit not without numerous surveillance and human rights-related concerns (Maalsen and Dowling, 2020). Indeed, digital health technology use throughout the pandemic has resurfaced a range of longstanding concerns related to the relationship between technology, democracy, and inequality. As recent commentators have noted, changes in digital health ushered in by the COVID-19 pandemic are “neither newly conceived nor short-term,” contributing to a range of dislocations and disruptions in clinical care (Milne and Costa, 2020), deepening many longstanding issues associated with digital divisions in access to care (Eruchalu, Pichardo and Bharadwaj, et al., 2021), and exacerbating structural inequalities and forms of technological oppression (French, Guta and Gagnon, et al., 2020).

Digital health technologies in retrospect and prospect

What lessons does this account of the origins of digital health technologies offer for research in STS and, correspondingly, how can this interdisciplinary field help us to better understand technological responses to the COVID-19 pandemic? STS scholars have helped problematize pandemic technologies, for example, by examining how techniques of quantification and datafication in contract tracing have entrenched exclusionary conceptions of “standard” users (Milan, 2020). We contend that in our current moment, in which the COVID-19 pandemic has accelerated Big Tech’s growing influence in the global economy, incorporating additional frameworks from political economy into STS is increasingly relevant, particularly in domains of healthcare and public health. As we demonstrate in this essay, the value of applying this approach to STS to examine the political economy of digital health technologies is twofold: not only does it enable us to dig beneath dominant techno-determinist discourses which depict technological innovation as the only solution to address the “unprecedented” COVID-19 crisis, but moreover, it offers a more capacious means for situating science and technology within the social. Applied to digital health technologies, this lens reveals how digitization emerged alongside broad shifts in global health governance that prioritized market-led approaches. Conditions of perceived crisis bolstered discourses of techno-solutionism and further accelerated the incursion of private-sector technologies into public health systems around the world. While the effectiveness of technological responses to the COVID-19 pandemic has varied in different global contexts and remains to be fully assessed, the rapid adoption of digital health technologies has often substituted for or detracted from large-scale public health interventions, at the risk of exacerbating underlying social and health inequalities.

Situating technologies in historical as well as political and economic contexts allows us to appreciate how these recent trends are not inevitable and how different political values could inform our technological applications. While the scale of COVID-19 pandemic demands that we leverage all collective resources, which includes utilization of our technological capacities, we must not be constrained by techno-solutionist narratives, which often serve private interests at the expense of public needs, and instead envision more democratic digital health technologies. Between the poles of a digital sphere dominated by Silicon Valley or controlled by authoritarian states, scholars have sought to chart a more democratic digital infrastructure that can both protect and empower citizens while re-imagining the ownership and control of digital infrastructure to serve more egalitarian ends (Bria, 2020; Crawford, Dobbe and Dryer, et al., 2019). Historicizing current technologies will remain central to this project in order to re-imagine how digital health technologies might be differently developed and deployed to enable more equitable responses to current and future public health crises.