Wearables: the New Handcuffs? Silicon Valley Surveillance Meets Healthcare’s Mechanisms of Control
Three trends in health and fitness are converging, leading to an Orwellian future that few may anticipate:
- The medicalization of daily life (food, movement, sleep, etc)
- Wearable surveillance devices
- Government Control of Healthcare and its Data
In combination, these trends threaten values their proponents must hold dear and believe themselves to be protecting: an individual’s dignity and right to a freely-chosen private life. If “healthcare” include everyone’s daily life activities, and healthcare monitors and controls those activities through wearable devices, and the federal government controls healthcare, then the federal government will monitor and control everyone’s behavior at all times. No longer will we retain a sphere of private life separate from political control. The government will be in charge. In charge, that is, of everything.
Dr. Ezekiel Emanuel, PhD. may be the single most influential figure in recent US healthcare policy, as an architect of Obamacare and healthcare advisor to President Donald Trump. Dr. Emanuel has predicted:
“There will be extensive monitoring of patients in their real, everyday lives-monitoring of their weight, whether they take their medications, their exercise, sleep and other health-related activities …
New wireless ways of monitoring patients in real time — not only their weight and heart rhythms but also their blood counts and chemistries — will be developed and deployed, as will the software to sift through and analyze all the data so as to alert clinicians to serious abnormalities.”
Dr. Emanuel peculiarly presents this scenario as a welcome development, suggesting it enjoys the backing of America’s healthcare elite.
The Medicalization of Daily Life
The medicalization of daily life began with the pathologization of the healthy. And the effort to make the healthy sick began with the misuse of epidemiological studies. To quote Jahed Momand,
“Instead of simply empowering doctors to prevent disease, the Framingham study instead gave the super-organization of pharma, government, and the medical trade exactly the tools it needed to turn healthcare into a market, and clinical trials provided the tools to increase the scope of disease and grow prescriptions. By 1961, the pharmaceutical industry understood that with a sufficiently broad definition of risk, they could begin to medicalize larger and larger populations, relatively healthy people who had yet to see themselves as patients.”
In 2019, the process Momand described has progressed to the point that healthy people are a dwindling minority. Two thirds of Americans are overweight or obese. The American Medical Association has classified obesity as a disease, so those Americans are all either diseased or on the verge. Six in ten adult Americans have at least one chronic disease, and four in ten have two or more conditions, if you believe the CDC. Nearly half have diabetes or prediabetes. And the American Heart Association’s new, lower, blood pressure standards, classified an additional 31 million Americans suffering from high blood pressure, with uncertain clinical implications for the newly sick.
Now that everyone is sick, everything is medicine. Take Coca-Cola’s Exercise is Medicine scheme, or the US House of Representatives’ Food is Medicine Working Group. The US Navy and Kaiser Permanente even advise that “sleep is medicine.” California doctors have begun “prescribing” meals to their patients. In 2019, is anything not medicine?
In support of the campaign to medicalize everything, politicians have proposed numerous pieces of legislation. Democratic President Barack Obama’s Affordable Care Act incentivized workplace wellness programs, despite their failure to demonstrate efficacy, and mandated that insurance companies fully cover, without co-pay, preventive services approved by the Preventive Services Task Force. Republican Senator Bill Cassidy sponsored the Treat and Reduce Obesity Act, which would require Medicare to fund bureaucratically-approved nutritional advice and “community” fitness programs. If the federal government starts funding fitness training, then business success will be determined by who has the best-connected lobbyists, not the best fitness program. Moreover, when bureaucrats artificially limit the possible sources for a service, prices inevitably rise.
The Physical Activity Recommendations Act would mandate the “Department of Health and Human Services (HHS) to publish a report at least every 10 years that contains physical activity recommendations for the general public.” The congressmen behind it are seemingly undeterred by the utter, near-unanimously acknowledged failure of the US Dietary Guidelines to stem historically unprecedented increases in diabetes and obesity.
The hope to become part of the healthcare complex motivated previously distinct, non-medical professions to lobby for occupational licensure of their fields. This process began with physical therapists and athletic trainers. And recently nutritionists and fitness trainer associations have lobbied to ban the general public from giving nutritional advice or carrying out workouts. The nutritionists have succeeded until recently, though the Institute for Justice’s several court cases and CrossFit’s lobbying campaign pose new challenges for them. CrossFit’s lobbying efforts also prevented the ACSM, ACE and NSCA’s lobbying efforts in DC from bearing fruit, thus stopping fitness licensure from gaining a foothold in the states, and preventing Big Soda’s proxies from gaining regulatory control over CrossFit affiliates and the rest of the fitness industry.
These fitness trainers and nutritionists may have unintentionally signed on to an agenda quite distinct from what they envision, however. That is, there is no way to reach most Americans through in-person, licensed trainers or nutritionists. There are only 100,000 members of the Academy of Nutrition and Dietetics, and roughly as many members of the Coalition for the Registration of Exercise Professionals. Now consider the 327,000,000 American citizens, all of whom need to eat and move. The numbers do not add up, as Dr. Lon Kilgore, PhD, has pointed out.
Incorporating daily life activites into healthcare may work, though, if imposed through wearable devices instead of humans.
Wearable Surveillance Devices
“The role of wearable devices and their feasibility as surveillance tools will need to be regularly evaluated.”
ACSM recently declared wearable technology the New Top Fitness Trend for 2019. With Fitbits and other surveillance technology, food, exercise, and sleep really could become “medicine,” with wristbands in lieu of trainers or nutritionists. New Zealand health insurer Southern Cross “plans (to) roll out a data collection programme that will encourage people to monitor their sleep, what they eat and how much they move in a day.” And Aetna signed an agreement to share health history data with Apple, in order to “reward Aetna customers for meeting activity goals and fulfilling recommended tasks, such as getting vaccinations or refilling medications.”
Do wearables actually work? They do not do what they claim to do, i.e. track “fitness” and aid weight loss. The 10,000 steps a day goal we are all admonished to hit was the 1965 creation of a Japanese ad man peddling pedometers. Wearables are especially inaccurate at measuring work performed during calisthenics and weightlifting. Researchers warn that wearable inaccuracy may discourage people from continuing with effective programs:
“People may experience significant physiological benefits from HIFT (high intensity functional) training, but if the activity trackers do not pick up on the potentially complex movements…they may think that they are not expending the proper amount of kilocalories and discontinue the exercise.”
Worse, wearables may be counterproductive for weight loss. Attempting to explain these disappointing results, Time Magazine suggested that,
“It’s possible that when the people saw their physical activity throughout the day, they felt a false sense of security that since they had walked so much, for example, they could eat more.”
(This might not be an unwelcome development for the interests behind Exercise is Medicine).
This May, the New York Times reported That Sleep Tracker Could Make Your Insomnia Worse. Dr. Milton Packer declared the “Apple Watch … a serious competitor for the worst heart device ever” after finding “that the chances of the Apple Watch detecting undiagnosed atrial fibrillation in this study were lower than the chance of a person being struck by lightning during their lifetime.”
While the benefits of wearables are sketchy for individuals, their utility for mass surveillance and behavioral control is undeniable. The incorporation of wearable surveillance into healthcare is therefore entirely incompatible with individual privacy and autonomy.
Commercial fitness trackers emit a “unique code at regular intervals, transmitted over Bluetooth, which could be captured and associated with a location and a time.” The tracking companies are the first recipient of this data, though not necessarily the last.
While nutritional tracking is usually self-reported, Microsoft filed a patent in 2017 for a “Wearable food nutrition feedback system” — basically glasses that monitor what you eat and tell you what you should be eating instead. As this technology becomes more popular, it too will expose users’ diet and location data to independent hackers and state actors.
Not even the US government’s secret programs are immune from the risks of wearable surveillance. Strava, “the social network for athletes,” inadvertently divulged the location of covert US military bases and CIA stations in 2018.
One can understand why the Department of Defense would be concerned about fitness tracking apps. Yet should a civilian really permit their personal health information and location to be regularly uploaded to an easily-accessible database? 150 million MyFitnessPal fitness and nutrition tracking accounts were affected by a 2018 breach. this data is now for sale on the dark web. An Australian app “funnelled hundreds of users’ private medical information to law firms seeking clients for personal injury claims.” And Buzzfeed reported this year that Family Tree DNA, “is working with the FBI and allowing agents to search its vast genealogy database in an effort to solve violent crime cases.”
Government Control of Healthcare and its Data
While any “surveillance capitalism” is concerning, it is one matter for individuals to intelligently weigh fully-disclosed risks, and voluntarily decide to use fitness trackers and related apps. It is another matter, however, for this surveillance system to be imposed on us through healthcare and the federal government.
We may tolerate a high degree of surveillance into our private lives, as long as we are confident that it will not be used to coerce or control us. The Department of Defense may collect our phone calls and emails, but it does not have an effective means for leveraging that data to control a mass population — it cannot even control countries occupied by the US military. Facebook and Google may collect our communications, location, and preferences, but as private corporations they tend to influence us through targeted advertisements. We still have the choice whether to succumb to their increasingly creepy ads, or not. Yet incorporating wearables into healthcare pairs mass surveillance with scalable “mechanisms of control,” to borrow a phrase from French philosopher Gilles Deleuze.
Not only will our data be collected, but it will be used to make us behave differently than we prefer. Advocates of this model openly support “incentivizing” individuals to comply. It is not hard to imagine how healthcare will incentivize compliance through wearables. Fail to take your medicine as prescribed and your premium will go up. Refuse to follow the government physical activity or exercise guidelines, or to put on wearables that track your federal guideline compliance, and your access to emergency medicine or surgery may be in jeopardy.
On the public side, a clinical commissioning group within the United Kingdom’s National Health Service has already proposed withholding surgery from smokers or the obese — is it a stretch to imagine a government withholdings surgery from individuals who refuse to follow government nutrition or exercise guidelines?
In the private sector, John Hancock, a top tier life insurance provider, began in 2018 to exclusively offer “policies that collect health data through wearable devices such as a smartwatch.” CEO Brooks Tingle’s motivation behind this “Vitality” program is clear, “The longer people live, the more money we make.”
John Hancock customers who fail to submit to the wearable regime and upload data on their intake and movement do “not benefit from the discounts if they chose not to.” And John Hancock’s incentives can be significant: “customers will be able to reduce annual premiums by as much as 15 percent, but they will also be asked to report their habits on eating, drinking and exercise.” Full compliers also receive major travel discounts, as well as gift cards from Amazon and elsewhere. Nor is John Hancock alone. In New Zealand, insurer AIA announced “rewards to its 500,000 customers who upload health and exercise data from wearable devices.”
So money is on the line. And predictably, people are cheating. Which is worse, though: people cheating on wearables, or wearable regimes that cannot be cheated? And what does it mean to incentivize submission to a surveillance regime? Incentives for compliance are tantamount to punishment for non-compliance. Moreover, incentive-based systems will only remain voluntary if people can afford to do without the incentives. Facing the prospect of significantly elevated premiums, or decreased access to medical care, most Americans will not have a choice.
The following graphic illustrates a 2016 model of incorporating wearables into healthcare. It comes from a paper co-authored by Coca-Cola-funded CDC official Michael Pratt and Michael McConnell of Google’s Verily Life Sciences initiative:
In this model the wearable data is sent not just to an insurance provider, but to an entire “healthcare team,” and recorded indelibly in electronic medical records.
Should citizens trust health care systems, or governments, with their personal health information? History suggests there are good reasons not to do so. In 1997 Iceland launched a DNA database and collected DNA from nearly half of its citizens. Fifteen years later Iceland sold all of the data to Amgen.
The US Government’s collectors of private health data are even cozier with private companies. NIH’s All of Us initiative is soliciting Americans’ DNA, in addition to their “data from wearables like Fitbits and Apple Watches.” And it will “share data with corporate partners, including Verily, Google’s life sciences division.”
PBS reporter Hari Sreenivisan asked the Washington Post’s Lenny Bernstein if the US Government would reassure Americans it was “not going to share this information with any third party.” Bernstein responded, “I think that would defeat the purpose.”
The technical term the US government uses to refer to tracking Americans’ movement through wearable devices is “physical activity surveillance.” Assuaging privacy concerns does not appear to be a priority.
Let us assume you trust the US government and all of its corporate partners with this information. There is still no assurance that it will be confined to this circle, as millions of US federal employees have discovered this since the Chinese Government hacked the US Office of Personnel Management and the CIA’s secret communications system, enabling China to execute dozens of US intelligence assets on the mainland and roll up a Lebanese network. If the CIA communications are not secure, what chance do your electronic health records, or Fitbit data, have?
Notably, this data will be constantly updated, enabling lifelong government monitoring, and manipulation, of your health. Last year, “The National Institutes of Health … awarded a $225,000 contract to Litmus Health to build a platform to capture and manage data from wearable devices like Fitbits and smartwatches.” The plan is that “analyzing a constant stream of health information from these devices could help doctors more effectively manage chronic illness and tailor treatments to fit the individual.” At that point, Americans will “all be part of an ongoing, eternal clinical trial because we’ll be capturing so much data.”
I, for one, am less than enthused by the prospect of being inserted into a never-ending science experiment. And from the perspective of scientific ethics, this raises some red flags. Research on human subjects normally requires Institutional Review Board approval and the informed consent of the subjects. If we are all constantly involved in an ongoing experiment, how will scientists get their protocols approved and achieve informed consent from the millions participating? Perhaps this is why Dr. Emanuel has advocated for “more emphasis on risk-benefit ratio and less emphasis on informed consent …”
So far we have only addressed the current generation of wearables. The US Department of Defense is funding research on wearable wristband sweat sensors in hopes of assessing biomarkers that normally require a blood draw. The lead researcher on the exercise component of this research is William Kraemer, who, as demonstrated in CrossFit Inc.’s lawsuit, coerced the fabrication of data and knowingly published fraudulent claims about CrossFit. The overwhelming evidence of Kraemer’s fraud has apparently not yet excluded him from government funding.
Kraemer’s sweat sensors will make Dr. Ezekiel Emanuel’s vision of constant biomarker tracking possible. Such technology would enable the government and healthcare system to track an individual’s hormones, blood pressure, and cholesterol, as well as their metabolism of drugs. This would grant the government and healthcare to constantly monitor and adjust the individuals’ pharmaceutical and food intake. Lead researcher Jason Heikenfeld, co-founder and Chief Science Officer of Eccrine Systems, a DOD contractor that produces and tests these sweat sensors, explains,
“Imagine a complete, continuous biochemical view of lifestyle choices for a cardiac patient, measuring potassium and brain natriuretic peptide continuously on both good and bad days … was the spike in blood pressure due to eating a cheesesteak sandwich or because of a daily stress event? Or did the patient simply stop taking their statins?”
If you have been reading CrossFit.com’s posts this year, you may see some issues with these assumptions. Is it a good idea to use technology to enforce the wider consumption of statins, given their questionable evidentiary support? And that’s not to mention the dietary implications of granting the US federal government, which has repeatedly denied a link between sugar and diabetes, the authority to monitor and control food intake. “Big Data” based on the wrong surrogate markers, and inaccurate disease models, will yield confusion and coerced profits, not clarity or health. And given Dr. Kraemer’s involvement, what hope is there for scientific rigor and integrity to prevail?
If this all seems like science fiction, consider Abilify, “the first FDA-approved pill with a tracking mechanism.” The pill “contains a digital sensor that tracks whether a patient has ingested the drug, then shares that information with doctors, family, or whoever is programmed to receive it.” Attorney Shain Neumeier, an advocate for disability rights, predicts that,
“The people who will be hardest hit by the consequences of this will be members of other populations that are already disproportionately subjected to coercion and surveillance. … People who are already institutionalized in prisons as well as psychiatric hospitals would lose some of the few shreds of privacy such settings allow, and proof of medication non-compliance could postpone or prevent their re-integration into the community through parole or discharge.”
Neumeier is correct that this process will start with the mentally ill and institutionalized. If everyone is sick, everything is medicine, and wearables are healthcare, the process will not end there. Intake control may begin in the asylum, but the whole world is becoming an asylum, and we, its inmates.
The push to incorporate wearables into healthcare does not appear to be motivated by evidence of efficacy, nor by need. If the healthcare system really seeks to assess and encourage fitness, wearables make little sense. Why attempt to track a patient’s movement at all times when a single set of push-ups, a hand-grip test, or a sitting-rise test, all provide a sounder indication of the patient’s physical capacity and health, absent the invasion of privacy? Physical activity advocates should promote functional fitness, not surveillance technology.
It is beyond the scope of this article to debate single-payer vs. the United States’ current healthcare system. Nonetheless, as Reason’s Peter Suderman has observed, “health care advocates and policy experts on the left have settled on a goal,” whereas Republicans “have no idea where they stand on health care, or what they really want.” Some variant of universal government healthcare may be inevitable over the long term. That by itself, is probably not a serious threat to liberty.
Universal healthcare is only compatible with individual liberty, however, if healthcare means the necessary care for the sick, not the “preventive” control of an entire population’s private life. Recall the Republican-sponsored Treat and Reduce Obesity Act, which adds fitness and nutritional coverage to Medicare. Pair that bill with the Democrats’ Medicare for All plan. If Medicare includes food and movement, and Medicare is for all, then the federal government will have annexed not just veritable medicine but the provision of fitness and nutritional services to all citizens. Add wearables and this means not government controlling not just those services, but those daily activities themselves. And, eventually, controlling our insides.
Do we really want the government constantly monitoring and manipulating how we move, eat, and sleep, and whether we take our meds? If we do not decide now, we may never have the chance. Preventing Fit Brother is more feasible than dismantling it.
