NDS: I was in the first cohort of the Robert Wood Johnson Health & Society Scholar postdoctoral program. I was definitely an outlier as a cultural anthropologist, but the pitch I made to them at the time was that research angles on addiction should include more qualitative work, and should also attend to the addictive effects of consumer interfaces and technology, not just drugs, as a public health issue.
I think any good addiction researcher would recognize that addiction is in a large part a question of the timing of rewards or reinforcements, or the so-called event frequency. So it makes sense that if digitally-mediated forms of gambling like slot machines are able to intensify the event frequency to a point where you’re playing 1,200 hands an hour, then they’re more addictive. Waiting for your turn at a poker game, by contrast, isn’t as fast – there are lots of pauses and lots of socializing in-between hands. Slot machines are solitary, continuous, and rapid. Uncertainty is opened up and then it’s closed — so quickly that it creates a sense of merging with the machine.
If you accept that gambling can be an addiction, you can then broaden the conversation to include other less obviously addictive contemporary experiences, whether it’s an eBay auction or Facebook photo clicking or even just checking email, and certainly texting. It’s so compelling to take your fingertip and just keep clicking, clicking to get that response.
EM: That’s fascinating. Or this word game on my phone — it’s become really, really addictive for me. I’m curious if you’ve had interactions also with people in game design? There’s a certain point of view that seems really prevalent right now about game design and play.
NDS: People in the general world of game and app design don’t see themselves as in the business of producing addiction but they have reached out to me. Often they want to hear about how to avoid creating addiction.
I was recently invited out to the Habit Summit, an event in Silicon Valley held at Stanford, with lots of local tech people who are all there to figure out how to design habit, how to retain attention. In my presentation to them, I talked about the increasing prevalence of little ludic loops in design, as ways to retain attention. With Candy Crush and so many phone apps, if you ride a subway in the morning there are people sitting there zoning out on these little devices. I think the reason they’re so able to retain attention and form habits is that they are affect modulators. They’re helping people to modulate and manage their moods. It’s addictive because it’s right there at your fingertips, and you’re able to reach out and just start clicking this thing to create a stimulus response loop.There are more and more moments of zoning out – to use a phrase from the slot machine gamblers – moments that are configured very much like a slot machine in terms of the continuous, rapid little loop where something is opened up and then it’s closed… open it up and then it’s kill the monster; kill the monster again; kill the monster again.
It’s so compelling to take your fingertip and just keep clicking, clicking to get that response.
I have been thinking and writing about mobile apps recently and how they are used for medical and health purposes. Millions of apps designed for smartphones, tablet computers and other mobile devices have been developed since their first appearance in 2008. Many of these are health and medical apps. In mid-2014 there were over 100,000 health and medical apps listed in the two major app stores, Apple App Store and Google Play, and new ones are being issued every day.
Several health and medical apps feature on Apple’s lists of popular apps, and download figures provided by Google Play show that some health and medical apps on their store have been downloaded hundreds of thousands or even millions of times. In late 2012 a Pew Research Center survey found that 85 per cent of American adults owned a mobile phone. Fifty-three per cent of these were smartphones, and one fifth of smartphone users had used their phone to download a health-related app. The most popular of these apps were related to monitoring exercise, diet and weight. A more recent market research study found that almost one-third of American smartphone users (equivalent to 46 million people) had used apps from the health and fitness category in January 2014Public health researchers have sought to evaluate their use in health promotion campaigns and gathering data on health-related practices. But few researchers have investigated the broader social, cultural, political and ethical dimensions of medical and health apps.
Healthcare practitioners and administrators are also increasingly using apps as part of their professional practice. Hundreds of apps have been developed by hospitals and other healthcare providers. A growing number of medical schools are now offering at least part of their education via apps and require their students to own a tablet computer. In one study that surveyed American doctors, more than two thirds said that they used apps as part of their work. Another survey of medical students and junior doctors in a UK healthcare region found that over half of both students and junior doctors had medical-related apps on smartphones, with apps for medical education purposes the most popular. The medical literature now often refers to ‘prescribing’ apps to patients.
Despite the ever-increasing popularity of apps, very little academic research focused on these devices has been carried out in the social sciences and humanities. Numerous market research reports and medical journal articles have been published that provide some quantitative data on their content, accuracy and use, but these are largely instrumental and descriptive rather than critical.
In recent years I have been interested in developing a research agenda in critical digital health studies, including research into medical and health-related apps. I adopt a sociomaterial perspective drawn from science and technology studies to investigate the digital health phenomenon. From this perspective, mobile apps, like all technologies, assume certain kinds of capacities, desires and embodiments; they also construct and configure them. Apps are new digital technology tools but they are also active participants that shape human bodies and selves as part of heterogeneous networks, creating new practices. Indeed apps may be viewed as sociocultural artefacts, the products of human decision-making, underpinned by tacit assumptions, norms and discourses already circulating in the social and cultural contexts in which they are generated, marketed and used. As they not only present information and health and medicine but also often invite users to generate and share digital data about themselves, apps participate as actors in the digital knowledge economy.Read More… App-ography: A critical perspective on medical and health apps
Rachelle Annechino invited me to write something about the concept of “public health” as I experienced it in my decades-long and checkered past in the drug field. That past is described in unbearable detail in a book called Dope Double Agent: The Naked Emperor on Drugs. The bottom line of my memory (if memories can have a bottom line) is that the phrase “public health” was a severe case of metaphor abuse. I only got clear on this slowly over the decades. This is the first time that I’ve tried to box it up in a summary, courtesy of ten years of hindsight after leaving the field.
The history of policy and practice around psychoactive substances in the 20th century U.S. has been a long slow-dance between docs and cops. Consider opioids as an example – opium and morphine and laudanum, and later heroin, and later methadone, and later buprenorphine, and now oxycontin — all opioid drugs that range from the organic to the synthetic. The docs first celebrated them for their medical use, then got upset when users broke the compliance rules and used them on their own, at which point the cops stepped in. In their different historical contexts they went through the same cycle, from legit (more or less) medication to popular use to crime. To those of us working in what the bureaucrats called the “demand” side of the drug field, attention to public health made a lot more sense than what the better funded “supply” side lusted after, namely, toss the addicted into jail.
Like most U.S. presidential elections, “public health” was only the better of two bad choices. “Public health” has its uses. Boas studied with Virchow, a founder of social epidemiology, after all. It isn’t the right framework to describe and understand people in their social worlds and how chemicals they ingest do and don’t fit into the flow. But, if you want to join policy conversations about “substance abuse” in most countries I’ve worked in, you have to translate your arguments into a doc/cop creole to make sense to the other participants. It’s the old problem of naïve realism, as the social cognition types say, or doxa, if you’re a Bourdieu fan. Do you push from the outside or talk on the inside? I chose the latter. So the question was, how could anthropologists, among others, use and subvert the public health discourse in useful ways?
Here’s a pretty easy example of one way we did that. Historically, public health arose out of successes at finding and then controlling the biological mechanisms that caused a disease. Public health found those mechanisms using epidemiology and then attempted to control them with biology. Epidemiologists built a database of “case records.” A good case record consists of clinical criteria for diagnosis, severity, time and place of onset, and demographics. (See, for example, this introduction to epidemiology [pdf].)
In the drug field, “ diagnosis” and “severity” were corrupted by war on drugs ideology. The insanity reached a peak in the 1980s with the official definition of “drug abuse” as “any illicit use of a substance” — any at all — including “illicit use” of a legal substance as well. This madness occurred at about the same time as the famous “library purge” of 1984, in which the National Institute on Drug Abuse (NIDA) expunged a set of its own titles from its archives and encouraged librarians to remove them from card catalogs. With time, as the DSM molted during its travels along its Roman numeral marked trail, diagnostic criteria have become more subtle and more reasonable, but that official definition of “abuse” remains on NIDA’s web page today. By this definition, it’s hard to imagine anyone who hasn’t been, at least at one point in their life, a drug abuser. The “diagnostic” part of a case record lost any useful meaning for research or intervention.Read More… Public Health on Drugs