Digital Health and the Gamification of Life

Antonio Maturo, Veronica Moretti

• Publisher: Emerald Publishing Limited
• Year: 2018
• ISBN:
  9781787543676
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

This book analyses the role of technology in the realm of health. Health apps can promote medicalization and the idea that health is an individual matter, rather than a political and social one.The authors base their arguments around three theoretical frameworks. Quantification: the growing importance in our society of markers, rankings, and scores, which thanks to digital devices is fueled by the ease with which it is now possible to collect data. Gamification: a powerful trend in digital society, using playful features to transform what are seen as dull tasks into competitive and appealing ones. Gamified self-tracking seemingly increases our productivity without oppressing us with apparent self-governance. Finally, Medicalization: a growing social phenomenon of the transformation of a 'normal' condition into something pathological. Several health apps presuppose a conception of the user as an individualized subject divorced from any social determinants of health. The authors investigate the possibility of people sharing their most private states leading to new forms of algorithmic surveillance.Alongside this negative vision of medicalization the authors recover the now-rare concept of positive medicalization, looking at how apps can work as positive self-help devices though promoting a medical framework. A selection of digital programs related to fitness in the workplace are also presented and discussed.

Chapter 1

Self-Tracking and the Quantification of Everyday Life

Abstract

In a world dominated by scores, ratings, and rankings, near-constant measurement can make one think, and in turn act, differently. Quantification is felt to be necessary. On a social level, the manufacturing of numbers paves the way for the politicization of numbers, which then allows the regulation of a person’s activities. The setting of seemingly unobjectionable thresholds and limits in fact contributes to the creation of government strategies that conceive of every citizen as a calculable thing. Further, assuming that these numbers are socially constructed elements, a numerical hegemony may develop in which those who do not possess the desired scores suffer social exclusion. The quantification of life has many implications in the realm of social justice. It is conceivable that, in the future, society could acquire some of the characteristics imagined by the writers of dystopian literature. Fourcade and Healy (2013) write that our society is experiencing a transition from distinct social classes to classification based on personal scores and ratings. Indeed, in the United States, the “credit score” is a number which is as important for the modern individual as titles were to medieval to nobility because they determine one’s access to credit. Personal scores and ratings – which could be not only financial but also social or political – could therefore exclude some sectors of society. In this case, too, a numerical indicator holds immense power, making this form of political violence appear as objective and even natural.

Keywords: Quantification; numbers; algorithms; personal scores; rankings; calculating power

1. The Rise of Quantification and the Power of Numbers

In the Seventeenth Century, philosopher Leibniz claimed that:

if controversies were to arise, there would be no more need of disputation between two philosophers than between two calculators. For it would suffice for them to take their pencils in their hands and to sit down at the abacus, and say to each other (and if they so wish also to a friend called to help): let us calculate.

In the same century, Galileo stated that mathematics was the “alphabet” with which God had written the world.

However, quantification has never been as intensively central to our society as it is today. As Espeland and Stevens (2008) claim, it is so important that we take it for granted – while Leibniz and Galileo were well aware of the strength of numbers. Access to credit, funding public policies and even the way in which financial algorithms “make decisions” to sell or buy shares are based on indicators, rankings, and numerical thresholds. Furthermore, because of digitization, the quantification of life now covers all aspects of our life, including the public, economic, medical, and even the intimate side of it. The numerous forms of quantification, from probabilistic calculation to accounting “transform the world, through their very existence, through their dissemination and its uses of an argumentative, scientific, political or journalistic type” (Desrosiers, 2011, p. 378). Furthermore, classifications, cost-benefit analyses, and audits are currently considered necessary to administer public policies.

The term quantification mainly refers to two different – although intertwined – phenomena:

1. The transformation of information of various types into numerical data.
2. The huge amount of data that are produced today through technological devices (big data and data-deluge).

Therefore, if we read these two features sequentially, we will draw the conclusion that today we have a huge amount of numeric data related to multiple dimensions of human life and the life of organizations and that these data were not previously expressed in numerical form.

Both these two aspects occur in self-tracking. Self-tracking can serve as a tool to virtually quantify all aspects of our life. From physiology – menstrual cycle, heartbeats, and blood glucose level – to internal states of being (mood tracking). Obviously, we can also quantify our behaviors (steps and coffee taken, money spent, etc.). A few years ago, quantification was limited to organizations only, whereas, today, it is a possibility for individuals as well. Gary Wolf (2010), founder of the “Quantified Self” movement and website, wrote an article in the New York Times titled “The data-driven life.” In that article, Wolf explains how the quantification of daily life through self-tracking can help us make better decisions and make us happier. Relying on concepts of cognitive psychology and behavioral economics, Wolf argues that we make decisions based on irrational aspects or at best on suboptimal rationalities. A reliable database has always been missing. Yet, smartphones, biosensors, and wearables are altering this limit. We are realizing that quantification can offer us enormous and even existential possibilities.

We tolerate the pathologies of quantification – a dry, abstract, and mechanical type of knowledge – because the results are so powerful. Numbering things allows tests, comparisons, and experiments. Numbers make problems less resonant emotionally but more tractable intellectually. In science, business, and the more reasonable sectors of government, numbers have won fair and square.

For a long time, only one area of human activity appears to be immune. In the cozy confines of personal life, we rarely used the power of numbers. The techniques of analysis that had proved so effective were left behind at the office at the end of the day and picked up again the next morning. The imposition, on oneself or one’s family, of a regime of objective record keeping seemed ridiculous. A journal was respectable. A spreadsheet was creepy.

Yet, almost imperceptibly, numbers are infiltrating the last redoubts of the personal. Sleep, exercise, sex, food, mood, location, alertness, productivity, and even spiritual well-being are being tracked and measured, shared, and displayed. (Wolf, 2010, p. 38)

Clearly, self-tracking is not the only engine that has powered quantification. Increasingly autonomous software and increasingly powerful computers have contributed to filling databases with numbers from all areas of finance, medicine, and business. The evidence-based governance or new public management of the public sector plays a central role in the production of numbers and in the legitimization of knowledge based on numbers. This represents a shift from a hierarchical and command-and-control government model to a type of results-based management, which builds on social involvement, consensus, and improvement. It is a profound change in the provision of public services and, as a consequence, in their organization too. Since the nineties, when the new public management was established, there has been a huge increase in measurement activity. This form of governance, where the public sector is assimilated to a private company, emphasizes aspects like competition and efficiency. As a result, this approach led to the development of indicators, rankings, and audits based on numbers and quantities:

in contrast with earlier systems, which relied on rules and punishments for violations, this mode of governance works through the collaborative production of standards and the evaluations of outcomes, including the use of self-assessment and ranking techniques. (Merry, 2016, p. 11)

Paradoxically, over the course of three decades, this efficiency-driven tendency has given rise to an intense “neoliberal bureaucratization of the world” (Hibou, 2015). The informational structure of the neoliberal capitalism, which is its cognitive basis, has indeed undergone a deep (and fast) transformation. These informational bases are increasingly becoming abstract, presenting themselves as procedures, standards, certification models, online platforms, and, even more visible, numbers, index, quantitative targets, and scores (Borghi & Giullari, 2015). This technicization of public governance activates a radical de-politicization of the issues at stake, as extremely standardized and formalized thoughts translate politically related issues into mere technical debate. This de-politicization is produced by blurring and neutralizing social and economic dimensions. This is essentially realized “through the creation of knowledge tools and devices that are needed for the management and technocratic control of individuals’, institutions’ and organizations’ actions” (Borghi & Giullari, 2015, p. 396). An example might be the redefinition of policies for managing chronic diseases on a purely individual basis and emphasizing personal responsibility. This quantitative approach toward standardization, technicization, and abstraction tends to disregard and reduce creativity and “other” types of rationality. Using the words by Luhmann (1993), one could say that the system will only see the things it can see and does not see the things it cannot. This somewhat cryptic quote means that the frame – which in this case refers to the quantitative and standardizing frame of neoliberalism – defines each situation according to its cognitive patterns. In our case, patterns tend to neutralize any qualitative differences by making them more abstract and opaque. In ethical terms, the bureaucratization of the world is characterized by a growing production of indifference (Herzfeld, 1992).

This neoliberal tendency is evident in universities as well, where both individuals and the organization themselves are constantly exposed to assessment. The outcomes of these assessments – carried out through indicators and rankings – affect the extent of public funding and individual careers. Driven by this neoliberal frame, we think more and more in terms of academic productivity. In another context, Espeland and Stevens (2008) provide reliable examples of the role played by census data in order “to inform social policy, assess business opportunities, report news, measure progress” (p. 406). Another example showing the power of numbers comes from the realm of health: the Diagnostic and Statistical Manual, or DSM. The DSM of Mental Disorders is the basis of any mental disorder diagnosis. Whereas the first two editions of the DSM were characterized by a strong theoretical view, mainly based on psychoanalysis, the DSM-III and, even more, the DSM-IV and the DSM-V try to be atheoretical and symptom based (Horwitz, 2010). Indeed, the “syndromization” present in the last version of the DSM is a good example of quantification “in action” because the diagnoses are based on the observation of a minimum number of symptoms over a set period. To define a mental disorder, the emphasis is put on the numbers and length of symptoms, while causes are neglected. The focus has therefore shifted from illnesses to disorders and syndromes – the latter being a specific number of symptoms occurred for specific numbers of weeks. The key assumption of diagnostic psychiatry is that overt symptoms indicate discrete underlying diseases. Whenever enough symptoms are present to meet the criteria for a diagnosis, a particular mental disorder exists (Horwitz, 2010). There are no explanatory aims in the last versions of the DSM: symptomatology (i.e., the number of symptoms) replaces etiology.¹

Moreover, the quantification of daily life – including physiological, molecular (Rose, 2007) and intimate dimensions of people – is both the cause and the effect of the so-called society of algorithms (Pasquale, 2015). In order for the social environment to be captured, processed, and modified in an algorithmic context, it needs to be made numeric. As Neyland (2015) writes, in order to become part of the social world of the algorithmic system, the external world must be mathematically modeled. The external world is recognized and therefore “accepted” in the algorithmic system only if communication occurs through numbers. The external world is gradually re-codified and reconstructed in the algorithmic reality, until it becomes the only actual reality. As Beer (2009) writes, “algorithms are integrated into everyday social processes and become an organic part that can reinforce, maintain or even reshape our social world, knowledge and relationships with information” (p. 81). Algorithms are not just the products of specific economic, social, and cultural processes but, in turn, they produce specific effects on the economy, social organization, and cultural dimensions (Kitchin & Dodge, 2011).

1.1. How Do to Things with Numbers

At this point, it should be noted that numbers not only enable individuals to understand or be socialized to new situations, but also provide a way for us to alter reality. Quantification has a performative aspect. This performative aspect can be connected to the so-called “linguistic turn” that occurred in the twentieth century. To do so, we need to conceive quantification as a kind of language, in which numbers are words. On the basis of Wittgestein’s theory of linguistic games, Austin (1962) stresses the importance of the performative aspect of linguistic acts, along with the semantic aspect. That is, linguistic acts not only say something, but also they do something. Linguistic acts have real effects. Through linguistic acts, we can make promises, declare two persons husband and wife, or give a name to a boat. Not only does the (linguistic) game enable us to represent and understand new aspects of the world, but it also makes it possible to do things. It is not by chance that Austin’s book, in which he proposes this theory, was titled How to Do Things with Words, and Desrosiers (2011) suggests a change in title from “How to do things with words” to “How to do things with numbers.” Numbers therefore build reality and these constructions appear solid and “objective.” Yet, as we have already mentioned, numbers are tied to underlying social processes.

Research carried out within the sociology of science, and further refined following the Science, Technology, and Society (STS) studies, has showed that objectivity and neutrality of numbers are the results of social practices, micro-negotiations, and political choices. Intuitively, numbers are neutral because they are (apparently) objective. The “naturalization” of numbers consists precisely in overlooking their social and inter-subjective genesis. Hence, an “artifact” becomes a “fact” (Latour & Woolgar, 1979). In a world governed by scores, grades, and rankings, quantification lead individuals to think and, consequently, act differently. From the STS perspective again, we can note how numbers:

turn from evidence for supporting scientific facts into “ready-to-use” scientific facts, which appear as objective entities, that is, they become independent from their process of construction and the more they are used the more they strengthen as such. (Neresini, 2015, pp. 406–407)

In other words, numbers come with agency (Latour, 1987; Neresini, 2015) because, at the same time, they produce and make us produce facts. To use the words by Tesnière (1959), numbers work as “actants” of the system in which they operate; they are not limited to describing the world but they contribute to its modeling. Desrosiers also notes an initial bias. The issue relates to the semantic connection between measurement and quantification. Though the former implies the existence of measurable differences, for example, physical quantities, the latter implies that measured objects are produced by conventions. However, if in the public language – including institutional language – these two terms are widely used as synonyms, conventions that are at the origin of enumerations in quantitative processes can get lost. Rather, conventions are replaced by objective and natural descriptions of reality. For instance, there is quite a difference between measuring one’s height and quantifying their coolness index or their rate of inflation. Not only do numbers naturalize conventional aspects, but on a pragmatic level also these fictions become even more real when they are internaliz...

Table of contents

• Cover
• Title
• Introduction
• Chapter 1. Self-Tracking and the Quantification of Everyday Life
• Chapter 2. Getting Things Done: Gaming and Framing
• Chapter 3. How Apps Foster Medicalization
• Chapter 4. The Self of the Quantified Self
• Chapter 5. The Dark Side of Digital Health
• Chapter 6. The Positive Medicalization: Digital Meditation
• Chapter 7. Exercise is (also) Medicine
• Conclusion
• Appendix: Questionnaire Digital Meditation
• References
• Index