Critical Perspectives on Digital Health ... - Wiley Online Library

Sociology Compass 8/12 (2014): 1344–1359, 10.1111/soc4.12226

Critical Perspectives on Digital Health Technologies Deborah Lupton* University of Canberra

Abstract

Discussions of digital health technologies in the popular media and the medical and public health academic literature frequently comment on how these technologies might offer new or improved ways of delivering health care, conducting health promotion activities and monitoring public health. Following the presentation of an overview of the range of digital health technologies that are currently in use, I review the work of researchers in the field of critical digital health studies who have addressed their broader social, cultural and political dimensions. The discussion focuses on four major topics: health and medical websites and platforms; telemedicine and telehealth; the politics of digital health; and digitised embodiment. I end with identifying some important directions for future research in critical digital health studies.

Introduction In the contemporary era, digital technologies have become increasingly ubiquitous across all social institutions. The emergence of mobile digital devices such as smartphones, tablet computers and wearable devices, social media platforms, the collection of massive digital datasets and the surveillance of people’s movements in public space using digital technologies has led to social relations, knowledge production and dissemination, commercial enterprises and governmental agencies and practices becoming digitised. Writers on digital technologies now frequently draw distinctions between the Web 1.0 and Web 2.0 eras (Lupton 2015). While these distinctions are not without their critics (Allen 2013), they are useful heuristics in defining changes in technologies and their use. Web 1.0 refers to the initial stages of the World Wide Web, characterised by static websites that were designed for viewing by users, the content of which was infrequently updated. Online discussion groups, emails and listservs provided the means by which greater social interaction of users could be achieved. The Web 2.0 era has been identified as emerging in the early 2000s with the development of social media and mobile devices, promoting greater user interaction, enhanced access to the Internet from a variety of locations and the facility for users’ geolocation and online use of their devices to be monitored. Some commentators argue that we are now moving towards Web 3.0 (otherwise referred to as the ‘Semantic Web’) or the Internet of Things, in which ‘smart’ objects are able to exchange data directly with each other, thus allowing for more powerful data integration (Kamel Boulos and Wheeler 2007). Another digital phenomenon to have emerged in recent years is that of the massive data sets that are generated by digital technologies, often referred to as ‘big data’. Big data are generated from routine online interactions and transactions online, the sensors that are embedded in devices and physical environments and the creation of digital content by users when they upload information to the Internet. Cloud computing technologies now facilitate the production, storage and exchange of these big data, and a growing digital economy has emerged in which these data have taken on commercial value (Kitchin 2014; Lupton 2015). These developments in digital technologies have had a major impact on health care and public health, for both lay people and those employed in these sectors. Digital health is a term that is becoming frequently adopted to encompass a wide range of technologies related to health and © 2014 John Wiley & Sons Ltd.

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medicine. Table 1 outlines a typology of contemporary digital health technologies. As this table demonstrates, there are many technologies that come under the rubric of digital health, from those directed at individuals to those used at the population level. The popular media and the medical and public health literature are replete with statements about the potential of such technologies to revolutionise and ‘disrupt’ medical and public health practice and produce better outcomes for patients; facilitate health care, preventive medicine, health promotion and care of the elderly; gather better data on patients, medical outcomes and disease patterns; and reduce healthcare expenditure (for example, Kamel Boulos and Wheeler 2007; Swan 2012; Topol 2012; Hill, Merchant and Ungar 2013). It is routinely suggested that these technologies provide particular opportunities for people who live in rural or remote regions or in developing countries, where healthcare provision and health promotion activities may be limited, thus potentially overcoming geographical and socioeconomic barriers to access (WHO 2011; Chib 2013; Edwards, Thomas, Gregory et al. 2014). Medical practitioners and public health professionals are using technologies such as social media platforms, apps, smartphones and smart objects to collect data on health and medical topics; access and share medical information and develop networks; deliver health care; and monitor people’s health-related activities, illnesses and disease outbreaks. Smart pillboxes, digital pills and implants containing microchips, electronic patches, digital wireless blood pressure monitors (see Figure 1), ECG monitors and blood glucose testing devices have been developed. Smart objects such as special clothing, shoes, chairs and mats are now available with embedded sensors that are able to measure and monitor physical movement and other bodily activities as part of providing care to elderly people or those with disabilities. Doctors and other healthcare practitioners are able to exchange ideas and experiences with each other on social media sites such as Twitter and platforms that have been developed for them such as Sermo and QuantiaMD (online communities exclusively for doctors that facilitate discussion of medical matters and share professional advice). In the health promotion and public health literature, academics and practitioners have frequently represented digital technologies as offering new ways of tracking disease outbreaks Table 1. A typology of digital health technologies. Telemedicine and telehealth: medical consultations, clinical diagnosis and healthcare delivery offered remotely via digital technologies Medical education, training and exchange of information between doctors and other healthcare providers using digital technologies Digital diagnostic, genomic, risk-assessment and decision-making technologies: including apps, online tools and add-on technologies to smartphones for use by doctors Digitised devices for delivering medicine or regulating/enhancing bodily functions (cochlear implants, cardiac monitors, insulin pumps, digital pills and so on) Health informatics such as electronic patient records and other online health information, triage and appointment booking systems Digital health promotion: disseminating health education messages via digital technologies Biometric tracking, patient self-care and monitoring devices: apps, smartphones, smart objects and wearable technologies for monitoring and tracking bodily functions and activities Patient blogs, social media sites and dedicated platforms for exchange of information by patients, enrolment into drug trials and crowd funding for medical research Digital epidemiology: tracking disease outbreaks and spread using digital media Sensor-based environmental monitoring, community development and citizen science initiatives Digital health games: console, online and app games designed for fitness, tracking biometrics, health promotion and health education

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Figure 1 Digital blood pressure monitor.

and educating members of the public about illness and disease prevention. Various social media tools have been employed in public health efforts to disseminate information about health risks and disease outbreaks and to collect data on the incidence of illness and disease. Big data are viewed as having great potential for producing new knowledge about illness and disease and contributing to preventive medicine and health promotion: Figure 2 gives an example of a map produced using big digital data sets as part of public health surveillance. Health promoters have experimented with using text messages, social media sites and apps to disseminate information about preventive health, collect data about people’s health-related behaviours and attempt to ‘nudge’ members of target groups to change their behaviour in the interests of their health. Strategies for community development and ‘healthy cities’ are now articulated that include citizen data-generation and sensor-based technologies for collecting environmental and health data. Lay people, for their part, are able to access an array of social networking platforms such as PatientsLikeMe (Figure 3), where they can exchange their experiences with other members of the site, contribute to aggregated data that are used by site members and medical researchers and sign up to drug trials. They can upload photographs and videos showing the bodily signs and symptoms of their conditions using services such as Instagram and YouTube and create Facebook pages on their condition to share information and comments. They can comment about their condition and share links with others via Twitter. They can read, edit or create a Wikipedia entry on a medical condition or treatment. They can rate their healthcare providers and provide their views on the quality of care offered on sites such as Patient Opinion. They can use an app to self-diagnose a condition and find further information about it. Lay people can also watch videos of surgical procedures that doctors have uploaded to YouTube and download apps that give detailed medical or anatomical information about the human body (see Figure 4). They can check sites such as HealthMap to determine whether there is an outbreak of infectious disease in a specific geographical location and also contribute data to these sites about their own illnesses. Patients can even resort to crowd funding websites such as GiveForward to seek contributions towards the medical expenses. People can use their smartphone or a wearable self-tracking device to monitor their bodily functions (such as the digital fitness tracker shown in Figure 5) and upload these data onto a social networking site or send it to their doctor. © 2014 John Wiley & Sons Ltd.



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Figure 2 A predictive model of spatial dengue disease risk, combining various big digital data sets.

Critical digital health studies Many accounts published in the popular media and the medical and public health literature represent digital health technologies in largely uncritical ways that frequently refer to them as ‘solutions’. Discussion of digital health in the popular media and the medical and public health literature has rarely addressed the broader implications for how understanding and knowledge of the body, health, disease and illness are developed and for issues relating to medical and public health practice, power relations and the doctor–patient relationship. In contrast, the contributors to a growing body of literature that I term ‘critical digital health studies’ offer a somewhat different perspective. Such researchers, who are mostly found within sociology, anthropology, science and technology studies, media studies or cultural studies, have sought to identify the social, cultural, political and ethical dimensions of the digital health phenomenon. © 2014 John Wiley & Sons Ltd.



Figure 3 PatientsLikeMe platform for sharing patients’ experiences.

The critical digital health studies literature is dominated by a number of theoretical perspectives. These include political economy approaches that incorporate a focus on digital social inequalities, medical dominance and medicalisation, globalisation, the role played by commercial entities such as Big Pharma, the biotech industry and digital developers and the implications for social justice; Foucauldian perspectives on the discursive construction of knowledge and matters relating to biopolitics and biopower, disciplinary power, governmentality and surveillance; the sociomaterial approach that directs attention at the intersections of human and non-human actors in creating digital assemblages; and the digital cultures or cybercultures literature, focusing on the production and experience of selfhood and embodiment via digital technologies. © 2014 John Wiley & Sons Ltd.



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Figure 4 Personal health apps for smartphones.

Figure 5 Wearable self-tracking device – Nike Fuelband.

From a position that is informed by these theoretical approaches, digital health technologies are sociocultural products located within pre-established circuits of discourse and meaning. These writers are not simply preoccupied by the instrumental uses, the benefits or drawbacks of digital health technologies, although these are identified and acknowledged. They seek to draw attention to the role played by digital technologies in configuring and enacting concepts and experiences of embodiment, selfhood and social relations in the context of medicine and public health. There is not enough space here to discuss all of the insights offered by researchers adopting a critical perspective on digital health technologies. In what follows, I review some of the work that has been published on four major topics: health and medical websites and platforms; telemedicine and telehealth; the politics of digital health; and digitised embodiment. The review ends with some observations of gaps in the literature and where researchers who are interested in critical analyses of the digital health phenomenon might focus their attentions in the future. © 2014 John Wiley & Sons Ltd.



Health and medical websites and platforms Health and medical websites and platforms have comprised one of the major research interests of critical social researchers who are interested in digital health technologies. In the wake of a growing number of health and medical-related websites emerging around the turn of the century, an extensive body of research was published in late 1990s and into the first decade of 2000 on the ways in which people used these Web 1.0 technologies to seek information about health, to blog about health issues, to construct communities of lay people exchanging personal experiences and information about particular conditions and to develop support and activist groups. During this period, researchers addressed such topics as how support groups, discussion boards, blogs or chat rooms operate socially; the kinds of messages portrayed on such forums; the impact on the doctor–patient relationship; and the reasons why people from different social groups seek information or support from the Internet (for an overview of this literature, see Kivits 2013). As outlined earlier, the advent of Web 2.0 technologies has ushered in an even greater variety of ways for people to seek information and advice, record and share their own opinions and experiences, and monitor their bodies’ functions and health states, producing their own healthrelated data. The term ‘prosumption’ (a neologism combining consumption and production) has been employed to describe the new ways in which digital technology users are now able to create the content of online materials and share this content with many others as part of participatory web cultures (Beer and Burrows 2010; Ritzer 2014). These changes have meant that social researchers are faced with the challenge of researching Internet and digital device use in a multiplicity of sites and a diverse range of practices. Social researchers have continued to recognise the importance of online sites for configuring patient networks and lay knowledge about health and medicine. The prosumption practices afforded by social media sites that encourage patients to share their experiences, to participate in drug trials or to comment on or rate healthcare providers have been examined by several critical researchers (Adams 2010; Levina 2012; Adams 2013; Lupton 2014a). Online diagnostic testing, particularly those inviting lay people to send samples of their DNA for genetic testing, has attracted attention in some studies (Levina 2010; Harris, Wyatt, and Kelly 2012; O’Riordan 2013; Wyatt et al. 2013). A small number of researchers have focused on the sociocultural aspects of representations of health and medical topics on YouTube (Longhurst 2009; Mazanderani, O’Neill, and Powell 2013; Del Casino and Brooks 2014; Harris, Kelly, and Wyatt 2014). However, few critical analyses have investigated how these topics are portrayed on Twitter or Facebook (notable exceptions are Brown and Gregg 2012; Murthy 2013). Importantly, social researchers have begun to recognise the complexities of the digital knowledge economy and to comment on the ways in which the participatory democracy and sharing ethos (Beer and Burrows 2010) that were characteristic of the early years of Web 2.0 have transformed into a commercial environment in which the harvesting of personal data has become a source of economic revenue not only for the platforms’ developers but also for third parties who seek to mine the data that are generated on these sites (Kitchin 2014; Lupton 2015). The data that are generated from apps, self-tracking digital devices, patient support and opinion websites and those scraped from social media sites where medical and health topics are discussed possess great value to companies as well as government agencies and public health enterprises (Ebeling 2011; Mazanderani, Locock, and Powell 2013; Lupton 2014a,2014b). These researchers have identified the social practices, relationships and identities that are configured and reproduced via these digital health technologies. They go beyond simple description of the ways in which people are using health and medical websites and platforms to focus attention on how knowledge, social relations and power relations are generated and circulated on these forums. As such, this research differs from more instrumental approaches in the © 2014 John Wiley & Sons Ltd.



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medical and public health literature that tends to be interested predominantly in the quality of information presented on these sites, how to use the Internet to ‘nudge’ people into changing their behaviour or the threat to medical practitioners’ authority presented by ‘Dr Google’. Telemedicine and telehealth Another commonly-researched topic, particularly on the part of sociologists, is that of telemedicine and telehealth technologies. Telemedicine is a specific term that refers to the use of communication and digital technologies to communicate with patients, effect clinical diagnoses and deliver health care in remote locations. Telehealth more broadly refers not only to these services but also to non-clinical services offered via digital technologies. Critical social researchers have delved into the ways in which patients and healthcare workers take up, negotiate or indeed resist the use of these technologies, often adopting an ethnographic or phenomenological approach to do so. Using these approaches, rich contextual data have been generated on the lived experiences of being the subject or provider of telemedicine and telehealth. A number of studies into technologies designed to promote self-monitoring of patients’ bodies or self-care routines have uncovered the complexity of patient response to these devices (Andreassen, Trondsen, Kummervold et al. 2006; Nicolini 2007; Mort, Finch, and May 2009; Mort and Smith 2009; Andreassen and Dyb 2010; Oudshoorn 2011; Greenhalgh, Wherton, Sugarhood et al. 2013). This research has found that some patients find onerous the imposition of home-based digital technologies designed by their doctors to maintain surveillance of their health and body function. Patients must respond to precise daily schedules of monitoring and treatment, and they may feel as if they have little control over their doctors’ decision to employ these technologies and may wish to return to a doctor–patient interaction model in which they are physically attended by a healthcare professional rather than remotely monitored. Alternatively, they may find that the provision of such technologies allows them a sense of control over their bodies and enjoy not having to attend medical appointments or being able to return home from hospital. While these technologies extend the medical gaze into the home, therefore, they may also give patients the opportunity to avoid this gaze. Here, the emotional investments that patients place in technology use, both positive and negative, are important to consider. Trust becomes even more important to patients who are dealing remotely with their healthcare providers (Andreassen, Trondsen, Kummervold et al. 2006). Such devices may be considered both a ‘friend’ and a ‘foe’ by patients (Hortensius, Kars, Wierenga et al. 2012). The readings provided by tele-monitoring devices may give reassuring results, but they may also inspire anxiety and dread if the data exceed acceptable ranges (Huniche, Dinesen, Nielsen et al. 2013). Critical scholars have also called attention to the messiness and contingencies of patients’ interactions with telemedical and telehealth technologies. The fantasy of technological control is routinely challenged by the realities of everyday use. Despite the claims to accuracy and ease of use that often accompany such devices, detailed observations of patients and interviews with them have revealed that in practice, these devices can be tedious, frightening, difficult and frustrating to use. The technologies themselves can be erratic, and they are attempting to monitor, measure and exert control over human bodies that are also unpredictable. The devices also get in the way. Patients may feel as if they clutter up their homes and interfere with their daily activities (Mol and Law 2004; Mol 2009; Oudshoorn 2011; Greenhalgh, Wherton, Sugarhood et al. 2013). Support for older patients wanting to continue to live in their own homes – the concept of the telehome (Milligan, Roberts, and Mort 2011) – has been a feature of digitised health care for some years now. Such digital devices such as motion sensors, electronic drug dispensers, smartphones, wireless blood pressure monitors, chairs and f loors embedded with sensors and © 2014 John Wiley & Sons Ltd.



even companion robots have been employed in the effort to create telehomes. These devices may act as enabling technologies, allowing people to stay in their homes if they prefer. However, concerns have been raised that the use of surveillance technologies designed to monitor the bodily movements and functions of older people living at home may contribute to institutional ageism and lack of privacy and lead to people feeling as if they are overly monitored and their choices constrained. They may contribute to feelings of isolation and dependence if they take the place of face-to-face contact with family members or caregivers (Brittain, Corner, Robinson et al. 2010; Milligan, Roberts and Mort 2011; Long 2012; Mort, Roberts and Callén 2013). It has also been contended that the deployment of these devices may support the perception that older people are frail and dependent, meanings that contradict the discourses of ‘active’ or ‘good ageing’ that also attempt to frame ‘aging in place’ policies and practices (Greenhalgh, Wherton, Sugarhood et al. 2013; Aceros, Pols and Domènech 2014). Digital technologies are not just part of lay people’s experiences of health and illness. They also are essential features of the medical and public health workplace. An extensive body of social research has been published that identifies the ways in which healthcare workers use digital health technologies as part of their professional employment (see, for example, Mort and Smith 2009; Halford and Obstfelder 2010; Milligan, Roberts and Mort 2011; Oudshoorn 2011; Roberts, Mort and Milligan 2012; Pope, Halford, Turnbull et al. 2013; Greenhalgh, Stones and Swinglehurst 2014; Pope, Halford, Turnbull et al. 2014). Critical social research has identified that when healthcare workers demonstrate resistance to using these technologies, such a response is multi-faceted and complex. It is not simply a matter of inertia or technophobia on the part of these professionals, as some of the health informatics and other digital health literature within health services tend to imply. The doctors interviewed by Greenhalgh et al. (2014), for example, found that using a centralised online appointment booking system interfered with the local and contextualised knowledge they had developed through their work. In their study of clinicians using telemedical devices, Mort and Smith (2009) discovered that their work practices involves much invisible work. They observe that the clinicians’ knowledge and actions were often acquired despite of, rather than facilitated by, digitised information systems. As sociologists have observed, telemedicine disperses the spaces of medical care and also the medical gaze from well beyond the clinic into patients’ homes. Telemedical and telehealth devices have disciplinary and surveillant capabilities, making specific demands of patients and workers. The research reviewed above has demonstrated the contingencies and compromises that are routine to the use of digital health technologies by both patients and healthcare workers. Many writers adopt a sociomaterial perspective, emphasising that such practices are part of a network of actors, both human and non-human, that construct what might be called digital healthcare assemblages. Human actors respond to digital health technologies by shaping them to fit their domestic or work practices where they can. Technologies are thereby appropriated and domesticated as part of regular or everyday routines. However, human users may themselves disciplined by the technologies at those points where the technologies are resistant to intervention or change. The politics of digital health Social justice concerns are important to many critical researchers writing about digital health. They have drawn attention to the neoliberal political orientation that underpins discourses on the engaged patient and the empowered health consumer. They have contended that many accounts of digital health in media portrayals and the medical and public health literature focus on the importance of personal responsibility and self-care that these technologies are promoted as facilitating (Andreassen and Dyb 2010; Andreassen and Trondsen 2010; Lupton 2012a,2012b, 2013a,2013b). Such discourses therefore conform to a general move in neoliberal political © 2014 John Wiley & Sons Ltd.



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systems to encourage citizens to voluntarily engage in strategies to improve their lives and productivity (Lupton 1995; Ayo 2012). These issues have become particularly pressing in the wake of the global financial crisis and the introduction of austerity measures in many countries (De Vogli 2011). Those who advocate the ideal of the self-responsible actor fail to recognise the socioeconomic and political factors that inf luence people’s use of digital health technologies. Mass surveys have shown that many lay people frequently use some forms of digital technologies as part of their health and medical practices. Finding health-related information online is a particularly widespread practice. A survey conducted by the American Pew Research Center found that one in three respondents had gone online to find information about a medical condition, and that women, White people and those with a high education level and income were more likely to have done so (Fox and Duggan 2013). However, Pew’s research points to continuing differences in Internet use between social groups. It has found that 15 percent of American adults do not use the Internet at all, and that this group is dominated by those aged 65 years or older. While the expense of Internet access and lack of availability are issues, more significant are lack of interest and a perception that the Internet is not easy or is risky to use (Zickuhr 2013). Internet use is strongly correlated not only with age but also with income and education level and geographical location. Those with lower levels of income, education and understanding of how to use digital technologies and people living in rural and remote regions and less wealthy countries are less likely to want to go online, do not possess the skills to do so or do not have access to the Internet (Hargittai and Hinnant 2008; Chen 2013; Olphert and Damodaran 2013; Zickuhr 2013; Baum, Newman, and Biedrzycki 2014). People from disadvantaged social groups often lack both health literacy and digital literacy, resulting in less knowledge and fewer skills in using digital technologies for health promoting purposes. As a result, existing social inequities that contribute to poorer health states and higher levels of poor health can be exacerbated by lack of access to or knowledge about digital technologies (Baum, Newman, and Biedrzycki 2014). Health status is also important: people with disabilities and chronic health conditions are less likely to use the Internet than others due to lack of access, expertise and physical conditions that made Internet use difficult (Fox and Boyles 2012; Choi and DiNitto 2013; Ellis and Goggin 2014). The broader landscape of the digital data economy and the ways in which the Internet empires of Google, Facebook, Amazon, YouTube and the like structure and configure the digital user also requires attention as part of identifying the digital politics (Franklin 2013; Van Dijck 2013; Lupton 2015). Researchers who contribute to the critical digital health literature have pointed out the competing interests that configure and delimit individual users’ deployment of digital health technologies. Many stakeholders now jostle for lay people’s attention in the world of digital health information, including members of the medical profession and allied health professionals, health insurance companies, pharmaceutical and medical technology companies, hospitals, patient support associations, government agencies and digital device and software developers. As noted above, an important part of identifying the political dimensions of digital health is discussing the ways in which such entities as Big Pharma, the biotech industry and actors in the digital data economy are involved in creating digital content and harvesting the web for digital data for commercial. Here again, it is important to recognise that human actors are part of complex networks of technologies and power relations. Digitised embodiment Sociologists and other cultural analysts have pointed out that rather than simply neutrally mirroring key aspects of a pre-given natural body, digital technologies as they operate in © 2014 John Wiley & Sons Ltd.



medicine and public health configure and reconfigure the body in certain ways, changing how they are understood and treated (Miah and Rich 2008; Rich and Miah 2009; Lupton 2012a; Prentice 2013). Medical technologies have produced knowledge about and intervened into human bodies for centuries, contributing to notions of what is considered normal and deviant, healthy and pathological (Casper and Morrison 2010; Clarke, Shim, Mamo et al. 2010). In this digital age, it has been contended by a number of sociologists that medicine and health care have become increasingly represented and experienced as a digitised information science, creating a new medical cosmology and new forms of technological embodiment. The human body has become conceptualised in terms of computerised images and data as new ways of accessing and monitoring the body have developed (Haraway 1991; Waldby 1997; Nettleton 2004; Miah and Rich 2008; Mort and Smith 2009; Rich and Miah 2009; Halford and Obstfelder 2010; O’Riordan 2011). Digital technologies are able to peer into the recesses of the body in ever-finer detail, creating new anatomical atlases (Waldby 1997; Lupton 2012b, 2013b, 2014b; Ruckenstein 2014). This has led to the configuration of ‘biodigital bodies’ (O’Riordan 2011). New forms of digitising the body have become increasingly important to ways of viewing and treating patients. The virtual world platform Second Life has been used for some years for medical training (Kamel Boulos, Hetherington and Wheeler 2007; Wiecha, Heyden, Sternthal et al. 2010): see Figure 6 for an example. Medical schools are beginning to offer curricular that use apps and tablet computers to deliver materials and wearable devices for training purposes (Husain 2011). Medical practices that were once embodied in the f lesh, including the development of doctors’ expertise in touching the patient’s body and determining what is wrong, have increasingly become rendered into software. Virtual bodies have been developed for medical training purposes, allowing students to conduct virtual surgery. To achieve this virtuality, the processes by which doctors practice – their customs, habits and ways of thinking – are themselves digitised. Both doctors and patients are rendered into ‘informatic “body objects”, digital and mathematical constructs that can be redistributed, technologized, and capitalized’ (Prentice 2013).

Figure 6 An example of using Second Life for medical training: a diabetes specialist avatar reviews a patient’s medical results with her. © 2014 John Wiley & Sons Ltd.



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It is not only medical technologies that have contributed to new forms of digitised embodiment. Digitised images of human bodies in all possible states proliferate on the Internet. With the use of social media platforms, digital imaging and medical apps, the anatomical details or functions of the human body – whether that of anonymous individuals or one’s own body – have become public displays (Miah and Rich 2008; Longhurst 2009; Del Casino and Brooks 2014; Lupton 2015). As noted above, people with medical conditions are now able to upload descriptions and images of their bodies to social media to share with the world. Even the earliest stages of human bodily development – the embryo and the foetus – are now public bodies, featuring on detailed websites and in proud parents’ Facebook, Twitter or YouTube accounts (Lupton 2013c). People who use digital devices to voluntarily track their body metrics often upload the detailed data that they have collected to the Internet to share with others on social media sites or fitness or weight-loss platforms (Lupton 2013b, 2013d, 2014b). Older writings on digitised bodies often evoked the figure of the cyborg to articulate the intersections of human and machine that were enacted. The concept of the digital cyborg assemblage moves on from the more static concept of the cyborg to represent the dynamic nature of contemporary digitised bodies. Digital cyborg assemblages are configured when human actors interact with digital technologies. As prosthetic technologies, digital devices extend the capacities of the body by supplying data that can then be used to display the body’s limits and capabilities and allow users to employ these data to work upon themselves and present themselves in certain ways (Levina 2012; Lupton 2012a). The digital data assemblages that are thus configured, which have also been referred to as ‘data doubles’ (Haggerty and Ericson 2000), comprise new forms of embodiment. They have their own social lives and materiality, quite apart from the f leshy bodies from which they are developed (Lupton 2013b, 2014b; Ruckenstein 2014). Contributors to the critical digital health literature have identified the possibilities of these developments in ways of thinking about bodies, the new forms of virtuality that are generated as part of the configuration of data doubles. However, there is much here yet to explore, particularly as novel forms of monitoring, measuring and visualising human embodiment continue to be generated and incorporated into medicine, public health and everyday life. Directions for future research Critical researchers have identified many important issues relating to the digital health phenomenon. The body of literature here reviewed has provided a solid basis for further empirical research and theorising on this topic. Given the rapid proliferation of digital technologies relating to health and medicine, however, many more aspects require continuing or further investigation from a critical and in-depth perspective. While the topic of digital social inequalities has received attention, few studies have focused on the implications for people’s access to and use of digital health technologies. As yet, little critical social research has addressed the role played by digital technologies such as apps, gaming devices, YouTube videos, Twitter or Facebook networks or wearable technologies in the medical or public health domains. Detailed research that investigates the ways in which these technologies are incorporated into everyday life for both lay people and healthcare workers is called for. Analysis of the ways in which digital technologies are used for medical education and training, public health surveillance, health promotion or the sharing of information between themselves by healthcare and public health workers has received almost no attention from critical scholars. The movement of digital health technologies into new arenas such as healthy communities and cities initiatives, school physical and health education and prenatal and postnatal care for and surveillance of new mothers and their infants requires further research. © 2014 John Wiley & Sons Ltd.



We also have very little information about the working practices and mentalities of the commercial interests involved in the development, production and marketing of digital health technologies: the technology developers, coders, designers and those for whom they may be commissioned to build software and hardware. While big data continue to receive widespread publicity, few social researchers have examined the implications for medicine and public health. Yet there many are important privacy and ethical issues to consider in relation to the highly personal data that are collected from digital devices, apps and platforms. There are significant topics to explore in relation to how digital data and the algorithms that collect and manage these data contribute to certain ways of categorising and producing subjects and bodies, particularly in a context in which these data have increasing commercial value. As noted above, people’s prosumption activities are now frequently commodified in ways of which they may be unaware. This is a crucial area of research in a context in which digital data have become increasingly valued and commodified and will require greater attention in future critical digital health research. On a deeper theoretical and political level, many epistemological and ontological questions are raised by the use of digital health technologies. How are concepts of health, illness and the body generated or transformed by digital health technologies and the data they generate for both lay people and professionals? What are the implications for medical power and knowledge and the doctor–patient relationship (and other lay person–healthcare worker relationships)? How are professional work practices and identities changing as new digital technologies are introduced into the workplace? What are the new forms of surveillance that are generated by these technologies, how are they used and what are their effects for lay people and professionals? In a context in which the Internet empires are gaining greater control over digital data, what are the implications for lay health practices and professional medical and public health work? Addressing these issues and topics need to be part of critical social research into the digital health ecosystem. They offer many intriguing opportunities for researchers and theorists who are interested in bringing together a focus on contemporary medical and public health with an understanding of the new digital society.

Short Biography Deborah Lupton is Centenary Research Professor in the News & Media Research Centre, Faculty of Arts & Design, University of Canberra. Her latest books are Medicine as Culture, 3rd edition (Sage, 2012), Fat (Routledge, 2013), Risk, 2nd edition (Routledge, 2013), The Social Worlds of the Unborn (Palgrave Macmillan, 2013), The Unborn Human (editor, Open Humanities Press, 2013) and Digital Sociology (Routledge, 2015). Her current research interests are in big data cultures, self-tracking cultures, the digitisation of children, academic work in the digital era and critical digital health studies.

Note * Correspondence address: Deborah Lupton, News & Media Research Centre, Faculty of Arts & Design, University of Canberra, Canberra, Australia. E-mail: [email protected]

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