On the Promise and Peril of Technology for Population Health: A Public Health of Consequence, November 2017

The digital revolution started around 40 years ago with a shift from analog to digital technology and accelerated with the widespread adoption of personal computers and digital record keeping. Time magazine declared the personal computer its machine of the year in 1982, heralding an era in which everyone had access to computing power that exceeded, by orders of magnitude, what was available to institutional servers just decades before. And, about a decade ago, Apple’s introduction of the iPhone transformed portable digital computing, creating seemingly boundless opportunities for personal engagements with digital devices. The digital revolution has been described, with some merit, as the most important change humans have lived through since the introduction of steam, and indeed it is hard to think of any aspect of daily living that is now not touched by and in some way dependent on digital devices, whether portable, laptop, desktop, or embedded within the systems that influence our daily lives.

Insofar as our health is shaped by the context in which we live, it is not surprising that the digital innovation that has so transformed our context also has a role to play in shaping population health. One could readily point to the innumerable ways in which digital approaches have transformed the functions of core public health activities, reliant as they are on record keeping and analysis, and the actions of large, complex health protection and health care systems. In many ways, this represents public health’s natural embrace of state-of-the-science approaches to improve its function. That is, at face value, all to the good. However, the widespread adoption of digital approaches, and the readily apparent promise that it represents, also embeds potential challenges. Five articles in this month’s issue of AJPH illustrate, to our minds, three points that merit consideration whenever a particular innovation sweeps through our lives, transforming aspects of how we live.

PUTTING TECHNOLOGY TO WORK

First, new technologies have real potential to improve what we do and how we do it. Openness to ideas that emerge from new technologies can make our core actions better and more effective or introduce us to new ways to tackle old challenges, to the end of doing ever better at improving the health of populations. The articles by Nguyen et al. (p. 1776) and Cohen et al. (p. 1795) make this point in this issue of AJPH.

In their article, Nguyen et al. make use of Twitter to identify norms and behaviors associated with adverse health indicators. In addition to well describing the current limitations of Twitter as a surveillance technology, this article builds on an emerging literature showing Twitter’s promise as an early surveillance mechanism that can guide public health intervention and prevention efforts. About 6000 tweets are sent every second, corresponding to about 500 million tweets daily (http://www.internetlivestats.com/twitter-statistics). This represents a powerful technology that can provide reach into the thoughts and sentiments of populations in ways never previously possible. It would be negligent of public health not to grapple with how we can indeed capitalize on this technology to improve our core functions, and articles by Nguyen their colleagues, and others emerging in the field are doing just that.

Cohen et al. capitalize on the potential of smartphone applications to deliver test results to patients faster, which in the context of sexually transmitted infections is an important consideration. A large body of literature is already taking shape regarding the use of smartphones for health behavior communication. Several reviews have shown that such interventions are promising and may be effective, but much longer follow-up in larger samples is needed before there can be clear evidence about the benefits and limitations of these approaches.¹ Centrally, however, these three articles showcase innovative thinking that aims to adapt rapidly evolving technologies to the aim of promoting population health. Doing so within the framework of robust research and evaluation seems to us a positive, and we would be eager to see which of these approaches truly hold potential over time.

THE DIGITAL DARK SIDE

Second, however, is a sobering caveat introduced by Grundy et al. (p. 1783), who studied the major stakeholders in mobile app development and used social network analysis to assess their financial relationships. Perhaps not surprisingly, Grundy et al. found that most app development is based in North America and that each app involves, on average, nearly five financial relationships. This reflects the reality of app development. It is an expensive proposition and potentially has a real financial upside. App development therefore is embedded within a complex ecosystem of funders and investors, each of whom brings particular perspectives and interests to the evolution of these products. The infusion of money to support the original app development almost inevitably suggests a foundational interest by commercial partners, all bringing an interest in financial return on investment that can trump other, even population health, concerns.

There is a robust literature describing how we may think about the commercial determinants of health.² Grundy et al. sound a clarion call about how the adoption of new technologies, particularly those as pervasive as the digital technology that infiltrates all aspects of how we live, can embed within it complex motives and conflicts that require careful study and scrutiny. None of this is to suggest that commercial interests and the interests of population health cannot align; far from it. It simply urges caution and challenges those of us in the business of studying the drivers of population health to study the commercial underpinnings of new technologies to the end of casting light on potential conflicts and ensuring that population health needs always remain paramount.

ANALOGUE STILL WORKS

Third, although we are enthusiastic about the potential of new technology and how it may influence and improve population health, it is important to explore how much we can still improve through the appropriate use of what we already know, through technologies that have long been with us. This issue is studied by Runyan et al. (p. 1789), who show how law enforcement agencies and gun retailers are willing to offer temporary gun storage when there are concerns about the mental health of family members, keeping guns away from homes where they may be used for self-harm.

There is nothing particularly innovative or digital about gun storage. However, it is a technological solution to a problem that haunts the United States: the country’s disproportionate (relative to peer countries) rates of gun-related injuries, driven principally by suicides. Although discussion in the field has turned, perhaps productively, toward the introduction of smart guns that capitalize on technological innovation, the Runyan et al. article shows that technologies we already have—and have long had—can, if used better and more widely, save lives and protect health. We see this as an important reminder in any discussion of technological advances: we already have solutions to public health challenges that, if used better and more effectively, can save lives and promote the health of populations.

MAINTAINING FOCUS

In summary, technological innovation holds promise for our core mission: improvement of the health of populations. It will take research to document whether new technologies do indeed improve the health of the public and to determine the extent to which they provide value over technologies we already have. At the same time, new approaches introduce new challenges and a new potential for competing interests that challenge the core interests of population health. It is the role of public health practitioners and population health scholars to be vigilant to the potential perils inherent in these new approaches and to identify how we can nimbly and effectively capitalize on technological advances to the betterment of the health of the public.