Tuesday, 9 May 2017

A Waiting Room of One’s Own

Silicon Valley gives you health care without all the sick people

FORWARD, THE STARTUP TOUTED by Bloomberg as “The Doctor’s Office of the Future,” doesn’t call itself a medical clinic. Instead, it bills itself as a “health membership,” like a gym. When I entered its office in San Francisco’s Financial District, the logic behind this turn of phrase began to reveal itself. Its medical robes for patients are designed by Lululemon, a brand that embodies the notion of wellness as a capitalist enterprise, in which the self, like an operating system, is primed for upgrades. More talismans of the self-improvement industrial complex are displayed somewhat conspicuously on the reception desk. On one side are bottles of the sleep supplement melatonin and assorted vitamins; on the other are rows of Aesop products and vials of anti-ageing serums by a company called SkinCeuticals (brand motto: “Skincare backed by science”) that can cost over $100 for a fluid ounce. A glass cabinet gleams with self-tracking gadgets like Wi-Fi-connected “body cardio” scales, blood pressure cuffs, and Fitbits. The promise of self-optimization lurks in the company’s slogan, “Design Your Health,” which is emblazoned in capital letters on the waiting room walls and on posters hanging in the shopfront window, accompanied by photos of lithe specimens in activewear.

The premise of Forward, founded by ex-Google employee Adrian Aoun and early Uber employee Ilya Abyzov, is that software can encourage a greater emphasis on preventative health care and solve the intractable structural problems and perverse incentives beleaguering an ailing system. Among its investors is real estate scion Joshua Kushner (brother of Jared), the co-founder of a health insurance startup that rewards customers who meet their step goals with Amazon credit, and Peter Thiel’s Founders Fund.

Forward’s aims are ambitious. It is betting that its use of body scanners, machine learning algorithms, and sensors can help lower the cost of primary health care by drastically shortening consultation times and improving the accuracy of diagnoses. Members enjoy unlimited visits, attention from a primary care physician, nurse, and “health coach,” and 24-7 access to the startup’s services through an app. In consultation rooms, your vital statistics are displayed on a flatscreen TV while conversations with your physicians are recorded—no need for them to take notes. In case you’re wondering, Forward does not accept health insurance—its $149 monthly fee (slightly cheaper than a membership at Equinox) is paid directly to the company. Patients will, however, need health insurance for specialist services (surgery, dermatology, psychiatry) that are not provided by Forward.

When I visit, there’s no waiting room queue or patients in sight, bar one woman who wanders in out of curiosity. One co-founder described this vision to Forbes as “a doctor’s office that feels more like an Apple Store . . . an Apple Store that learns so it gets better with more data.” It’s an idea that runs counter to the conventional experience of a physician’s waiting room, which is a kind of unpleasantness. This is hardly surprising, given that waiting rooms are sites of illness and unconfirmed diagnosis, not to mention desperation; most of us are reluctant to visit the doctor unless we really need to.

At Forward, however, wellness appears to be a guiding ideology, in which individual responsibility for one’s health is spun as a form of empowerment. This is borne out in its aesthetics, which could be mistaken for a coworking space. The room is minimalist. It combines utilitarianism with the aspirational longing of a Pinterest board. There is a smattering of replica mid-century modern chairs, unadorned walls, polished timber floorboards, and plants in glass bowls. A report in Quartz gushes that Forward’s bathrooms have vestibules that allow you to deposit your urine samples without the threat of prying eyes. It’s one of many flourishes that makes Forward seem oddly squeamish about the business it’s in. That it is resolutely committed to erasing any association with sickness illustrates its profound misunderstanding of the obstacles impeding access to health care. It seems all the more inexcusable in the context of the GOP’s onslaught on health access that these Silicon Valley technocrats do not realize that it is the prohibitive cost of accessing services, rather than a clinic’s ambience, that actually matters.

But whether we like it or not, we’re likely to see more sleek schemes like Forward’s over the coming years. Forward’s accumulation of physiological data is a mere extension of the wholesale aggregation of data that has already taken place on smartphones and wearable devices. On the one hand, Forward’s access to such data may well mean that health plans can be tailored more accurately, or that patients can plan for better health in the long-term. Used judiciously, such data could fill the gaps in health care research. On the other, there’s something unnerving about subjecting oneself to a constant regime of granular diagnostic surveillance, even if the choice to opt in to the medical panopticon is a conscious one. Forward is cashing in on the story we tell ourselves in a neoliberal world: that we alone are the determinants of our self-interest.

The practice of logging our physiological signs and symptoms isn’t novel; its origins are as old as the Roman Stoics. The philosopher Seneca the Younger is said to have kept meticulous logs of his dietary habits and dreams. Self-tracking technologies, once the preserve of the Quantified Self movement, are easily found on the shelves of Walmart. Yet the proliferation of self-tracking is symptomatic of a more insidious sickness: the fixation with the body as an entrepreneurial project. Of course, there’s nothing wrong with taking an active role in improving your health—cutting back on booze and processed foods will give an overworked liver a hard-earned break. But I wonder how much of self-tracking is concerned with wellbeing. Performing health has become the ultimate humblebrag: being on top of your stats is as important as improving them. More troubling, though, is that good health is often seen as a matter of moral responsibility, which falls squarely on the individual. That Forward’s messaging deliberately resembles a high-tech gym aligns with this vision, where the pursuit of good health is often an expression of one’s tax bracket. Being equipped with the ability to constantly monitor and analyze our health metrics is framed as a productive enterprise. To “Design Your Health,” as Forward’s exhortation demands, is to exert control over your bodily destiny—that is, if you can afford it. For others, health is a literal matter of life and death.

Forward’s business model is a tech-driven, somewhat more affordable version of the concierge medicine movement that began in the nineties when Howard Maron, a former doctor for a professional sports team, launched a medical care program that caters to “fifty select families” who pay a retainer of more than $25,000 a year. The problem with concierge medicine is not so much its aims of personalized, preventative care and lower physician-to-patient ratios, but how it achieves them. It’s difficult to see the practice as promoting anything other than a starkly unequal two-tiered system, which only heightens existing imbalances in access to affordable health care.



  1. Universal health care is a hypochondriac's dream!

  2. In ancient times, the practice of "medicine" was essentially the practice of "diet" and "Gymnastics"

    Plato "Gorgias"

    Soc. And now I will endeavour to explain to you more clearly what I mean: The soul and body being two, have two arts corresponding to them: there is the art of politics attending on the soul; and another art attending on the body, of which I know no single name, but which may be described as having two divisions, one of them gymnastic, and the other medicine. And in politics there is a legislative part, which answers to gymnastic, as justice does to medicine; and the two parts run into one another, justice having to do with the same subject as legislation, and medicine with the same subject as gymnastic, but with a difference. Now, seeing that there are these four arts, two attending on the body and two on the soul for their highest good; flattery knowing, or rather guessing their natures, has distributed herself into four shams or simulations of them; she puts on the likeness of some one or other of them, and pretends to be that which she simulates, and having no regard for men's highest interests, is ever making pleasure the bait of the unwary, and deceiving them into the belief that she is of the highest value to them. Cookery simulates the disguise of medicine, and pretends to know what food is the best for the body; and if the physician and the cook had to enter into a competition in which children were the judges, or men who had no more sense than children, as to which of them best understands the goodness or badness of food, the physician would be starved to death. A flattery I deem this to be and of an ignoble sort, Polus, for to you I am now addressing myself, because it aims at pleasure without any thought of the best. An art I do not call it, but only an experience, because it is unable to explain or to give a reason of the nature of its own applications. And I do not call any irrational thing an art; but if you dispute my words, I am prepared to argue in defence of them.

    Cookery, then, I maintain to be a flattery which takes the form of medicine; and attiring, in like manner, is a flattery which takes the form of gymnastic, and is knavish, false, ignoble, illiberal, working deceitfully by the help of lines, and colours, and enamels, and garments, and making men affect a spurious beauty to the neglect of the true beauty which is given by gymnastic.

    I would rather not be tedious, and therefore I will only say, after the manner of the geometricians (for I think that by this time you will be able to follow)

    attiring : gymnastic :: cookery : medicine; or rather,

    1. (cont) attiring : gymnastic :: sophistry : legislation; and

      as cookery : medicine :: rhetoric : justice. And this, I say, is the natural difference between the rhetorician and the sophist, but by reason of their near connection, they are apt to be jumbled up together; neither do they know what to make of themselves, nor do other men know what to make of them. For if the body presided over itself, and were not under the guidance of the soul, and the soul did not discern and discriminate between cookery and medicine, but the body was made the judge of them, and the rule of judgment was the bodily delight which was given by them, then the word of Anaxagoras, that word with which you, friend Polus, are so well acquainted, would prevail far and wide: "Chaos" would come again, and cookery, health, and medicine would mingle in an indiscriminate mass. And now I have told you my notion of rhetoric, which is, in relation to the soul, what cookery is to the body. I may have been inconsistent in making a long speech, when I would not allow you to discourse at length. But I think that I may be excused, because you did not understand me, and could make no use of my answer when I spoke shortly, and therefore I had to enter into explanation. And if I show an equal inability to make use of yours, I hope that you will speak at equal length; but if I am able to understand you, let me have the benefit of your brevity, as is only fair: And now you may do what you please with my answer.

  3. ...of course, that was before things like sex reassignment and other plastics surgeries became acceptable medical "treatments" for a "non-illnesses".

  4. ...of course, that was before things like sex reassignment and other plastics surgeries became acceptable medical "treatments" for a "non-illnesses".


    Years ago, under Thatcher, eye-care and dental care were taken out of the NHS. That turned out to be a Neoliberal dream

    1. I sure hope that they never do that for liposuction and collagen injections!

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