In C.S. Lewis’s That Hideous Strength the protagonist of the story— Mark Studdock, a young and naïve sociology professor—is tempted to join forces with N.I.C.E. (the National Institute for Co-ordinated Experiments), a sinister, technocratic organization. At a pivotal point in his recruitment into N.I.C.E., he is ushered by two of the organization’s leading bureaucrats to the building’s inner sanctum. Here, to his horror, he is brought face-to-face with the center of the organization’s agenda: a severed head, kept alive in a vat of liquid, to which his conspirators kneel. It becomes clear that the whole project of N.I.C.E., while dressed in the garb of scientific humanism, has been to channel dark spirits to take ownership of this head (and many others), for the rest of humanity to ultimately receive its directives from this sinister ensemble, and for this arrangement to last forever. In a spell of nausea, Studdock faints onto the floor, only to wake several hours later with vague memories of the encounter.
Such was, with a few inconsequential differences, my experience after encountering the W.H.O.’s AI-powered “digital health promoter,” S.A.R.A.H. (Smart AI Resource Assistant for Health). As the W.H.O. states, “SARAH is trained to provide information across major health topics, including healthy habits and mental health, to help people optimize their health and well-being journey. It aims to provide an additional tool for people to realize their rights to health, wherever they are.” If one were to open that link (not advised if you have children nearby), one will encounter a disembodied avatar who oddly (or intentionally) looks like a 20-something female who just finished grad school. Like some hideous chimera between a mid-level bureaucrat and a lady of the night, that thing (out of respect for the humanity of man’s first task, I refuse to call it a name) even requires you to turn on your camera.
For Lewis, a head-in-a-vat that channels gnostic truth to befuddled humanity is an icon of a thoroughly technocratic approach to life—one which demands a so-called scientific mastery of human nature and the natural world to serve man’s own ends (which, as Lewis always insists, is really some men’s ability to master other men). As such, I take the WHO’s rollout of that thing as the ultimate icon of a thoroughly technocratic approach to the work of public health.
It does not take a sophisticated analysis to reveal that the profession of public health is nowadays not in great shape. The morale within the profession is low and skepticism from outside of the profession is high (I speak from personal experience, myself having served in that profession for the greater part of the last decade).
Just as Lewis’s novel is an attempt to work out the social assumptions which tend toward head-in-a-vat aspirations, we might look at that thing to interrogate the assumptions that might tempt some to create such a monster—a set of assumptions that might not be unrelated to the current malaise experienced by my colleagues. If there was ever a moment to consider how the profession could become more human, here it is.
The Public Health Machine (PHM)
The primary goal of technocratic public health is, as I have observed throughout my career in the profession, to affect the physical health of a population at scale by bringing it towards some predetermined end (e.g., decreasing diabetes rates in the population by 10%). A predetermined end for what? However much the critical insights of Foucault’s conception of biopolitics may hover in the background, any answer remains undefined. It is as though the predetermined end is merely given, and therefore activity within the PHM is constrained by that end. To question that end is to, in no small way, challenge the entirety of this model. Of course, there are always answers to this question, and they range from the benevolent to the nefarious, but these answers are always hidden by the operation of the machine.
The scope of this approach—its various goals, strategies, metrics, outcomes—is constrained to physical health. While this can be pitched as “stay in your lane” respectfulness, the narrowness also serves technocratic assumptions. Expertise means nothing if the kind of knowledge maintained by the expert is easily accessible to a broader audience, and therefore numerous incentives exist to ensure that the knowledge maintained by the expert is as specialized (i.e., narrow) as possible. As such, knowledge is limited to physical health, if not further divided into subspecialities and further subspecialities of physical health (e.g., diabetes, type II diabetes, type II diabetes among youth, type II diabetes among youth from marginalized backgrounds, etc.). The more that knowledge is divided, the more efficient (targeted) its deployment may be. To presume that physical health is not the entirety of human well-being is, therefore, to fundamentally challenge the efficacy of this model and its assumptions about the value of specialization.
The geographic scope of its work is the population, which is ultimately just an assembly of statistical measures (e.g., the prevalence of diabetes within a state, based on representative sampling or surveillance methods). As James C. Scott writes in Seeing like a State, it is through such techniques that the population is rendered as a legible object that can be manipulated from a distance. This is necessarily an abstracted geography; there is no place that those working within this model must know personally. As a master image, the posture of public health technocrats is much like laboratory scientists operating on a petri dish—intervening at one moment, returning to inspect the health effects of the intervention at another moment, all the while operating the rest of their life outside the lab (indeed, as if the petri dish didn’t exist at all). Practically, this enables those in this model to operate from wherever (a tendency enabled by technologies like screens and telephones), as the actual distance between their person and the work being done is beside the point, so long as they have sufficient information to deploy the right means to achieve the predetermined end. The contextless character of the technical knowledge they possess further contributes to this ability.
A final move is required. Since the birth of public health in nineteenth-century rationalism, the profession has been tempted by gnostic seductions. A prominent history of public health reads that “health education today is one of the most important expressions of the modern theory of community health action. Its value will undoubtedly increase even further as more is learned about human nature and its modifiability.” In other words, “if only we can enlighten the masses, they will be healthy.” As the theologian Brett McCarty writes, to presume that good health is primarily a function of knowing the right combinations of healthy behaviors is to presume that the “problem” of disease is one that can be sufficiently addressed through “knowledge” of the health impacts of those behaviors. Knowledge from who? Public health experts, of course. (according to the WHO, it has “expertise to help prevent some of the biggest causes of death in the world including cancer, heart disease, lung disease, and diabetes”). This temptation only enlarges itself with the expansion of behavioral sciences and statistical methods which all amount to “X behavior is associated with a Y% chance of health outcome Z.”
Thus, we have that thing: a disembodied digital avatar descending from the highest echelon of bureaucratic public health to shower the entire world with scientific enlightenment. It is the ultimate attempt to improve population health from a distance, with as little interaction with flesh and blood people as is needed to achieve that goal (the core aspiration of technocratic public health). It is no wonder that people are, at times, frustrated by the arrogance of this approach. When the ultimate trajectory of a profession is the creation of that thing, how can one not feel skeptical of the profession as a whole (however much its participants may or may not align with the technocratic approach)?
Indeed, that thing is ultimately a kind of alien which one cannot fully know or trust. Not incidentally, our engagement with that thing renders us alienated from every part of our being that could otherwise be strengthened for the sake of human health. We are alienated from the process of thinking to diagnose the ways in which we are not living a healthy life; we are alienated from our friends, family, and broader community to which we can turn with questions regarding health and disease; we are alienated from the cultural habits and traditional beliefs about healing and the body that are particular to one’s time and place in history (that thing is a completely ahistorical, universal construct); as with any digital platform, we are alienated from listening to the experiences of our own body—the first “investigation” any of us should make when we think we are ill.
A More Humane Alternative
If a certain approach to public health seeks to manage population health through the creation of that thing, a better approach does the exact opposite. Rather than inserting further distance between us and the sources of health that exist externally to us, it seeks to bridge those gaps and remind us how good physical health is often a byproduct of healthy relationships to the world and other people. Indeed, public health very often aspires to be on the community side, and the best of the profession does just that. Many of my colleagues have worked within community coalitions to restore the health and sustainability of fragile ecosystems, improve our connections to local sources of food, advocate for policies to limit the addictive features of digital technology, and address epidemics of substance use and addiction through close partnerships with those in religious communities. Through these efforts, individual communities take collective responsibility for the wide determinants of health on their own terms. The future of public health, if it is to take earnest steps towards rebuilding trust with the public, must replicate those kinds of practices.
And yet, that thing could not be a more thorough indictment of the profession’s default orientation. Every attempt to find answers about health-related questions from that thing is a missed opportunity to have that question answered by a real person and is therefore a step away from community. To whom should you go with questions about parenting? Your mother? No, that thing. To whom should you turn to when you’re looking to get out of a depressive funk at 3:00 a.m.? Your close friend? No, that thing. To whom should you get off the couch to visit when you’re confused about a particular medical condition? Your primary care provider? No, that thing. I cannot imagine a more inhuman solution for a profession supposedly dedicated to improving human health. Like any AI chatbot, that thing is untrustworthy, and moreover, it cannot possibly understand the totality of one’s personal needs and surrounding context and therefore cannot possibly render the kind of personal care we’re all really interested in when we look for answers about our health or that of a loved one. Indeed, the design of that thing would not nearly be so disturbing were we not at the same time experiencing an epidemic of loneliness and social isolation—one which, according to the former Surgeon Generals own report, is largely caused by addiction to digital media platforms.
While that thing has now been temporarily deactivated, during its tenure it was capable of “[engaging] users 24 hours a day in 8 languages on multiple health topics, on any device.” At times when I’m about to fall asleep, the image of that thing appears from nowhere. I’m reminded that it was once out there. Talking to people. Likely many people. Likely all at once.
If that thing was in front of me, I would punch it in the face. If I had the power, I would pull the plug on the whole program lest it reappear in some vulnerable corner of the world. Seeing as though I can do neither (the power imbalance between the technocrats and the personalists is part of the problem), I resort to the only power which should be able to heal the whole world at the same moment: prayer.
As Ransom (leader of the followers of Logres and a devoted servant of God) eventually exhorts his comrades who oppose the dark forces of N.I.C.E.: “And if he comes with you, all is well. If he does not — why then, Dimble, you must rely on your Christianity. Do not try any tricks. Say your prayers and keep your will fixed in the will of Maleldil. I don’t know what he will do. But stand firm. You can’t lose your soul, whatever happens; at least, not by any action of his.”
Image Credit: Luis Jiménez Aranda, “Doctors’ Rounds in the Hospital Ward” (1889)
