Technological determinants of health: a looming apocalypse

Perhaps nobody predicted the damaging dysfunction of a health service and the collapse of society as we know it because of a decision to withdraw an instant messaging service, but it may be about to happen. Regulation of WhatsApp and similar technologies, specifically by allowing access to messages to investigate crimes such as terrorism, could lead to them being unavailable in the UK.

Services such as WhatsApp and Signal offer end-to-end encryption that ensures privacy, making them an attractive way to share and discuss confidential patient information. Use of WhatsApp for clinical purposes boomed in the covid pandemic as healthcare organisations eased restrictions to respond to the emergency. Messaging apps are easy and quick to use and help busy staff maintain their professional and social relationships.

Stephen Armstrong finds that when an amendment to the Investigatory Powers Act becomes law this spring “the government will have installed surveillance on all encrypted messaging” (doi:10.1136/bmj.q52).1 Patients’ information will no longer be secure. The law mandates both government access to encrypted information and vetting of security updates that will apply to technology companies worldwide. The impact seems both undesirable and unfeasible.

Technology companies like Meta, Apple, and Signal are threatening to withdraw their services from the UK if the law “unduly affects their ability to innovate and introduce new security features.” Meredith Whittaker, Signal’s president, believes the new powers invite “shocking levels of state interference” and will compromise patient safety.

New technologies, of course, bring benefits and harms. Measles outbreaks are affecting areas of low vaccination uptake (doi:10.1136/bmj.q113),2 and part of the explanation is the misinformation and scientifically invalid information generated on social media about covid vaccination. A BMJ online collection examines the complex relations between social media use and vaccine hesitancy (https://www.bmj.com/social-media-influencing-vaccination). Better research is important, and Sander van der Linden argues that research on social media misinformation and vaccine hesitancy needs a stronger framework, a gold standard (doi:10.1136/bmj.p1007).3

Misinformation often has its greatest effects on the most disadvantaged people, who also experience “overlapping systems of discrimination” or intersectionality (doi:10.1136/bmj.p2953).4 Recognising the multifactorial nature of health outcomes isn’t new, but more sophisticated methods are now needed to investigate intersectionality, and these should appreciate that effects of individual factors such as ethnicity, gender, and social class are “not necessarily additive or multiplicative.” Technology is now one of these factors. Beyond the differential impact of social media on disadvantaged groups, technologies—from telehealth to artificial intelligence—can amplify society’s divisions.

Grappling with these complexities is important; a worrying rise in maternal death rates (doi:10.1136/bmj.q62) and a crisis in child health (doi:10.1136/bmj.q68) are two vivid examples of the play of deprivation and intersectionality.56 Michael Marmot estimates that one million fewer people might have died in England between 2012 and 2019 if “everyone had the good health of the least deprived 10% of the population” (doi:10.1136/bmj.q93).7

With the promise and harm of technology, and an ever widening gap between rich and poor, we are living in the best and worst of times. The case for a social determinants approach to health in national policy has never been clearer (doi:10.1136/bmj.q96).8 Technological determinants of health also now require serious consideration. The chat apocalypse isn’t now, but it may be soon.