Minding Our Health: The Nudge, Part Two

Reposted with permission from Wrench in the Gears.

Center for Health Incentives

The topic of the hearing was reducing healthcare expenditures on chronic illness, which they claimed would amount of hundreds of billions of dollars in “savings.” Given the amount of money on the table, it seems clear this sector is ripe for outsourced, outcomes-based contracts that will deploy emerging technologies like health care wearables. Six measures of good health were identified during testimony: blood pressure, cholesterol level, body mass index, blood sugar, smoking status and either the ability to meet the physical requirements of your job (or on this one the Cleveland Clinic person said unmanaged stress.)

This piece expands upon my prior post about digital nudging and behavioral economics. Disruption in the healthcare industry mirrors the ed-tech takeover that is well underway in public education. If you explore the webpage for Catalyst, the innovation PR outlet for the New England Journal of Medicine (remember, social impact policy makers and many investors are based in Boston), you’ll notice the language being used to direct health care providers towards big-data, tech-centered solutions is eerily similar to the language being used on educators and school administrators.

The FCC’s “Connecting America: The National Broadband Plan” of 2010 outlined seven “national purposes” for broadband expansion. Healthcare and education were the first two topics covered in that report. Both chapters focus on “unlocking the value of data.” Who will the big winners be as we further digitize our lives? My assessment is the telecommunications industry and national security/police state will come out on top. Locally, Comcast and Verizon are key players with interests in both sectors.

Education and healthcare fall under the purview of Lamar Alexander’s Senate HELP (health, education, labor and pensions) Committee, so the similarities in tactics shouldn’t come as a surprise. In researching the $100 million federal Social Impact Partnerships Pay for Results Act (SIPPRA) launch I attended in Washington, DC last month, I noticed one of the Republican Senators who presented, Todd Young of Indiana, had attended the Booth School of Business MBA program at the University of Chicago. Recent Nobel Prize winner in behavioral economics Richard Thaler teaches there, and I was curious to see if Thaler’s thinking had influenced Young. Interactive version of Young’s map here.

I located C-SPAN coverage of a Senate hearing on healthy lifestyle choices, which Young participated in on October 19, 2017 (transcript follows). Lamar Alexander and ranking member Patty Murray, who inserted Pay for Success provisions into ESSA, chaired that hearing. Behavioral economics was discussed extensively. Young’s remarks start at timestamp 34:00.

https://www.c-span.org/video/standalone/?435978-1/senate-panel-explores-healthy-lifestyle-choices

The topic of the hearing was reducing healthcare expenditures on chronic illness, which they claimed would amount of hundreds of billions of dollars in “savings.” Given the amount of money on the table, it seems clear this sector is ripe for outsourced, outcomes-based contracts that will deploy emerging technologies like health care wearables. Six measures of good health were identified during testimony: blood pressure, cholesterol level, body mass index, blood sugar, smoking status and either the ability to meet the physical requirements of your job (or on this one the Cleveland Clinic person said unmanaged stress.)

The claim was that if an insured person met four of the six measures, saw a doctor regularly, and had their vaccinations up to date they would avoid chronic illness 80% of the time. Of course the conversation was entirely structured around individual “choice” rather than economic and racial systems that make it difficult for people to maintain a healthy lifestyle.

This neoliberal approach presumes people have free time for regular exercise, not considering they may be cobbling together several gigs to make ends meet. It presumes the availability of healthy food choices, when many black and brown communities are food deserts with limited access to fresh produce. It presumes the stress in people’s lives can be managed through medicalized interventions and does not address root causes of stress in communities steeped in trauma. It presumes ready access to a primary care physician in one’s community.

It is a gross simplification to push responsibility for chronic health conditions solely onto the individual, giving a free pass to social systems designed to harm large subsets of our communities. By adopting a data-driven approach to health outcomes, as would seem to be the case with the above six measures (check a box health), the federal government and health care systems appear to be setting health care consumers up to become vehicles for data generation in ways that are very much like what is happening to public education students forced to access instruction via digital devices. Imagine standards-based grading, but with health measures.

The people who provided testimony at the October 19 hearing included Steve Byrd, former CEO of Safeway, now at Byrd Health; Michael Roizen of the Cleveland Clinic; David Asch Director of the Wharton School’s Center for Health Care Innovation; and Jennifer Mathis of the Baselon Center for Mental Health Law and representing the Consortium for Citizens with Disabilities. Mathis was the only one who testified strongly on behalf of the rights of the insured to withhold personal information and was very concerned about the discriminatory nature of incentivized medical insurance programs, particular with regards to people with disabilities.

In his testimony, David Asch, director of the Center for Healthcare Innovation based in the University of Pennsylvania’s Wharton Business School, described effective designs for health incentive programs, noting that concerns about losing money were more effective from the insurer’s point of view that interest in receiving financial rewards. For that reason Asch said taking away money from someone should be considered before offering a reward. Asch also noted that effective programs included emotional engagement, frequent rewards (tweaked to people’s psychological foibles to they didn’t have to be too large), contests and social norming, including the use of public leader boards.

The date of the hearing is interesting, because right around the same time, public employees (including the teachers) of West Virginia were facing dramatic changes to their insurance plans. These changes included compulsory participation in Go365 an app-based health incentive program that imposed completion of intrusive surveys, wearing a fit bit (if you didn’t there was a $25 fee imposed each month), and meeting a certain step count per day. I include a transcription of testimony from one of these teachers, Brandon Wolford, given at this spring’s Labor Notes conference at the end of this post.

The incorporation of mHealth (mobile health) technologies is a key element of the healthcare disruption process. Increasingly, wearable technologies will transmit real-time data, surveilling the bodies of the insured. mHealth solutions are being built into healthcare protocols, so private investors will be able to track which treatments offer “high-value care.” The use of wearables and health apps also permits corporate health systems to insert digital “nudges” derived from calculated behavioral economic design, into the care provided, and monitor which patients comply, and which do not.

At the moment, the tech industry is working intently to integrate Blockchain technology and Internet of Things sensors like fit bits and health apps on smartphones. Many anticipate Blockchain will become a tool for securing IoT transmissions, enabling the creation of comprehensive and supposedly immutable health data logs, which could be key to mHealth expansion. Last summer the Medical Society of Delaware, a state that touts itself as a Blockchain innovator, announced a partnership with Symbiont, to develop healthcare records on Blockchain. Symbiont’s website claims it is the “market-leading smart contracts platform for institutional applications of Blockchain technology.” The company’s initial seed round of funding took place in 2014 with a second round raising an additional $15 million in May 2017 according to their Crunchbase profile.

The July/August 2018 issue of the Pennsylvania Gazette, the alumni magazine for the University of Pennsylvania, features Blockchain as its cover story, “Blockchain Fever.” The extensive article outlines use cases being considered for Blockchain deployment, including plans by a recent Wharton graduate to develop an application that would certify interactions between healthcare agencies and Medicare/Medicaid recipients for reimbursement. The University of Pennsylvania Health System is deep into innovative technologies. David Asch, director of Penn’s Center for Health Innovation, testified at the October 2017 hearing. The Penn Medicine integrated health system was created in 2001 by former UPenn president Judith Rodin in collaboration with Comcast Executive David Cohen. Rodin went on to head the Rockefeller Foundation, and in the years that followed the foundation spearheaded the creation of the Global Impact Investment Network. GIIN fostered growth of the social impact investing sector, at the same time healthcare began to transition away from a pay-for-service reimbursement towards a value-based model predicated on outcomes met.

Below is a relationship map showing the University of Pennsylvania’s involvement in “innovative” healthcare delivery, which I believe stems from Rodin and Cohen’s connections to Comcast. It is important to note that the Center for Health Innovations claims to have the first “nudge unit” embedded within a health system. Asch is an employee of Wharton, and Wharton is leading initiatives in people analytics, behavior change via tech, and Blockchain technologies. Interactive version of the map here.

New types of employer-based health insurance systems have started to emerge over the past six months. Based on this New York Times article, it seems employees of Amazon, JPMorgan and Berkshire Hathaway will have a front row seat as these technological manipulations unfold. Last fall Sidewalk Labs, the “smart cities” initiative of Alphabet (parent company of Google), announced an expansion into managed healthcare. City Block(read Blockchain) will tackle “urban health” and populations with “complex health needs.”

Reading between the lines, it appears Alphabet aims to use poor black and brown communities that have experienced generations of trauma as profit centers. Structural racism has created a massive build up of negative health outcomes over generations. Now, with innovative financial and technological infrastructures being rapidly put into place, these communities are highly vulnerable. Ever wonder why ACES (Adverse Childhood Experiences) has scores? I expect those numbers are about to be fed into predictive profiles guiding social investment impact metrics.

How convenient that the “smart city” solutions Sidewalk Labs is likely to promote will come with IoT sensors embedded in public spaces. How convenient that healthcare accelerators are developing emerging technologies to track patient compliance down to IoT enabled pill bottle caps; sensors that allow corporate and government interests to track a person’s actions with precision, while assessing their health metrics in excruciatingly profitable detail. Technology platforms are central to City Block’s healthcare program. Many services will take place online, including behavioral health interventions, with the aim of consolidating as much data as possible to build predictive profiles of individuals and facilitate the evaluation of impact investing deals.

Interesting aside, I have two friends who had emergency room visits at Jefferson Hospital this summer and were “seen” by doctors on a screen with an in-room facilitator wielding a camera for examination purposes. This is in a major East Coast city served by numerous research hospitals. Philadelphia is not Alaska. Where is that data going? Where were those doctors anyway?

As these surveillance technologies move full steam ahead, it would be wise for progressive voices invested in the “healthcare for all” conversation to begin considering strategies to address the serious ethical concerns surrounding wearable technologies, tele-health / tele-therapy, and value-based patient healthcare contracting. If guardrails are not put in place that guarantee humane delivery of care without data profiling, the medical establishment may very well be hijacked by global fin-tech interests.

As someone who values the essence of the platform put forward by Alexandria Ocasio Cortez, I worry supporters may not understand that several key elements of her platform have already been identified as growth sectors for Pay for Success. If public education, healthcare, housing and justice reform are channeled by global financial interests into outsourced-based contracts tied to Internet of Things tracking, we will end up in an even worse place than we are now. So, if you care about progressive causes, please, please get up to speed on these technological developments. You can be sure ALEC already has, and remember that Alibaba (Sesame Credit) joined in December. It’s not too much of a stretch to imagine patient rating systems regulating healthcare access down the road if we’re not careful.

Senator Todd Young was the first person to respond to witness testimony during the hearing, and his line of questioning revealed he is a strong advocate of Thaler’s “nudge” strategies. The “nudge” is a key feature of “what works” “Moneyball” government that deploys austerity to push outsourcing and data-driven “solutions” that embrace digital platforms that will gather the data required prove “impact” and reap financial returns. See this related post from fellow researcher Carolyn Leith “A Close Reading of Moneyball for Government and Why You Should Be Worried.”

Young asked David Asch of Wharton’s Center for Innovative Health, what employers could learn from behavioral economists? He also posed several specific suggestions that would scale such programs within the federal government namely: embedding units charged with experimenting with behavioral economics into federal government programs; developing a clearinghouse of best practices; and bringing in behavioral scientists into the Congressional Budget Office.

Asch, a doctor employed by the Wharton Business School, runs UPenn’s Center for Health Care Innovation created in 2011 to test and implement “new strategies to reimagine health care delivery for dramatically better VALUE and patient OUTCOMES” (emphasis added). The 28,000-foot facility houses simulation learning labs and an accelerator where research on use of “smart” hospital systems, social media, and emerging technologies in healthcare is conducted. The accelerator aims to rapidly prototype and scale “high impact solutions,” read Pay for Success.

Besides the Acceleration Lab, the Center also contains the Nudge Unit, which according to their website is the world’s first behavioral design team embedded within a health system. The goal of the unit is to “steer medical decision making towards HIGHER VALUE and improved patient outcomes (emphasis added).” Sample healthcare nudges include embedded prompts in digital platforms (for screenings), changing default settings (to generic prescriptions), framing information provided to clinicians (not sure what this means), and framing financial incentives as a loss.

This is longer than intended and hopefully provides some food for thought. This life datifying impact investing machine we are up against isn’t just coming for public education; it’s coming for ALL human service. We need to begin to understand the depth and breadth of this threat. I’m still mulling over a lot of this myself, and my knowledge base in healthcare is much shallower than my expertise in education. I’d love to hear what folks think in the comments or if you know of others writing on blockchain and IoT in medicine with a critical lens send me some links. Below are transcripts from West Virginia teacher Brandon Wolford about Go365 followed by the Senator Young / David Asch hearing exchange.

-Alison McDowell

Go365 Transcript

Brandon Wolford, West Virginia Teacher: When I first began teaching in 2012 the insurance, in my opinion, was excellent, because I had worked for one year in Kentucky and I had known that the premiums were, although they were being paid five to seven thousand more than we were, they still had to pay much more for their insurance. So it balanced out. However, after the first year or two I was there, that was when they started coming after us with the tax on our insurance. First of all the premiums, we started to see slight increases for one, and another was they started to enforce this “Healthy Tomorrows” policy.

So, the next thing you know, we get a paper in the mail that says, you know, you have go to the doctor by such and such a date. It must be reported. Your blood glucose levels must be at a certain amount. Your waist size must be a certain amount, and if it is not, if you don’t meet all of these stipulations then you get a $500 penalty on your out-of-pocket deductible. So, luckily for me, I eat everything I want, but I was healthy. My wife on the other hand, who eats much better than I do, salads at every meal, has high cholesterol, so she gets that $500 slapped on her just like that.

Okay so, that was how they started out. In the mean time, we have been filling these out for a year or two, and they keep saying you know you have to go back each year and be checked. And then comes the event that awoke the sleeping giants. The PEIA Board, which is the Public Employee Insurance Agency that represents the state of West Virginia, they, um it’s just a board of four to five individuals that are appointed by the governor, they are not elected. They have no one they answer to; they just come up with these things on their own.

So they come to us and they say we’re raising your premiums. This was somewhere between November and December of last year. We’re raising your premiums. You’re going to need to be enrolled in a program called Go365, which means that you have to wear a fit bit, as well record all of your steps. You have to check in with them, and it included private questions like how much sexual activity do you perform, and is it vigorous? All of these things that they wanted us to report on our personal lives, and that was all included. In addition to that we had to report all of those things, and if we refused to wear that fit bit and record all of our steps, or if we didn’t make our steps, we were going to be charged an additional $25 per month.

So, when everyone sees this along with the increased premiums, then they’ve also introduced a couple more bills to go along with that, because the PEIA Board, they have the final say. Whatever they do, it’s not voted upon by the legislature. It’s basically just law, once they decide it. But in the meantime our legislature was presenting these bills. We were currently on a plan of sixty, uh excuse me, eighty/twenty we were paying out of pocket. Well, they had proposed a bill that would double that and make us pay sixty/forty.

So, they presented that along with charter school bills and a couple of other things that were just direct attacks on us. We had been going by a process of seniority for several years; and they also introduced a bill to eliminate seniority to where it was up to the superintendent whether or not you got to stay in your position. It was up to the principal and regardless if you were there thirty years or you were there for your first or your second year…they were trying to tell us you know, it’s just up to your principal to decide. The superintendent decides. They don’t want you to go, you’ve been there for thirty years and you have a masters degree plus forty-five hours, you’re gone. It’s up to them. Your seniority no longer matters. So those things combined with the insurance is actually what got things going in our state.

Excerpted Testimony Healthy Lifestyle Choices, Senate HELP Committee 10/19/17

Lamar Alexander: We’ll now have a round of five-minute questions. We’ll start with Senator Young.

Senator Todd Young: Thank you Chairman. I’m very excited about this hearing, because I know a number of our witnesses have discussed in their testimonies behavioral economics and behavioral decision-making. I think it’s really important that we as policy makers incorporate how people really behave. Not according to an economist per se, or according to other policy experts, but based on observed behaviors. Often times we behave in ways that we don’t intend to. It leads us to results that we don’t want to end up in.

So, Mr. Asch, I’ll start with you, with your expertise in this area. You’ve indicated behavioral economics is being used to help doctors and patients make better decisions and you see opportunities for employers to help Americans change their behaviors in ways they want from tobacco mitigation to losing weight to managing blood pressure and you indicate those changes are much less likely to come from typical premium-based financial incentives and much more likely to come from approaches that reflect the underlying psychology of how people make decisions, encouraged by frequent rewards, emotional engagement, contests, and social acceptance and so forth. And you said in your verbal testimony you haven’t seen much of this new knowledge applied effectively by employers, but there’s no reason why it cannot be. So, my question for you sir is what might employers learn from behavioral economists. Just in summary fashion.

David Asch, Wharton Center for Health Care Innovation: Sure. Thank you senator. I think I’ll start by saying there is a misunderstanding often about behavioral economics and health. Many people believe that if you use financial incentives to change behavior you’re engaged in behavioral economics, and I would say no, that’s just economics. It becomes behavioral economic when you use an understanding of our little psychological foibles and pitfalls to sort of supercharge the incentives and make them more potent so that you don’t have to use incentives that are so large.

So I think that there are a variety of approaches that come from behavioral economics that can be applied in employment setting and elsewhere. I mentioned one, which is capitalizing on the notion that losses looms larger than gains, might be a new way to structure financial incentives in the employment setting in ways that might make it more potent and more palatable and easier for all employees to participate in programs to advance their health. The delivery of incentives more frequently for example. Or using contests or using certain kinds of social norming where it’s acceptable to show people on leader boards in contests and get people engaged in fun for their health. All of these are possibilities.

Senator Todd Young: Thank you very much. You really need to study these different phenomena individually. I think to have a sense of the growing body of work that is behavioral economics. Right, so we need the increased awareness, and I guess the education of many employers about some of these tics we have. That seems to be part of the answer. In fact, Richard Thaler who just won the Nobel Prize for his ground-breaking work in this area indicated that we as policy makers ought to have on a regular basis not just lawyers and economists at the tables where we’re drafting legislation, but ought to have a behavioral scientist as well.

And the UK, they have the Behavioral Insights Team. The United States, our previous administration, had a similar sort of team that did a number of experiments to figure out how policies would actually impact an individual’s health and wellness and a number of other things. Some of the ideas that I think we might incorporate into the government context, and tell me if any of these sort pop for you; if you think they make sense?

We need to continue to have a unit or units embedded within government that do a lot of these experiments. We need to have a clearinghouse of best practices that other employers included might draw on. This doesn’t have to be governmental, but it could certainly be. We on Capitol Hill might actually consider aside from having a Congressional budget office than an official budget office, we might have an entity or at least some presence within the CBO or individuals that understand how people would actually respond to given proposals. Do any or all of those make sense to you?

David Asch: Thank you for your remarks. Yes, I think they all make sense. And one of the lessons that I guess I have repeatedly learned is that seeming subtle differences in design can make a huge difference in how effective a program can be and how it is perceived and that will ultimately care about the impact of these programs. So, I am very much in favor in the use of these programs, but in addition, greater study of these programs, because I think we need an investment in the science that will help all of us in delivering these activities, not just in healthcare, but in other parts of society.

Senator Young: That makes sense. I am out of time. Thank you.

 

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“Smart and Surveilled:” Building Sanctuary Part 3

Reposted with permission from Wrench in the Gears.

smart and surveilled

The future is uncertain and unlikely to play out exactly as described. Nevertheless, we must begin to comprehend how technological developments combined with concentrated power and extreme income inequality are leading us to increasingly automated forms of oppression. My hope is that communities will begin to incorporate an understanding of this bigger picture into resistance efforts for public education and beyond. Let us join together, embracing our humanity, to fight the forces that would bring us to “lockdown.” How can we preserve our lives and those of our loved ones outside the data stream? How can we nurture community in a world where alienation is becoming normalized? What do we owe one another? What are we willing to risk? I have divided my story into seven parts. I hope you’ll read along and consider sharing it with others.

This installment highlights  smart city surveillance and the Internet of Things. Cam and Li’s lives, including their educational experiences, are shaped by ubiquitous algorithms that align their behaviors to the economic and social expectations put in place by the Solutionists. This is the third installment in the series. If you want to read from the beginning use this link to access the introduction and Part 1: Plugging In. The whole series can be accessed here: Link

Cam and Li have grown up in a world controlled by sensors and data. All day, every day sensors watch, track and transmit information. The devices that make up the vast web of Internet of Things are tiny, but their combined power is incalculable. The most common IoT sensor in the pre-lockdown years was the smart phone. Practically anyone over the age of ten had one. Acting as a sensor, people’s phones were a primary means of data collection, logging information about how people interacted with each other, with systems, and their physical world.

The first sensors were created to monitor global supply chain shipments. Then, corporate, government and academic researchers devised a dizzying array of sensors to transmit data about most aspects of the physical world and how people live their lives in it. Instead of tracking pallets on cargo ships, they now track people, buses, energy, animals, art, storm water runoff, even sounds and footsteps. Each processor gathers a particular type of information that can be merged into the data stream for analysis. Predictive analytics algorithms, complex mathematical equations that anticipate future outcomes, tap into the data stream. Such algorithms can be used to predict when the bulb in a streetlight will fail, when a storm sewer will overflow, or even where a crime will happen.

For years authorities quietly built datasets that digitally documented community life using police body cameras and later cameras embedded into robot patrols. It showed incredible hubris to roll out such a program under the guise of citizen protection. The cameras, of course, were always looking out at the people, not at the police. Even with footage, police were rarely held accountable for crimes committed. Meanwhile, all aspects of people’s daily lives were taken in; faces, routines, social connections; anything within the field of view of the camera was absorbed by Oracle.

That such data would be turned against citizens in times of civil unrest should have been anticipated. Some who lived in communities that had experienced the evolution of brutal policing were indeed skeptical, but many held on to the idea that the cameras were well intentioned. Cam’s mother vividly remembers the week of the lockdown, how teams were deployed strategically throughout the city in ways that made resistance futile. All those years, the police state’s neural networks had been “learning” their neighborhoods and their faces all in the name of public safety.

Post lockdown, sensors and technology have been integrated into more and more aspects of daily life, pressuring people to make “good decisions.” Strivers feel less and less in control of their daily activities. They await the next haptic pulse that will direct their attention and actions. Cam might crave a pint of chocolate ice cream, but her minder is watching the refrigerator and uses guilt to pressure her into choosing carrots and celery instead. If she doesn’t comply, it will most certainly go into her health data log. Maybe Li wants to sleep late. Well, the sleep monitor strives to keep her on a productive R.E.M. cycle, so it raises the shades in her bedroom and turns on the shower down the hall at the appropriate hour. Is Talia driving to the corner store when she should be walking? Well, her auto tracker knows, as does her step counter, which means her insurance providers know, too. Maybe she can get away with it early in the month, if she has time to make up her activity quota before the 31st. Resources for healthcare are so constrained that people must demonstrate through data that their personal routines and lifestyle choices optimize preventative health protocols.

The Nudge Unit is constantly looking for new ways to incorporate behavioral triggers and feedback loops into online education and VR platforms, too. Buzz, buzz, a text appears. “Cam needs more points on Skyward Skills. It’s time to log on.” Or the pulse monitor indicates Li is too tense. Buzz, buzz, “Take a mindfulness break kid,” breathe and reflect. Buzz, buzz, “Talia step away from the screen and walk around the block to avoid blood clots.” Action triggered, data logged, repeat has turned life into one unending Pavlovian experiment.

Existence has subtly shifted to align to the Solutionist outlook. Economic forecasters rely on people being rational actors as they develop financial projections, and if technology can be used as a tool to shape human behaviors and enforce “rationality,” it is all the better for the global financiers who generate their wealth by speculating on the lives of everyday people. For the strivers, optimization has erased freedom and personal agency.

In the post-labor era, people have become more valuable for the data they produce than for their capacity to do physical work. Thus all but the off-liners have been integrated into the global corporate value chain as commodities. With biometrically-enabled Citi Badges, Cam and Li are not unlike tagged calves or farmed salmon, managed and processed without agency or recourse; lives controlled for the profit of others. The bio capitalist economic model values them only to the extent that they contribute their digital labor to the Solutionists’ data-driven system of outcomes-based results.

Algorithms hold tremendous power over Cam and Li. Using data generated through the Internet of Things, Oracle can make predictions about the type of adults the children are likely to become. What their cost to society will be. What they might contribute as human capital. Should their family should fall into poverty, Oracle can evaluate how much profit there could be made providing services to “impact” their situation through Pay for Success contracts. Would the predicted rate of return on their lives justify expending the Global Coin required? The Solutionists say, “Just run the data; the data will tell us.”

Talia tries to shelter the family from the data stream as much as possible, but that is has proven difficult. Accessing any public services demands data. Walking outside means you are under surveillance. Even at home devices keep tabs. Data has also become a currency people use to supplement their insufficient Global Coin stipends. The pretense that a person “owns” their own data and can monetize it is supposed to make them feel better about their situation. It doesn’t. Each data transaction puts another piece of one’s soul on the auction block, scrutinized by a predatory system that thrives on want and suffering. And it’s always a buyer’s market. No person in need is going to get ahead selling bits of data. These transactions are just stopgaps until the next Citi Badge stipend hits, a release valve that has thus far kept rebellion at bay.

At first the sensors seemed innocuous, uploading information about when a trashcan was full or telling people where parking spots were available. There were sensors that monitored air quality and ones that made sure streetlights were efficiently managed. People were enthusiastic. But then came the noise sniffers, and the motion sensors, and the drones. Parks and recreation officials were brought on board and encouraged to incorporate cyborg roses into public landscape projects. When first introduced, people were astonished at Eleni Stavrinidou’s work transforming plants into transistors, and now there were rumors of computational forests being grown in remote outposts. Once plants had sensors, people started to get really worried.

Teachers never imagined how sensors would alter classrooms and eventually eliminate them altogether. Adoption of 1:1 devices eroded teacher autonomy until students were spending most of their day with volunteer aides, eyes glued to screens. The teachers that remained were left evaluating student data. In classes where teachers were still allowed to lecture, movement, vibrations and sounds were monitored through sensors embedded in seats. The aim? Supposedly to provide continual feedback regarding student engagement and quality of instruction, but everyone knew it was really to keep track of the content delivered and how students responded. It was chilling.

By that point, the last remaining veteran teachers abandoned the profession. Eventually teacher shortages, austerity budgets, and the corporate education lobby’s campaign for “anytime, anywhere” learning ushered in IoT-enabled learning ecosystems. No one had invested in public education infrastructure for years. Sending everyone home with a device meant there was no longer the expense of feeding poor children. Students too young to stay at home and whose parents were working strivers were packed off to community partners. These partners had been carefully prepared for their role providing standards-aligned summer and out of school time programs. Plus this approach brought education completely under the umbrella of social impact investing, which pleased the financiers. All in all it was a pretty seamless transition. Given how punitive the instruction had become, most felt a sense of relief when the time came to phase out schools entirely.

Ten years out Cam and Li, like the characters in Isaac Asimov’s short story The Fun They Had, have no idea what “going to school” means. Some nights before turning out the lights, Talia tells the girls stories that give them a glimpse into that past. Yet, it is so far removed from their reality that neither can imagine what it must have been like to learn with a group of other kids. To have a human teacher and books, and go to a school building and spend the day there is a frightening prospect. People live isolated lives. Encounters with others are carefully managed. To spend a full day as part of a group, talking no less, seems a perilous and fraught enterprise.

Now everyone is assigned an Artificial Intelligence (AI) “assistant,” a lifelong learning guide when they receive their first education voucher. Cam tolerates hers, but Li is another story. They have quite the adversarial relationship. Li accuses her AI of giving her assessments that underestimate her actual ability, so she has to spend days and days going over material she already knows. Her games are always shorting out at a critical moment, right before her points are logged. The algorithm gives her essays failing marks, even though her mom and Grandpa Rex both say she has a gift for creative writing. Cam says that because the companies are rolling out so many new programs, glitches just going to happen and to not take it personally. People have always had frustrations with their devices, from autocorrect fails to systems freezing unexpectedly, but now that devices control so much more of people’s lives their faults are harder to tolerate. Talia often finds herself having to get up from her work and do a hard shutdown of Li’s tablet to give them both a time out.

The AI conversational agents and the platforms that host them employ a variety of tactics to ensure that Cam, Li, and all the children remain on task. Devices record ISPs and timestamps for logins. Keystroke and facial recognition data is stored, too. Wearable and biometrics are part of the equation. The early headbands and wristbands were incredibly clunky, but five years in they switched to IoT temporary tattoos with sleek designs that prominently identify each child’s designated pathway and rank.

It’s a major milestone when a student attains enough credentials in their portfolio to upload and claim a pathway. The tattoos, not unlike military insignia, help communicate social order and expected etiquette when new people meet. A picture is worth a thousand words, and in a culture that is increasingly non-verbal, a pathway tattoo is an important tool.

To maintain order, the Solutionists knew behavioral engineering had to become central to the educational system. With little meaningful work, systematic mental health training was needed. They wanted people neither too depressed nor too rebellious. Resilience, and grit were traits instilled through apps and gamification; children’s mindsets tracked as closely as the knowledge they acquired. The system was calibrated to identify mental disorders and dissidents early, flagging them for intervention. Both Cam and Li knew kids who had been forcibly plugged into remediation, but it wasn’t discussed openly.

The isolation that resulted from cyber education took a toll on many. Social networks withered. Kids rarely spent time with friends face-to-face. Text-support only went so far in beating back the darkness. Suicide rates climbed, affecting younger and young children. Programmers scrambled to develop new monitoring procedures. The Global Well Being Program was a leader in the field, their cutting-edge algorithms effective, but expensive.

Despite the high cost, sector education officials from all but the poorest communities debited funds for the monitoring service directly from student vouchers to cover the cost. Timely intervention was a matter of life or death, and people were willing to pay. In the post-labor world, monitoring and treating depression was a growth market. Before long tele-therapy and mental-health VR surged past bio-pharmaceuticals as darlings of the venture capital investment crowd.

By 2025 most major and mid-size cities had become “smart cities,” integrating IoT sensors into a wide variety of infrastructure projects. In doing so, officials created a ubiquitous layer of surveillance across the public sphere. Now, in order to access communal spaces, residents had to acquiesce to being watched. Management of the complex IoT systems required expertise far beyond the in-house capacity of most cities; as a result, outsourcing to global corporations became commonplace.

Over time, voters found they had less and less voice in government. Officials kept up appearances for several election cycles, but it became obvious that technology companies like Sysko were really the ones in charge. People wanted to believe elections still mattered. The history modules made a point of expressing how hard people had fought for the right to vote and to fix problems like gerrymandering, but it the years leading up to lockdown it became a hollow exercise. Talia had memories as a teen of the media stirring up outrage over voting irregularities. Looking back, they should have realized something was amiss. The solution to this “problem” was to switch to voting on the Blockchain using Citi Badges. Of course that shift effectively shut all of the off-liners, those who had no badge, out of the process.

Democracy was exposed for the charade it had always been, and it became clear to all that they had been living under fascism for a very long time. The cloud-based computing, telecommunication, and global finance interests united under the Solutionist banner and ensured authoritarian control was firmly in place. Global law enforcement working through the Blockchain Collaborative backed the technocrats in their coup. Now for Cam and Li, voting was a topic touched upon briefly in history modules where it was framed as a messy process no longer suited to the well-structured, transparent society the Solutionists had devised.

As the end game neared, secure and exclusive sanctuaries modeled after billionaire and media mogul Richard Braddock’s island home began to appear. He was among the first to bring world thought leaders together to discuss ways to build and scale Blockchain applications. These thought leaders sold everyone a utopian vision of trust, transparency and collective support. Those purported values fell by the wayside, though, shortly after the lockdown.

People with knowledge of edge computing, IoT, and Blockchain deployment and who had the money constructed sensor free zones to which they could retreat. Of course kids like Cam and Li will never be able to obtain access to such sanctuaries. That world is limited to families that can afford the astronomical costs of having human teachers for their children, whose social networks are such that they don’t need citizen scores or e-portfolios to assert their value to society. Sometimes Cam and Li wonder about the sanctuary kids. Surely there aren’t many of them. Are they lonely? Do they feel isolated, too? Are they glad to be unplugged? Do they know about life on the outside, life on the ledger?

Continue to Part 4: Data Mining Life on the Ledger

Supplemental Links

Internet of Things IBM: Link

History of IoT Sensors: Link

What is Blockchain: Link

Supply Chain IoT: Link

Cash VS Digital Economy and Online Payments: Link

Sidewalk Labs: Link

Smart Cities / Noise Sniffer: Link

IoT and Predictive Policing: Link

Police Body Cameras and AI: Link and Link

Patrol Robots: Link

Street Lights and IoT: Link

IoT Parking: Link

Storm water IoT: Link

Smart Trash Cans: Link

Sensors and Smart Cities: Link

Cognitive Drones: Link

Cyborg Roses: Link

Internet of Battlefield Things: Link

Pay for Success and Big Data: Link

Blockchain Social Impact Token: Link

Human Capital Analytics: Link

Nudge Unit: Link and Link

Game Theory, Human Resources and Social Skills: Link

AI Nudge Bots: Link

Behavior Change for Good: Link

Haptic Devices: Link

Rational Choice and Behavioral Economics: Link

Education and Biocapitalism: Link

Behavioral Science and Social Impact: Link

Making Behavior Change Stick: Link

IoT Classrooms: Link

Sensors Determining Education Quality: Link

Affectiva Emotion Sensing Software: Link

Behavioral Biometrics: Link

World Well Being Project: Link

The Fun They HadLink

Device Use Behavior Tracking in Education: Link

Virtual Agents / USC Institute of Creative Technologies: Link

AI Conversational Agents / Amelia IP Soft: Link and Link

AI Teaching Assistant: Link

Conversational Agents / Articulab: Link

Applied Gaming and Mental Health: Link

Brainwave Data Collection: Link

IoT Tattoos / Duoskin: Link

Pathways to Prosperity / Jobs for the Future: Link

Characterlab / Grit: Link

CASEL / Social Emotional Learning: Link

Serious Games and Mental Health: Link

Government as Platform: Link and Link

IBM Smart Cities: Link

Cisco Smart Cities: Link

New York Smart City: Link

Blockchain Voting: Link

Neckar Island Blockchain Summit: Link

Edge Computing: Link

Blockchain Cryptoeconomics: Link

Blockchain Alliance: Link

-Alison McDowell