Sensing Health

Front matter

Bodies, Data, igital Health Technologies and

MIKKI KRESSBACH

DIGITAL CULTURE BOOKS

Contents

List of Figures

Acknowledgments

INTRODUCTION: Sensing Health Describing (Digital) Health Defining Health Organization A Note on Language

II. I2

15. 16.

17. 18.

Figures

. Screengrab of the “Close Your Rings” section of the

Apple website

. Screengrab of “Flo” app home interface

. Screengrab of “Flo” app “log” screen

. Screengrab of “Clue” app interface

. Screengrab of the “Flo” calendar interface

. Screengrab of “Flo” app analytics interface

. Screengrab of “Clue” app analytics interface

. Screengrab of an “Eve” app “cyclescope”

. Screengrab of Dame “About Us” web page

. Screengrab of the “Lioness” app “Types of Orgasms”

information page

Screengrab of “Lioness” app “logged session” interface Screengrab of “Fitbit” app home interface

Screengrab of the “Close Your Rings” section of the Apple website

Diagram mapping types of meditation

and breathing technologies

Screengrab of “Breathesync” app breathing session interface Screengrab of “Breathesync” app “wellness quotient” information page

Screengrab of “Muse” app logged meditation session Screengrab of the “Trends” section of the “Activity” app

Acknowledgments

This book is a collaboration misattributed to a single author. It is a project that would not have been completed without the support and feedback of my colleagues, friends, and mentors. First and foremost, this book is dedicated to my writing group. What started as a group of graduate students in Cinema and Media Studies at the University of Chicago has grown into a group of colleagues and friends who have supported one another through writing dissertations, navigating the challenges of the academic job market, and publishing their first books. It has been a privilege to learn from this group over the years. Membership has changed over the years, but I’m grateful for the group’s members who supported me during graduate school, including Hannah Frank, Matt Hubbell, Ian Jones, Tyler Schroeder, and Ling Zhang. However, I owe my greatest thanks to the group’s most dedicated members, Will Carroll, Nicole Morse, and Jordan Schonig, who have read every single page of this manuscript (multiple times). I cannot express how much their weekly feedback and overall emotional support helped shape this book. They have been there every week helping me map out arguments, troubleshoot sentences, debate theoretical minutiae, and calm my anxieties. Perhaps most usefully, they provide a source of relief by funneling all of our energy into absurd theorizations of pop culture and cinephilia. They are my coauthors. There would be no book without them. I would not be the scholar or writer I am without them.

I want to thank my colleagues and mentors at Michigan State University (MSU) and Loyola Marymount University (LMU), who continually offered their professional support for this project. Josh Yumibe served as a mentor in the early stages of this project, when I was still testing out xii - Acknowledgments methodologies, arguments, and audiences. He encouraged me to develop my class, Ordinary Media, which was the first time I incorporated wearable devices in the classroom. Josh also allowed me to test out early arguments for chapter 3 in an invited talk on fitness technology and data. I’m thankful for the feedback of Justus Nieland, Kaveh Askari, and Ellen McCallum, who not only attended the talk but provided essential support during my time at MSU, and pushed this project to consider a range of historical and theoretical perspectives. The community at MSU gave me the confidence to break from my dissertation project and pursue new research that I found exciting and invigorating. At LMU, I was welcomed and supported by my incredible department, including Miranda Banks, Rick Hadley, Carla Marcantonio, Anupama Prabhala, and Sue Scheibler. Even amid the challenges and isolation of COVID-19, they were my greatest champions, providing a solid and supportive foundation to complete this project. I feel so fortunate to have a department that wholeheartedly believes in me and this book and has given me the space to pursue a project that steps far beyond the boundaries of film and media studies. I want to thank Miranda and Anu, in particular, for repeatedly showing up to provide emotional and professional support during the end stages of this project, when I faced some of the toughest personal challenges of my life. At a time when I needed it most, they provided the calming voice of reason and took on extra academic labor when they were already overburdened with work.

Writing an interdisciplinary book requires juggling a number of audiences, each with a different set of stakes and methodological frameworks. I want to thank my editor, Sara Cohen, for her incredible help in navigating this daunting task. She was able to provide a fresh perspective on the introduction and helped me shape a project that (I hope) speaks to audiences across the sciences, social sciences, and humanities, while still holding on to the values and methodologies of my home discipline. Her thorough feedback helped me craft the framework for this project and allowed me to see the book from an outside perspective. I’m also thankful for her excellent communication and organizational skills, which helped keep the project on track.

While this book project emerged at the end of my time as a graduate student at the University of Chicago, the courses I taught and conversations with fellow graduate students were hugely influential in shaping the trajectory of the project. I want to thank Jean-Thomas Trembley for providing the opportunity and incentive to branch out into digital health through his special issue on breath and media for the New Review of Film

Acknowledgments + xiii and Television. Jean-Thomas’s excellent editorial feedback helped me work through very early arguments for this book. His creative thinking and presence in my graduate courses were always a source of inspiration, and the fourth chapter of this book is indebted to his work as an editor and peer. I was also fortunate enough to receive the Tave Teaching Fellowship, which gave me the opportunity to teach Popular Science and New Media, where with University of Chicago undergraduates I was able to explore digital health and some of its central methodologies. Over the course of ten weeks, I tested out phenomenological description, close analysis, and various philosophical and theoretical frameworks. Consequently, I learned alongside my students, locating points of interest, frictions, and challenges. The nineteen undergraduates in the course showed unwavering enthusiasm and often helped educate me on emerging media technologies. Their final projects showed unmatched creativity and gave me invaluable insight and inspiration for the core arguments for this project. Their voices appear in chapter 3 and served as a launching point for student-based research.

Pd also like to extend thanks to all of the students who have taken my classes on health and technology in the last five years. While they may not realize it, their contributions to class discussions and thoughtful writings were an endless source of inspiration. I specifically want to thank Ivan Medina-Mendez and Thomas Streed from my Ordinary Media class at MSU, who were not only excellent students but fantastic collaborators. Ivan’s and Thomas’s contributions to our pedagogy article on phenomenological description were essential to developing my lessons on description in the classroom, and to my own research. I also want to thank those students enrolled in my fall 2020 Science, Medicine and Digital Media class, who showed immense dedication to our virtual sessions week after week. Their experiences with digital health during the COVID-19 outbreak offered a new and enlightening perspective on my work at a critical stage of development. Phenomenological descriptions from students at MSU and LMU shaped the third chapter of this book, and I cannot thank them enough for their scholarly work.

The first, third, fourth, and fifth chapters have benefitted from feedback and discussion at conferences over the years, including the annual Society for Cinema and Media Studies conference, the Chicago Film Society, the Health Humanities Consortium, World Picture, and the Society for Literature, Science, and the Arts. I want to thank all of my former panelists and audiences for their generous time and feedback. In particular, I would like to thank Katherine Contess, Diane Negra, Scott Richmond, xiv + Acknowledgments

Andrea Charise, and Kirsten Ostherr for their invigorating conversation and questions. Diane specifically gave me the encouragement to submit an early version of the first chapter to Television and New Media, where it now appears in article form. At LMU, I have also had the opportunity to present versions of the third chapter and introduction in partnership with the health and society minor. I want to thank Rachel Washburn for giving me the opportunity to share my work with faculty across the school and students engaged in critical health studies.

This project has also been generously supported by grants from LMU. I received the School of Film and Television Fellowship, which allowed me the time to complete the final draft of the book, and the Academic Technology Grant, which provided funding to purchase wearable devices for my class. Without this financial support, I would not have had the opportunity to explore my research with my students and develop the critical examples of phenomenological description that appear in chapter 3.

I have to thank my friends who provided essential respite from this project over the years. This book was written during a period of immense grief and loss. I often lost myself in this project, using it as a way to get away from the difficulties of my personal life. My friends continually helped pull me out of this space, providing relief in the form of meals, laughter, film and television viewing, and continuous support. Thank you to Jordan Schonig for constantly distracting me with deep analysis of made-forstreaming romantic comedies and with reality-T'V-viewing parties. Jordan, I would not have made it without your daily commentary on the absurdity of academia. A big thanks must go out to Will Carroll for introducing me to the dangerous world of K-dramas. Our watch parties were such an excessive and addictive indulgence. Ian Jones provided endless distractions in the form of brain-breaking tweets, repulsive gifs, and videos of things moving real good. I would not have survived the last few years without my dedicated Bachelor watch group. Kristin Mahoney, Liz Mahoney, Lyn Goeringer, Yalena Kelinsky, and Brian, thank you for helping me on my journey. I want to thank David Clawson for bringing me along on some indulgent vacations. These escapes were essential to my mental health, and I look forward to future “writing retreats” around the world. Finally, my friends outside of academia provided some of the very few opportunities I had to truly step outside of work. A massive thanks to Tiffany Chow, my friend, sister, and forever-all-you-can-eat companion. Thank you for listening to me complain about things that are completely inconsequential and foreign to you, and for eating all the things with me. And thanks to Zach Hartline for putting up with us.

Acknowledgments + xv

Finally, I want to thank my late friend, Hannah Frank. Hannah passed away before I began this project, but the lessons I learned from her undoubtedly shaped the final version of this work. Her friendship and support helped me become the scholar I am today. Throughout the writing process, I found myself asking, “What Hannah would think?” Her memory helped guide me, and it’s hard to imagine that this book is here and she is not. Hannah, I miss you every day.

Introduction

A gentle vibration on my wrist, like the press of a thumb, triggers an almost automatic reaction. My arm raises from a resting position, tucked at my side, swiveling so my elbow settles into the crease between my leg and pelvis, about two feet below my tilted head, perfectly aligned with the direction of my gaze. With the rotation of my wrist, a message emerges from the bottom of the screen of my Apple Watch: a small icon showing three concentric circles in red, green, and blue sits next to a header labeled “Activity.” Below, text in a bold white font tells me, “You can still do it. 16 calories and you'll close your Move ring, Mikki. A brisk, 5-minute walk should do it” (Fig. 1). I raise my right hand and with a slight push on the dial to the right of the screen, the message scrolls down to reveal a statistic in boldface, comparing the number of calories ’ve burned to the set daily goal. A tiny bar graph visualizes spikes in my activity, showing tall lines early in the morning and tapering off as the day continues. As I glance at the screen, I can feel my upper body tense, pulling my shoulders toward my ears, muscles contracting inward. The sudden disruption of my relaxed, prone body with the tensing of muscles across my chest and back leads me to shift my hips back and forth, and stretch my legs forward as if my lower half is trying to resist the pull of my upper body at the screen’s instructions. I have to actively will my shoulders to sink back down into the pillow behind my head, stretching my head to the left and right to release the tension across my collarbone. As I feel my body sink further into the couch, I think to myself, “sixteen calories is nothing, you don’t have to move.”

8:23 6)

~~ ACTIVITY

Close your rings

Fig. 1. An example from Apple’s website of the notification delivered at the end of a user’s day. Apple describes the daily reminders as “coaching,” which includes a quantified suggestion for activity and data visualizations. (“Close Your Rings,” Apple, accessed February 2023, https://www.apple.com/watch/close-your-rings/.)

My habitual responses to the Apple Watch are partly related to how my body has learned the vibration patterns of the device; with a single, sharp pulse to my wrist, I may lift the screen to my gaze and watch the text message pop up on the screen, or the repeated vibration against my skin may cause me to stop all my actions and see who is calling on my phone. However, the imperative to move—to burn more calories in pursuit of a daily goal—cannot be reduced to a Pavlovian training of my body. The power of the message described above lies in the way it prompts not only a reaction but also a reflection on my body, my actions, and by extension, my health.

The statistics outlined on the Apple Watch interface are meant to implicitly reflect my health—or at the very least, my efforts to perform, pursue, or maintain health. The Apple Watch is a common example of a smartwatch, which combines a range of features typically supported by a smartphone, including messaging to calendar and geolocation services, with health- and fitness-tracking features. The smartwatch is perhaps one of the most recognizable examples of digital health technology, or the growing market of health-related material technologies and the algorithms and analytical methods they use and support. Digital health technologies include a wide range of commercial and medical products, from digital patient records to popular wearable technologies, but all roughly aim “to support health systems in all countries in health promotion and disease prevention . . . by improving the accessibility, quality, and affordability of health services” to promote “patients wellbeing.”' Popular digital health technologies like smartwatches locate these improvements in personal data tracking. Through sensors and algorithms, devices and platforms claim to grant access to a range of metrics, including heart rate, steps or distance traveled, and blood oxygen levels, and offer a tracking system to monitor the data over time. The data-tracking system is designed as a way to maintain or improve physical and mental well-being. Mobile technologies and networked platforms have become essential tools for the development of digital health: from digitized patient records to crowd-sourced diagnostics, to the health-monitoring apps that now come standard on Apple and Android smartphones. Across all of these technologies, health is defined both explicitly and implicitly, whether through quantified measurements or supporting medical information. These standards are reinforced through features such as biofeedback, or goal-based systems that frame behaviors and vitals in relation to the platform’s biostatistical health standards. Collectively, the data, supplementary information and visualizations, and tracking features claim to provide individuals with a representation of their health. Apple Watch, for example, reinforces a standard of health maintenance based on achieving a daily calorie count. This measure is communicated through a combination of vibration mechanisms and interface design that organizes statistical information and suggests strategies for maintaining and improving health. But where do these definitions of health come from, and how can they affect an individual’s perception of their body, health, and behaviors?

This book addresses this question by approaching digital health technologies as aesthetic experiences. By “aesthetics,” I am not referring to the Kantian association with beauty or judgment, but instead invoke its Greek origin, aisthetikos, which describes that which is perceptible to the senses.’ Aesthetics includes visual, auditory, and haptic forms of perception, all of which are central to the design and experience of digital health technologies. As the opening description illustrates, digital health technologies involve material technologies, data tracking, and feedback systems as well as a range of sense perceptions and embodied reactions. The definition of “health” emerges through an embodied experience of the Apple Watch, not simply through the biomedical data it provides. Indeed, the power and complexity of digital health technologies lie in the way the platforms and devices become embedded in day-to-day life, circling wrists or populating the screens of phones, supposedly monitoring and supporting an individual’s well-being. Consequently, the technology’s definition of health is found in the familiar and small interactions, the push notifications, reminders, visualizations, and statistics that pop up throughout the day. Like the experience of health itself, these encounters often fade into the background or go unnoticed. But their power often lies in their ordinariness, the ways these articulations of health are communicated through the most basic ephemeral encounters with technology: the glimpses, glances, and vibrations that occur throughout the day. Pinpointing the definition or experience of health is thus a challenge as it becomes dispersed across a range of ephemeral encounters with screens or devices.

‘To capture and analyze the aesthetic experiences of digital health technologies, I turn to the descriptive methods of film and media studies, a discipline challenged with understanding the relationship between the aesthetic forms of time-based audiovisual texts and mediated experiences. My approach combines two separate but interwoven modes of description. I first focus on descriptions of the technology’s design and interactive features as a way to analyze the visual and haptic rhetoric of health. I then turn to phenomenological description as a way to capture the corresponding bodily reactions and sense perceptions created through the structures of the device or platform. By combining these two modes of description, I consider the rhetoric and design of digital health platforms and interfaces as well as the range of sensuous experiences that collectively inform how individuals understand their bodies and health. These two modes of description offer a way to grasp and analyze how health is communicated to individuals, and the specific configurations of the body and lived experiences they generate.

Digital health technologies combine the features of mobile and digital technologies with biomedical preventative approaches to health that have developed over the last half-century. For example, Apple Watch has a default daily exercise goal of thirty minutes per day, in line with public health campaigns and official recommendations from the CDC.’ However, the emphasis on quantifiable measures of health ultimately reinforces a highly reductive, individualistic understanding of what it means to be fit, healthy, and well. Like Apple Watch, digital health technologies often foreground numbers tied to weight and physical ability, like the number of calories I burn or minutes I exercise, and efface any social and environmental determinants of health. Rather than considering how, for example, socioeconomic conditions or genetics may shape my health, Pm urged to continually examine my day through the lens of data, accumulating, improving, and conforming to the structures of the device imposed on me by the technology. Moreover, many of these devices and platforms are only financially accessible to those with expendable income, or they are made available through private insurance companies that ask for data sharing in exchange for reduced healthcare costs.t For example, Apple Watch pricing starts at $279 and requires a corresponding smartphone to access the full range of features.’ As a result, scholars have critiqued digital health for reinforcing preventative models for health that emphasize the ideology of bodily control, optimization, and improvement.’ Through a focus on numbers, and structures that encourage the improvement of metrics, digital health technologies promote a model of health that prioritizes individual self-surveillance and controlling the body and behaviors as a form of health maintenance.

At the same time, a user’s perception and understanding of health cannot be reduced to the goals or structures of the technology. As I describe above, I do feel the pressure to conform my body and habits to the structures of the device. Failure to accumulate those numbers can feel like a failure to be healthy or even a failure of the self. But my opening description cannot be reduced to a narrative of mindless conformity at the hands of technology. I ultimately resist the call of the device, choosing not to align my actions with the watch’s recommendations. Descriptions of the experience of digital health show that these technologies often create complicated relationships between the body and health. While the technologies reinforce preventative definitions of health that emphasize improvement, this does not necessarily mean that individuals conform their habits to the data on screen or ignore their bodies in favor of numbers.’ More often than not, the digital health experience incorporates moments of conformity and resistance, bodily alienation, and reflexivity.*

As a practice concerned with the specificity of subjective experience, phenomenological description can highlight the way individual bodies navigate the biomedical structures of technology. At the same time, phenomenological description cannot offer a generalizable account of the experience of digital health. The descriptions instead reveal how approaching digital health as aesthetic experiences can be used to explore the tensions between technologies and bodies, and the multiplicity of experiences generated through the platforms and devices. Put another way, my use of description acknowledges and critiques the biomedical structures of digital health technology while remaining attentive to the lived experiences of users.

The use of description in this book presents both practical and philosophical possibilities for the study, design, and use of digital health technologies. First, description can help researchers, designers, and users cultivate digital media literacies to understand the role of emerging technologies in a changing health and media landscape.’ By describing specific encounters with technology, it showcases how particular design choices and interactive features shape the perception and meaning of health. Accounts tracing the relationship between design and experience can be used by scholars in the social sciences and humanities studying the impact of digital health technologies, as well as designers invested in developing technologies that move away from biomedical frameworks for health. However, this literacy is not limited to the study of digital health. As I show, the act of description itself prompts critical reflection on the part of the describer. As digital health becomes integrated into institutions and official medical treatment regimens, it will be harder for individuals to opt out or resist the biomedical definitions of health promoted via the platforms and devices. It will become imperative for individuals to develop digital literacy skills to question, resist, and reflect on the structures of health and bodies that many commercial technologies promote. The practice of description prompts an individual to translate their experiences into language and may be capable of encouraging a more attentive and critical relationship to the experiences generated through digital health technologies. As a contribution to what Kristin Ostherr calls, “the digital health humanities,” my use of description can thus help expand the study of media and technology in the health humanities, which has largely been informed by traditions in literary analysis."

Second, the practice of describing digital health technologies can be used to expand the philosophy and theory of health. While health may remain “absent” or in the background, for the most part, I suggest that description reveals how technologies may be capable of bringing to the fore a sense of the body’s affordances and relationship to the world. The practice of describing often shows moments of friction and bodily attunement that escape the biomedical binary between health and illness— moments of what I call “feeling health.” Drawing on philosophical work in medical phenomenology, I question whether descriptive accounts can be used to move away from a strictly biomedical approach to health, in favor of a spectrum model that describes how the sense of possibility and “ability” fades or diminishes in illness. This phenomenology of health does not suggest that “ability” or capacity is measured by external (biomedical) standards, but is instead dependent on an individual’s subjective being-inthe-world."' Likewise, a spectrum model of health is not meant to suggest that bodily reflexivity and attunement is a moral good that can replace the exclusionary structures of biomedical definitions of health. Description instead provides a method for nuancing and clarifying how health is made meaningful and felt for individual bodies as they engage with digital health technologies.

The practice of describing the aesthetic experience of digital health technologies can thus be applied across a variety of practical and academic contexts. Scholars and practitioners analyzing the use and function of digital health may find the sections of close aesthetic description particularly useful, while those interested in developing critical reading practices may benefit from description as a method of self-reflection, and scholars interested in theories and philosophies of health may find the discussions of description and embodiment a useful resource for developing definitions of health alongside biomedical frameworks. As I show throughout this book, digital health technologies generate complex and contradictory experiences and understandings of the body. It’s only by attending to the “mundane frictions,” moments of resistance, reflexivity, and ambivalence, alongside moments of conformity that one can grasp how digital health technologies shape the perception of health.” By approaching digital health as aesthetic experiences, this book offers strategies for capturing, reading, critiquing, and theorizing the veritable configurations of the body and the embodied experiences they generate.

Describing (Digital) Health

Studies of digital health technologies have largely overlooked the role of aesthetics and design in favor of analyzing corporate rhetoric. Both sociological and humanist studies tend to focus on how language and the structures of commodification construct and exploit an imagined ideal user.” The marketing campaigns, quantified structures, gamified components, and price points of digital health all collectively imagine a single, unified fantasy of the ideal user. The advertisements for many devices showcase active, able bodies of young professionals who have incorporated the technology into the flows and rhythms of their busy, everyday lives. The companies rarely acknowledge disability (save for an occasional wheelchair user) or the range of environments and social conditions, such as parenting or types of work, that may prohibit conforming to the structures of the device.'* Instead, the simplicity of meeting a daily numerical goal is held up as the pathway to health. From the prices of the technologies to the reduction of health to calorie counts and exercise, and even the way the reminders and notifications implicitly assume how a workday is structured, digital health technologies (and fitness and wellness culture, more generally) imagine an ideal user who inhabits a middle- or upper-class white lifestyle.’ The fantasy of the digital health subject is supported through datafication of the body and behaviors that are compared to biostatistical norms. Scholars have thus argued that digital health technologies function as tools for normalization, “compelling” individuals to meet criteria that do not take into account nonnormative bodies or lived experiences.’

While such accounts provide essential critiques of how the language of healthism, neoliberal values, and biomedical authority are perpetuated via digital health, they ultimately overlook the power of the visuals and feedback features and risk homogenizing the digital health experience. Digital health technologies implicitly communicate a definition of health through a combination of visual and linguistic rhetoric and feedback features, and how individuals use, understand, and experience those interactions varies from person to person. Approaching digital health as an aesthetic experience helps provide an account of digital health that acknowledges how biomedical approaches to health are reinforced through design and feedback features while remaining open to the veritable sense experiences of the individuals who use the technologies."

However, the ephemerality of the digital health technology experience poses an analytical challenge. How does one translate into written form the experience of a push notification or audio feedback during a workout? Close visual analysis of an interface may reveal the rhetorical power of visualization, or analyzing the rhetoric of an advertisement may reveal the goals of a product, but these processes alone cannot capture the lived experience of interacting with the device. Thus, I approach digital health as scholars approach film and other moving-image media: as aesthetic experiences generated through a combination of formal properties, viewing conditions, and embodied sensations. By “aesthetic experience,” I don’t mean to suggest that digital health objects are experienced as artworks or even that they provoke experiences of beauty (the two major concepts that drive philosophical aesthetics). Rather, my use of “aesthetic” more broadly names a mode of experience that is attuned to the particularities of sensation, both bodily and perceptual. While the description of these particularities is most commonly associated with academic disciplines concerned with the analysis of artworks, such as film and media studies, all kinds of objects provoke aesthetic experiences and thus demand close description of them. In film and media studies, description functions as the method for quoting the ephemeral properties of a text as well as a means for analyzing the experience of cinema.'* That is, description functions as a way to trace the relationship between the formal structures of a text—e.g., editing, cinematography, lighting—and the mediated experience of such techniques. Because the discipline uses description as the grounds for analysis, scholars have argued that film and media studies has been highly influenced by phenomenological methods and modes of thinking. Though the use of description by scholars in the discipline is not always explicitly operating through traditions of phenomenology, description functions as a tool for capturing and elucidating the aesthetic experience of moving images.’ Thus, while I distinguish between descriptions of the device and platform design and phenomenological descriptions of the experiences of digital health technologies, these two strategies are ultimately intertwined and continuous with one another. In this respect, my use of description resembles the methods of medical phenomenology, which combines the close, firsthand description of one’s experience with analysis to make broader claims about the body, health, and medicine. This book brings film and media studies’ analytical methods into conversation with medical phenomenology to show how design choices and technological features inform the experience and perception of health.