Revolutionizing Healthcare in the Age of Control Societies: From Disciplinary Institutions to Strategies of Self Quantification and the Influence of Visual Cultures.
“Discipline is, above all, analysis of space; it is individualization through space, the placing of bodies in an individualized space that permits classification and combinations.”
– Michel Foucault, Incorporation of the Hospital into Modern Technology (1978) .
The extract above, from Michel Foucault’s The Incorporation of the Hospital into Modern Technology (1978), we are introduced to the historical notion of the hospital as a disciplinary institution of surveillance by focusing on the use of space to exercise power over the individual and reduce the body to a record of classifications . In this study on the association between visual cultures and the history of healthcare from the 18th Century disciplinary society in transition to a society of control, we will assess the causation of the democratization of health data and the extent to which visual cultures is an effective vessel for establishing a new healthcare of participation. Furthermore, this study will analyse the ability of visual cultures to interrupt the cycle of healthcare as an instrument orchestrated to exert power over the human body.
Constructing an argument for the relationship between the hospital of the 18th Century and Jeremy Bentham’s ‘panopticon’, Stuart Elden’s Plague, Panopticon, Police (2002) explains, “Hospitals required knowledge of contacts, contagions, proximity and crowding (…) at the same time to divide space and keep it open, assuring a surveillance which is both global and individualising.” This identification of a hospital’s dependency on surveillance and data echoes Foucault’s analysis of the use of space in a public institution, an oxymoronic combination of enclosed and open spaces that both facilitates the physicians need to observe and simultaneously ensures the internalisation of surveillance by patients in the 18th and 19th Century, a disciplinary procedure intended to mold society. The panopticon model is emblematic of this strategy to employ self-surveillance and self-discipline, providing a theoretical architectural framework to support the ‘medical gaze’.
The ‘medical gaze’ is initially introduced by Michel Foucault’s The Birth of the Clinic (1963) to delineate the dehumanization of the patient’s perspective and experience of a disease, emboldening the physician’s interpretation of symptoms . The ‘medical gaze’ cultivates a doctor/patient binary that enables a complex power dynamic. In these terms, the separation of the mind and body is paramount to the objective observation and treatment of the body. The ‘medical gaze’ can also be extended to surgical procedures such as the autopsy and other forms of medical research.
Figure 1: Cristin Millett, ‘Teatro Anatomico’ multimedia installation and interactive video project (2005) .
In Figure 1, Cristin Millett’s Teatro Anatomico (2016) channels the hierarchy of medical observation from the angle of the female reproductive system into her own visual cultures practice. Examined by Peripheral Visions Press, Millet’s multimedia representation takes inspiration from the historical anatomy theatre in architectural space and evokes artistic representations of 17th Century anatomy lessons . The architectural structure indicates a hierarchal organization of the medical as indicated in the diagram below (Figure 2).
In Figure 2, Millett’s architectural space is mapped, concentric ellipses facilitate a classification of the significance of the observers around the doctor, extricating knowledge from the subjugated female human body under scientific surveillance. Situated centrally is the part of the work entitled Abdominal Hysterectomy: Dissection of the Observer, displaying the surgical procedure while surveillance apparatus installed into the work captures the image of the observer and superimposes the image onto the face of the patient. Although differing from the surveillance model of the panopticon, Teatro Anatomico encompasses modes of observation and surveillance and features a role reversal of the power dynamic between doctor and patient that put the participant in the role of the subjugated body. Through participatory techniques, is the artist able to re-humanize the body in conjunction with the mind? Through the incorporation of modern technology, Millett is able to question historical and contemporary production of scientific knowledge.
Figure 2: Cristin Millett, ‘Plan for Teatro Anatomico’ (2005) .
Focusing on the body as a site of subjugation, the formation of ‘docile bodies’ encapsulates the characteristics of surveillance in human anthropology. In Jen Pylypa’s Power and Bodily Practice (1998), we are confronted with redefining Foucault’s use of the terminology of ‘biopower’ to analyse the exertion of power in activities and practices of everyday life that result in “self-surveillance” and “self-discipline” . Pylypa further discusses the “self-regulation of hygiene, health and sexuality” as components of social control. Similarly, to the work of Cristin Millett, Pylypa references Davis-Floyd on the reproductive body of the woman as an example of social control of the production of scientific knowledge – by means of performing obstetrical “rituals” that transform the nature of giving birth into a process that is subject to monitoring and surveillance . Analysing the objectified human body as the site of scientific research and knowledge producing practices of medicine that continue into the 21st Century perception of healthcare, the internalisation of control by the patient has aided the healthcare system’s transition from an instrument of the disciplinary society to a society of control.
Explored in Gilles Deleuze’s Postscript on the Societies of Control (1992), the transformation into the control society of the late 20th and 21st Century can be applied to healthcare from the process of being individualized by the disciplinary model towards being “dividuals” measured in accordance with “masses, samples, data, markets or banks.” This provides a foundation for the quantification of public health for data analytics with informatics. While the enclosures of discipline were limited to discontinuous control of bodies, the network of mechanisms constituting the control society initiate a never-ending subjugation to its ‘biopower’. Furthermore, when administered these strategies enable the modulation and influencing of the public. Deleuze continues by highlighting the “passive dangers” of the control society – “noise and the active, piracy and viral contamination.” – introduced by innovation of computational technology .
The catalyst for the transforming nature of the public institution from the disciplinary society to one of control is the consequence of what Deleuze refers to as the “mutation” of capitalism . Capitalist society shifted from an industry of production to that of services thus permeating all aspects of everyday life. This is symbolic of the mode by which ‘biopower’ infiltrates society in a continuous and constantly shifting process. In an era marked by the global financial crisis of 2007-2008, the role of the state of the control society and its relationship with the public institution has been vital to our understanding of ongoing healthcare crises. The commoditization of underfunded healthcare systems presents problems to the management and organization of hospitals at the point of care. The movement of corporations towards the provision of public services represents elements of marketization as improving ‘patient choice’. Symptoms of healthcare in crises have manifested into over-crowdedness and a lack of beds, the failing to meet waiting time targets in emergency rooms and waiting lists for surgery. While hospitals are under ever increasing pressure to meet the quantitative targets set by government policy to improve services, further quantitative measures are being enforced on patients by hospitals, resulting in implications that are detrimental to patient care and wellbeing and the treatment of health as a commodity.
In Figure 3 (below), printmaker Darian Goldin Stahl exhibits MRI IN USE (2017) at the Alberta Printmakers Gallery, expressing the encounter of the hospital patient with an MRI scanner, with research conducted on the artist’s sister who was diagnosed with multiple sclerosis; a “collaborative cycle” . The work uses photographic prints to fabricate hospital gowns which are deconstructed, obscured and suspended in the gallery space, a disembodied reference to the absent patient – symbolizing the disassociation and vulnerability of the patient in this environment.
Figure 3.1: Darian Goldin Stahl, ‘MRI IN USE’ hospital gown print installation and projection (Alberta Printmakers Gallery, 2016-2017) .
What are the implications of medical imaging on the patient? Projections of coded text and numerical data in Figure 3.2 explores what Stahl describes as the “sterile nature” of the hospital environment . In analysis of the overlaying of coded language, the patient’s own data is intended to be decoded by the healthcare professionals – inaccessible to the patient – and further signals the disassociation of body and mind when encountering medical apparatus of radiology.
Figure 3.2: Darian Goldin Stahl, ‘MRI IN USE’ hospital gown print installation and projection (Alberta Printmakers Gallery, 2016-2017) .
The intention of this work is dual in nature; by situating the exhibit in a gallery setting, Stahl intends the shadows of visitors to embody the work in order to reanimate the role of the patient in the composition, additionally, the printmaker hopes the work will encourage the public to “value the human condition” and consider our own future in relation to disability . In the context of this study, Darian Goldin Stahl’s work is able to identify the relationship between the patient and the hospital as fraught with tension, disembodiment and coded quantification of the patient experience.
The capabilities of data analytics in healthcare can be demonstrated in a variety of strategies, according to The Guardian “the human body contains nearly 150tr gigabytes of information” . In hospitals, the combination of retrospective data based on data collection from medical records and real-time clinical data captured at the point of care can produce predictive analytics – which could be the future of preventative healthcare and revolutionize diagnosis. Furthermore, the collection of big data is instrumental to global health in the form of public health surveillance. Public health surveillance is a strategy adopted by the World Health Organization that relies on “continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation and evaluation of public health practice” . Data analytics can help prevent and provide early warning on impending public health emergencies, monitor the epidemiology of diseases such as HIV/AIDS and is able to monitor progress towards humanitarian targets set by the United Nations .
Alternatively, elements of data collection in the name of healthcare have had more detrimental ramifications. Care.data, a database project eventually abandoned by the National Health Service in the UK, was an extension of NHS policy of storing patient information on ‘hospital episode statistics’ (HES) since 1989 in order to enable data sharing between general practitioners and hospitals . This proved controversial as the initiative was undecided on whether to share public health data with private corporations. In May 2017, the WannaCry ransomware attack on healthcare systems represented a threat or danger to the structure of the control society and served a dual role in both damaging the order of societal control and in exposing the population to the vulnerability of healthcare systems with such dependence on technology and quantitative patient data.
Figure 4 (below) highlights a case study and analogy for the advanced developments of controlling mechanisms in a contemporary hospital environment. In 2017, the Humber River Hospital in Toronto, CA invested in a hospital “command centre” based on data analytics that GE Reports equates to the technology of a mission control command centre .
Figure 4: GE Healthcare Partners, “New 4,500-square-foot Command Center using machine-learning and complex algorithms.” (2018). (Image Credits: CNW Group/Humber River Hospital) .
By using the centralised model of the control room, the hospital is able to aggregate patient data in real-time in order to administer preventative care and determine emergencies as well as offering a more streamlined, efficient service to patients. Furthermore, wearable technology is considered the next step in monitoring patients outside of the hospital .
What is the impact of this expansion of technology in healthcare control outside of the institution? This investment into revolutionizing technology to maintain a care of the patient outside of the hospital is beneficial to preventative and post-hospital care, but also contributes to the network of continuous control that surrounds the monitored body. Analysing the data representation in Figure 4, this case study provides further example of how the patients experience and identity is underrepresented to prioritise the benefits of big data, reducing the patient to a ‘dividual’.
Coupling the characteristics of healthcare, historically, from the Foucault’s disciplinary institution to Deleuze’s societies of control and its influence on the patient with the experience and interpretations of practitioners in the field of visual cultures representing healthcare, a narrative begins to materialize. Analysing these aspects of patient experience, we can deduce that the healthcare system as a public institution must be ethically nurtured and protected, but, in its transformation into a mechanism of the control society that despite attempts to eliminate the ‘medical gaze’ and drive patient inclusion and participation, the management of healthcare and the introduction of technology has led to a more quantified approach to patient care and the quantification of health and wellbeing. Where is the future of healthcare in a society inextricably linked to discipline and control? What strategies can be acquired by the patient to manage their own health concerns?
In 2016, Haus der Kulturen der Welt’s exhibition Nervous Systems: Quantified Life and the Social Question explores the changing relationship between the concept of the ‘self’ and the ‘social’ in the age of technological infrastructure. The use of the term “nervous system” refers to the concept of the synthesis of the organic – human life – and the machine. This exhibition ultimately examines data as a means of control and governance . A featured work in the exhibition, The White Room constructed by the Tactical Technology Collective is an installation designed to educate visitors on their own ‘digital shadow’ . The inclusion of this work in the Nervous Systems exhibition is demonstrative of the pedagogical turn of the exhibition space and how visual cultures is uniquely equipped to enlighten the public on matters of data surveillance and technologies of self-quantification. The. Tactical Technology Collective express the objective of the installation:
“Eye-opening, hands-on workshops, discussions, and demonstrations focused on the devices we use every day: How do they work? What individual data traces do they capture? Where do these go, and what kind of control can one regain?”
– The Tactical Technology Collective, The White Room (2016) .
The questions posed by Tactical Technology Collective are representative of the discourse of technology as part of the network supporting the control society. How can we overcome the control society? How can the energy of engagement in health be harnessed into visual cultures?
Figure 5: Laurie Frick, ‘Walking, Eating, Sleeping.’ (Marfa Contemporary, 2013). (Image Credit: Marfa Contemporary) .
Laurie Frick is a self-described data-artist, creating a coded visual language based on self-tracking. In her installation at Marfa Contemporary in 2013, Walking, Eating Sleeping is comprised of a dense aggregation of laser-cut wooden structures representing quantified self-tracking data, suspended inside the gallery space. Frick claims, “Numbers are abstract concepts, but we recognize pattern intuitively” .
This quote by Laurie Frick provides context for the coded visual language in an installation that represents the artist’s identity and aesthetic by expressing quantification through a personal code that replaces the numerical interpretation of the self through data. In achieving this, Frick is able to, in a sense, reclaim her own aggregated data, while in the same instance publicising it for consumption in the gallery space. Furthermore, the artist is able to decipher, interpret and ultimately control her own personal information. In the age of the control society, this work is able to individualize and produce embodied quantified data.
Figure 6: Michael Mandiberg, “Preliminary Video Documentation of ‘Self Portrait (Rhythms).’” (LACMA, 2017-2018) .
Another example of an artist’s endeavour to represent self-tracking data is performance artist Michael Mandiberg, who documented his own heartbeat partnered with the sounds of incoming and outgoing emails on his personal devices for a 365-day recording . In the work, entitled Quantified Self Portrait (Rhythms), the artist intends to explore the increased quantification of a society . In relation to the control society, this work recreates the inescapable experience of these networks in which constant access to technology facilitates. Quantified Self Portrait is generated by the technology of the FitBit and the work of LACMA Art + Technology Lab , using the technologies of such a society of control to criticise the quantification of the human body as documentation of its process, resulting in a sonically codified representation of the artist’s lifestyle and activities.
While technology that enables us to quantify the ‘self’ is an innovation that is rapidly being manipulated in order to develop the human body into a ‘dividual’, quantified in relation to the masses for the interest of data mining of private corporations, governments and public institutions such as the healthcare system; primarily motivated by the marketization of healthcare and social control, such technology can also be an effective tool for activism and engagement with our own healthcare. Wearable technology by companies such as FitBit, Apple and Shimmer can be exploited by such bodies, but can also be utilized as a catalyst of activism and awareness of uses of our public health data, also empowering the reclamation and regained control of our own personal information. This has been evident in Laurie Frick’s FRICKbits exemplifies how smartphone technology can be a platform for the creative democratization of self-tracking. Released as an opensource smartphone application in 2014, FRICKbits was an experimental work in “taking back your data” .
Finally, in compiling the findings of this study into the relationship between visual cultures and its reflection of the progression of healthcare institutions and practices employed by societies of control, we can understand how the work of artists and practitioners is able to democratize the technology dedicated to controlling health. By analysing the work of artists that have experienced subjugation and a lack of identity as a result of the historical mechanisms of discipline and control within healthcare, we can establish the implications of the medical gaze on concepts such as women’s reproductive health as indicated in Cristin Millett’s ‘Teatro Anatomico’ (2016) or the experiences of the disabled as exhibited in Darian Goldin Stahl’s ‘MRI IN USE’ (2017) which both criticise the healthcare systems treatment of the body. In the transition from the disciplinary institution to the control society, we can visualise the history of the hospital as an enclosure of observation and pedagogy, towards a complex, never-ceasing network of technological social control. As a result of quantification of public health in the era of big data, the visual arts have turned attention towards reclaiming their own data, a prominent feature in the work of Laurie Frick. Furthermore, the repurposing of technologies dedicated to the quantification and control of patient health by changing the function of wearable technologies has evolved engagement with our own health. Reflecting on these explorations of surveillance within healthcare by visual cultures has resulted in a resistant form of health and wellbeing that both recognises the necessity of a functioning healthcare system but is critical of the institution and aims to restore control to the individual.
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