Digital health futures: who guards the guards?

Vural Özdemir writes from Toronto: Digital technologies offer real prospects for health care in an era of COVID-19. But let’s not forget that health is ultimately analog. We have not become AI powered robots, at least not just yet. Digital health is a proxy, a tool, not an end point, to improve analog health.

Vural Özdemir

With COVID-19, digital health has become a hot topic. Digital technologies such as the Internet of Things (IoT) and artificial intelligence (AI) have found new applications in medicine, for example, to achieve the twin goals of social distancing and health care delivery. Digital technologies are topics for public debate at the moment as attempts are also made around the world for safe reopening of schools and to protect students’ health. Meanwhile, a new generation has been growing up over the past decade immersed in a digital world, long before the current pandemic. Governance concepts have not kept pace, however, with digital technologies and emerging applications in health.

Frames and framings of governance matter, precisely because they determine what knowledge is included and omitted, not to mention the methods by which governance is accomplished, and the ends to which governance instruments serve. 

In this analysis, I describe four new conceptual frames for equitable and efficient governance of digital health futures.

Health is ultimately analog, not digital

Digital technologies offer real prospects for health care in an era of COVID-19. But let’s not forget that health is ultimately analog. We have not become AI powered robots, at least not just yet. Digital health is a proxy, a tool, not an end point, to improve analog health, in some ways similar to cholesterol as proxy to improve cardiovascular health. 

The recognition that digital health ought to impact on analog health has important implications. For example, we are facing novel interfaces in health sciences: analog to digital health translation, and back to analog health. Another key challenge is different data and knowledge flow speeds in analog versus digital health. What works as governance in digital health may not work for analog health, and vice versa.

Health in the 21st century is a cyber-physical system

Health in the 21st century is a cyber-physical system (CPS), a concept that underscores the entanglement of analog and digital components of human health. The CPS has roots, in part, in the concept of Industry 4.0 that was launched in the 2011 Hannover Fair in Germany, as a digital high tech strategy.

Industry 4.0 has since expanded beyond Germany across the Atlantic and globally, and builds on CPS as a conceptual framing. 

The CPS governance frame has three pillars of importance for digital health futures:

  • Extreme planetary scale digital connectivity by the IoT,
  • Embedded biosensors and smart architecture design such as smart hospitals, and
  • Large-scale data analysis and sense-making tools such as AI. 

The CPS frame has several governance implications. We need to consider governance coordinately, in both digital and analog health. CPS and associated extreme digital connectivity can create an “all eggs in one basket” vulnerability for whole digital health system collapse through domino effects and echo chambers.

Critical governance and feminist studies of technology

There is an urgent need to shift toward critically informed technology and health governance in the 21st century. Since the 1980s, technology governance frames have focused narrowly on the neoliberal market efficiency criterion in particular, and bracketed out power asymmetries, social injustices and politics embedded in health, technology and society. The neoliberal transformation of technology governance materialized rather insidiously over the past decades, and even softening the ordinarily critical cutting edge of social sciences and humanities, not to mention steering the medical and health sciences education toward apolitical and uncritical directions.

It is noteworthy in this context that emerging technology analyses that put power, politics, and agency at their center, and examine not only knowledge but also framings of knowledge, offer the strengths of feminist technology governance frames, and ought to be considered for equitable and critically informed governance design for digital health futures. 

A feminist studies of emerging technology and digital health would allow a deeper examination of the vast disinformation and post-truth prevalent in digital ecosystems, and additionally, help move beyond anthropocentrism to take into account the systems level and socio-material impacts of digital technologies on nonhuman animals, plants and ecosystems as well.1

Public and youth literacy on democratic theory

Our collective ability to govern digital health futures on national and planetary scales depends on strong democratic institutions, and youth and public literacy on democratic theory. 

Democracy is not an externality for digital health governance but a key pillar and driver. The rise of global populism, concentration of political power by authoritarian leaders around the world, and threats to democratic practices are causing polarization and impediments to collective action, and collective governance of digital futures. With Covid-19, these regressive changes have, unfortunately, coalesced further. 

Who guards the guards?

The Roman poet Juvenal asked in the 1st century AC the following question: “Who guards the guards themselves?”. This question remains relevant in the early 21st century, and relates to whether any group, or elected leaders, can be trusted to look past their own interests for the common good. 

With weakening of democratic institutions, elections, alone, are not a guarantee for robust democracy or to prevent the majoritarian rule and the tyranny of the victor. For robust democracies, we also need free and fair elections, not merely presence of elections; separation of powers; rule of law; and free, independent and critical press and journalism to hold political and digital powers to account. Public literacy on democratic theory, particularly of the youth and beginning at high school stage, is therefore essential for critical governance of digital health futures. 

Despite the current climate of populism and authoritarian governance, there is hope, opportunity, and responsibility to cultivate public literacy on democratic theory among next generations, to hold digital and analog political power to account, and buttress democracies and governance designs for digital health futures. 

These four points on digital health governance frames invite us to rethink our unchecked assumptions in the technology and global governance fields. They might offer new solutions to ensure digital health futures materialize in ways that are broadly relevant, experiential, democratic, and socially just. 


1 Barad K. (2007) Meeting the Universe Halfway: Quantum Physics and the Entanglement of Matter and Meaning. Durham & London: Duke University Press.


Vural Özdemir is a physician-scientist and Diplomat of the American Board of Clinical Pharmacology. He writes on planetary health and critical governance of science, technology and innovation.