Of Apple Watches and Dreams

This week, Apple announced their forthcoming watch. I'm skeptical that this new wearable tool will be the 'next big thing' in health, in part because of the pricetag - $349 and a new iPhone 6 (a minimum of another $200 and a 2-year contract with AT&T). A couple of colleagues rebutted me on the price tag issue, noting that lots of lower middle-class and poor folks have what one might call fancy stuff - smartphones and flat-screen TVs (aren’t TVs almost all flat screens now?). One of these colleagues is African-American and does research among urban poor. The cost of “wearable” technologies as critically important, because obesity and cardiometabolic diseases are skewed to lower socio-economic classes.

Will expensive wearables improve health in populations that have health disparities?

Poor folks purchasing fancy stuff is a complex issue. When I was 7, my Dad left my Mom, so it was just my Mom and me and she didn't make much money working as a secretary at a university. We were poor. I recall coming home a few times to find the power or phone being turned off. I got my "new" clothes from the Salvation Army or from church friends whose kids had outgrown them. The only fancy stuff I recall having was a Scwhinn Sting-Ray bicycle my Dad gave me when I was about 11. On Christmas Day, back in 1967, I had pretty much concluded that there is no Santa Claus. Mom had some modest presents for me under the tree, and she said to me, “I’m sorry, Santa didn't have much money this year". But I wasn't at all unhappy, so her pain was less about my Christmas than it was about not being able to fulfill her dreams. All parents dream of boosting their children to a life better than the one they've got, and it can be a bitter, bitter pill to swallow when one cannot fulfill this dream.

My youth experiences aside, do poor people today have lots of fancy stuff? Anecdotally, my colleague who does urban research says they do. Among poor patients that I’ve seen in recent years, they almost all have cell phones, but I don’t recall seeing any iPads. Maybe the iPads were left at home. A few years back, the Nintendo Wii was somewhat popular for home exercise. I heard rationalizations the the Wii was good for the kids and grandkids, yet also helped Mom/Grandmom to work-out at home. Where I live, the fancy stuff is more likely to be a 4-wheeler or snowmobile, but there is more than a small amount of material goods that one might think of as fancy stuff. So I don't know if there's a lot, or just some, but it's not none. Even in my own life, it wasn't none. But as a clinician, I don't think it matters.

When I see poor patients who have fancy stuff, as a clinician I'm of the opinion that it's better to not pass judgment. It IS my place to make mental note of it, wonder if it's their best use of resources, while recognizing that such purchases serve a strong emotional need. But it doesn’t help my patient to question him or her on such purchases, at least not from the perspective of advancing his or her ability to navigate life challenges and improve health ecology. Yes, healthy coping probably means that patients have to come to some accomodation of their realities and make wise use of resources, but it's better for them to discover that very gently from a position of emotional trust. I find it much easier to earn trust when I don't pass any judgments.

Humans have a complex relationship with material goods. All people, rich and poor alike, have an emotional need to feel fulfilled, that their life has Divine meaning and validity. When poor patients buy the same fancy stuff that rich patients do, I don’t see issues of discretionary income. I see a purchase that was an expression of emotions and dreams, and I am far more curious about those dreams than about whether it was a wise expenditure. It’s the dreams, not the intrinsic material value, that drove the emotional need to buy, and those same dreams can power lifestyle change if I can help the patient harness that emotional energy. Indeed, it’s the patients in whom I see no evidence of dreams that I really worry about, fearing that they have lost hope - metaphorically speaking - of having a better Christmas.

Apple may well sell a lot of watches, iPhone 6's and iOS8 health apps to folks with health disparities. Interestingly, when I have advised the purchase of some device (often a pedometer), if the patient can't see the expenditure as an emotional expression of his or her own dream, my experience is that very few patients will spend anywhere near $550. Many of them balk at just $20. That seems somewhat of a conundrum, given that the average person trying to lose weight blindly spends well in excess of $1000 a year. But whether patients spend on such purchases or refuse to spend, remember that these purchases represent emotional pursuit of dreams, not rational choices as the best allocation of resources.

Finally, beyond the question of whether or not purchases of wearable sensors are good investments, lies the problem that lifestyle change is mainly about emotions that no gizmo can measure. Successfully helping people to better health has surprisingly little to do with the things that gizmos are good at - the number on the bathroom scale, calorie content in a meal or spent on a treadmill or exercise device, an exercise heart rate or any quantitative measure or data analysis. Quantitative measures don't help much because what patients need most is a human who can size them up and look them in the eye to say, "Yeah, you’re worthy, what do we have to do to fulfill your dreams"?

Will expensive wearables improve health in populations that have health disparities? I think probably some, but not that much. I don't see how any gizmo will ever put their arm around a patient and make them feel, very deep inside, that it's all going to work out, nurturing the patient's willpower to tough out difficult challenges that lie ahead.