Public Health vs. The Internet: LIVE from the American Public Health Association Annual Conference in Atlanta

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This is America Dissected. I'm your host, Dr. Abdul El-Sayed.

Last Sunday, we hosted our third annual live show from the American Public Health Association National Conference in Atlanta, Georgia.

Here's your show.

All right. Good evening, APHA.

I am so excited to be here with you.

I'm also super excited to be welcoming our guest today, Ian Bogosh.

Now, we'll talk a bit more with Ian, but I want to give you some context of why it is that we're talking about public health and the Internet.

Now, like many of you, I've given my fair share of public health lectures.

And usually when I give those lectures, I try to start from baseline first principles.

So what is public health?

And I know everybody in this audience is real quick.

We're always like, well, it's not medicine, OK? It's different.

Public health is what we as a society do collectively to assure the conditions for people to be healthy.

Now, all of us have heard that definition.

We probably heard it many, many, many times.

Can repeat it ad nauseum.

But I want to break it down quickly because I want to explain why it is that I think we're getting the Internet wrong.

Public health, of course, is not about individual action.

It is about collective action.

It's about all of us acting in concert to do a thing.

You can't do public health for individuals.

Instead, what you do is you do public health for communities, for society.

And then the last part is that doing public health is about what you do collectively to change the conditions in which communities live.

Now, when we think about conditions, we start from the most tangible.

The very air we breathe, the water we drink.

The sidewalks or not that we walk on.

The nature of our public transit.

But then we get more esoteric.

The nature of laws.

Whether or not you have a chance to help elect your public officials.

Whether or not your speech and your bodily autonomy are protected.

We all understand this when it comes to what it is that we do.

But I want us to think a little bit about what kinds of context we take seriously in public health.

And that's where I think we may be failing.

See, when we think about context, most of the time we limit the context that we admit into where it is that we do public health action to tangible context.

Places.

You should be able to see them and feel them and walk into them.

The problem, though, is that I think our definition of context may be too limited.

How many of you all here remember a time before you had Internet in your home?

All right, that's most of us, right?

I remember that time.

We didn't get Internet in my house until we had America Online in 1996.

I was 13 years old.

I had never bothered learning how to type until I was trying to AIM message my friends.

But I remember that you would walk away from the Internet.

I want you to raise your hand if you could access the Internet within three seconds right now.

Here's the thing about that.

When was the last time somebody told you that you should practice presence?

That you should really think about how to make sure that you are present in the space in the moment that you are in.

That this would be really good for your mental health.

Why is it that we have to give that advice?

Well, none of us and all of us.

And that's exactly it.

Is that when we think about being present in your current context,

we usually think about trying to keep your mind focused on the place in which you're inhabiting.

And the reason we say that is because it's so easy to inhabit what?

Another place.

And that's the place in your phone.

On the Internet.

And I think the fact that we assume that the Internet of today is just like the Internet from 1996,

that it's a place that you can choose to go to,

that maybe you can interact with some of your friends,

that can give you certain kinds of information,

and that that's all that's limited to.

I think that we're missing out on the opportunity to think through the broader impact of the Internet of today

on people's health.

Because here's the thing.

I'm coming to you as somebody who's about to turn 40.

And I barely remember a time before the Internet.

I think about my siblings.

One born in 1992, the other born in 1999.

For them, there was not a time before the Internet.

And for that reason, the ways in which the Internet space has started to take in,

has started to conquer, has started to color our ability to be engaged in the real space,

means that we fundamentally have to be asking about the public health implications of the Internet.

And I say this in 2023, in a time when the Internet is about to undergo some really profound changes.

So today, yes, we're going to talk about misinformation.

We're even going to talk about the ways that the Internet can enable us with real-time data.

Those are all great.

But I want you, for the course of this discussion, to take seriously the premise that the Internet is a place like other contexts.

And that if we're serious about engaging some of the biggest challenges of our time,

whether it's teen mental illness or the fabric of our civil society,

that we need to start thinking a bit about how it is that public health ought to act on this context we call the Internet.

We've got an incredible guest for us today.

But first, I've got to read a couple of messages from our sponsors.

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With that, I would love to introduce our guest today.

Ian Bogost is somebody who's been thinking a lot about the internet as context.

He's even designed part of it.

Ian Bogost is a video game designer, professor and author.

He's written 10 books, including How to Talk About Video Games.

His work can also be found at The Atlantic, where he's a contributing writer.

And he's a professor in arts and sciences, film and media studies and computer science at Washington University in St. Louis.

Please give a warm APHA welcome to Ian Bogost.

So Ian, how many public health conferences have you ever been to?

But also, like, we're a whole community founded on telling people what not to do.

Yeah, a little bit.

And you've designed digital spaces.

And do you think about them as real spaces?

And do you think about the ways that people are going to interact with this space vis-a-vis their health?

Digital spaces are real.

But they are distinct from other kinds of spaces.

We went through a couple kind of jags with ourselves on this over the years.

First, we thought there was the real world and there was the online world.

And when you're in the online world, there's something kind of wrong with you, you know?

Like you're in your basement too much or you're dialed into Prodigy or America Online.

And, you know, mom wants to use the phone.

Or you're gaming with your friends or whatever you're doing.

But now all of us are in those spaces all the time, as you pointed out.

And so it feels as though they've taken over the world.

But they are still distinct.

Like those of us in this room today are in this room.

And those of us who can also be on the Internet with one another.

You can text your friends or your parents or whatever.

You're in a different space.

So that can be very confusing.

It can be very confusing.

But it's really no different when you think about it.

It's no different than opening a book, turning on the television.

We're used to moving between what we call mediated experiences.

And the Internet is that.

But it's also weirder than that because you use it to do things.

You use it to do your banking.

You use it to go to the doctor.

You use it to find information, to buy stuff.

And increasingly we do a lot more things through it.

So it's made it even more confusing to think of them as separate.

And I think what's been really challenging in thinking about and watching particularly younger people interact for whom the Internet has displaced traditional community spaces is that even if you wanted to opt out as a young person, I don't actually think that's possible.

Because so much of that interaction is mediated online.

Like you walk into a lecture hall before lecture.

And I remember being in college.

And I'd be sitting there.

Either I have a group of friends with me.

We'd be talking, hanging out.

Or I might try and strike a conversation while we're waiting for lecture.

Today, everybody's literally on their phone.

And, like, that's the normal thing.

And if you tried to strike up a conversation, people would look at you kind of weird.

So how is it that the social feature of the Internet has started to, I guess, admix, almost steal from a lot of the social features in actual lived space?

There's a lot to unpack.

One feature you're observing is that not just young people but people of all kinds don't have other options.

Where are you going to go to do things?

It's true if you're a young person because, you know, we coop you up.

You don't go out and, like, ride your bike or hang out with your friends.

And there's sort of these stereotypes of what that looks like.

But it's also true.

But it's true in part because you can do it online.

And you're having true social experiences when you play Fortnite with your friends or what have you.

It's not fake.

It is real.

But it has displaced other forms of socializing.

Now, that said, the idea that you could just put your phone away.

Like, for this session, maybe you just don't need to look at your phone if you're in the audience.

Or, you know, that sometimes you go out to brunch or something with a group.

And they go, like, let's just all put our phones in the center of the table.

And, you know, let's be present with one another.

It's simply not the world that we live in anymore.

And we can't pretend as though we're not being drawn constantly back to those devices.

There are companies worth trillions of dollars whose sole purpose is to get you to pick up the phone again that's in your pocket or purse right now.

Or that's in the center of the table.

And it's simply not realistic to kind of wag our fingers at it as an undesirable activity.

It's just like a bad habit, like biting your fingernails.

The first is it gets to a couple of different modes of public health action.

And anybody who listens to the show knows that one of my big frustrations with what public health has become is that we have seeded this regulatory engagement space.

And we have limited ourselves to being, at best, informers of risk with some value-laden proposition of that.

And we use that value judgment oftentimes to try and coerce people about what they should and should not do without thinking about the broader structure within which they do that thing.

So we tell people you should eat well and exercise.

Well, that's great advice.

And so we're in this situation where when we talk about the health implications of phone use, of social media, the challenges were swimming against the tide.

And we've sort of not thought about or failed to appreciate the fact that in the same way we are working against a set of corporations who have made, like you said, trillions of dollars, monetizing eyeballs and eardrums so that we always pick up the phone.

Maybe it's even good.

At least some of the time.

And maybe most of the time.

I was thinking about this this year.

I was trying to remember what people did, what I did, because I remember before phones and the Internet.

What did I do during all those times when I would be looking at my phone now?

When you walk into the classroom, you're waiting for your coffee.

The bus hasn't come.

This session hasn't started and you need something.

What would you have done?

And what I realized is we were really bored.

It was super boring.

You go to the dentist's office or something and you'd read through the magazine from like three months ago that was on the counter.

And then when it was done or when you'd seen everything you wanted, you'd stare at the clock.

Or you'd read the pamphlet that they handed out to you.

People would read shampoo bottles just for something to do.

Just for something to do.

And you're working a boring job and waiting for the shift to end.

Nothing.

Nothing to do.

And now you can get information.

Sure, you can get misinformation.

But you can connect with people.

You can talk to your spouse or your friends or your parents.

You can read.

People read more than they ever have before.

So the activities that we're partaking of when we use those devices aren't just kind of compulsive.

It's not just, oh, I'm taking part in this compulsion.

That's what I'm doing.

It is that.

Don't get me wrong.

But it's more than that, too.

All of us need to eat food.

The challenge becomes what happens when our need to eat food is weaponized around creating foods that are artificially minimally expensive,

that are not as nutrient rich as they ought to be, and that are designed specifically to compel us to eat them.

And that's the aspect of, I think, nutrition that public health would look upon and say that's a real problem.

And I guess the question I want to ask you is we have an Internet, right?

An Internet 2.0, we'll say, right?

Internet 1.0 was AOL, you know, me, 13 years old in 96.

2.0 was me in 2007 on Facebook, right?

And we're about to get to 3.0, which is this AI media, and we'll talk a little bit about that.

But part of the problem here seems to be the Internet unto itself is not a problem.

You're right.

Like, it allows us to do all kinds of great things.

I don't think any of us, you know, would want to go back to a world where if you wanted a piece of information, you literally had to go to a library.

Libraries are amazing places, by the way.

But where you'd have to go to a library, talk to a librarian, find an actual physical journal, sit there and read the thing, maybe photocopy it, right?

We don't want to go back to that world.

The problem, though, is that it's a series of incentives.

I'd love to hear a bit about, you know, thinking about path dependency, given that we're about to be at another inflection point.

What are the set of choices that led to the Internet that we have that tends to be compulsive, that tends to, you know, pull us?

It's not just I'm hanging out, like, waiting for a doctor.

It's I'm with the person I love the most in my life, and we're having a lovely dinner, and I want to check my phone because my fingers are getting, right?

Yeah, and this is a long history.

So let me see if I can go through it rapidly.

It's a history of trying to solve a problem of access and trying to solve a problem of scale and of facing the consequences of those solutions.

So back way before the Internet, in the Cold War, there was a dream of making, kind of an officialist dream.

A guy named Vannevar Bush, who was partly responsible for the Manhattan Project, wanted to make scientific information more accessible, or at least loved the idea of making it more accessible.

And you could access all that information at your fingertips and make connections between them, and you could see what other people had made connections.

And this is 1945 when this vision was articulated in a piece for The Atlantic, actually, called As We May Think.

And this had enormous influence on people that came later, on the invention of the idea of hypertext, which then influenced the development of the World Wide Web, but also on the personal computer.

So one of the things that we have with the prehistory of the Internet is a desire to make information more accessible, and then a desire to make machines for accessing and managing information, a.k.a. computers, more accessible.

In the early days of the personal computer, in the 1970s when this idea was new, computers were the things of government agencies, of large corporations.

And the folks who invented the PCs, you know, the Apple One, Steve Wozniak and Steve Jobs, and even the folks who made early video game systems at Atari, they saw themselves as part of the counterculture movement.

They were taking control of this machinery of the future and putting it in the hands of the people.

So that's about access, right?

And then it's about scaling up that access by turning it into commercial products.

And those were the PCs that we got in the 70s and 80s.

And then connecting them together via a system of publishing information that came out of the sciences again.

That's where the World Wide Web originated as a tool for scientists to share information and researchers.

That then became commercialized in the Web One days, or the Internet 1.0, if you want to call it that.

And what if everything, the question then was what if everything that you do now you could do through a computer and you were connected to your bank and your electric company and you could look up the menu of the restaurant down the street to see if it was appealing to you.

So again, you know, it's this theme of access and then scaling up that access to more and more people.

Then suddenly you could publish.

You or me or anyone could have a web page or later a blog and you could say whatever you wanted.

You could publish video or audio on the Internet and you, at least in principle, were taking away the middleman.

You now had direct access to the whole world or at least the whole world that was online.

And all of that was liberating in many ways.

And it gave us access to one another and to information.

When things really started to shift was when that practice became a kind of practice like unto itself.

You know what I mean?

A computer was typically used to get work done.

You know, you were using it to do word processing or something and then you were publishing that information.

Even the early Internet was about getting things done.

I'm now doing, I'm paying my cable bill online.

You were getting something done.

But that social media era and then the smartphone era that followed on its heels was about using computation just for whatever it was, just for the activity of using it.

And that's when you started going on social media.

That's when you started just kind of using the phone to scroll through things or even just to play games to kind of touch the apparatus to feel what it was like to manipulate it.

So that shift from using these machines and the networks on which they were built to get things done, including to connect with one another, which was what the early days of social networking were all about.

You and I could keep in touch even if we didn't live together in the same town.

Even if we didn't call each other on the phone every week to, well, now we just, everyone's a publisher and we want them to speak as much as possible to as many people as possible.

That's the shift from social networks to social media.

That's when everything changed.

It became a game of maximizing content, as we now call it, engagement, monetizing that engagement, and turning it into not just a kind of platform for speech or for activities, but for attention and as a kind of way of life.

So that's the area to really focus on.

If you wanted to find remedies akin to those that you might analogize in food, in the food chain, it's there.

It's the quantity of information.

It's the speed at which it can be delivered.

It's the number of people that can see it all at once.

And you put all those things together, and it's just no wonder that it's explosive in a bad way.

And everybody wants to, quote, go viral.

I kind of always want to remind folks, like, going viral is not a good thing, right?

In public health, essentially a bad thing to go viral.

And it was absolutely, in his words, articulated as a bad thing because viruses are bad.

Got completely contorted.

And I think one of the challenges that I've had, particularly as we think about public health and are engaged with the internet,

is that so much, when you ask folks about the impact of the internet on public health, they'll usually say one of two things.

One good thing, which is, wow, we have so much information at our fingertips.

We can collect such great data.

And I think those things are true, and I want to ask a little bit more about that, particularly as it comes to AI.

But the second is it has become an engine for the proliferation of misinformation.

And I guess the point that you're making here, and I want us all to think a bit about this, is it did not have to be that way.

But it became that way as a function of the kind of marketplace that was built and cemented into place by a couple of very, very large actors.

And I think we missed the opportunity to be thinking about all of the externalities of that kind of action,

of tech as a potential public health bad, that I think we missed.

I want to think a little bit about that with you.

The intervention had to happen sometime between 2004 and 2008 or so.

And in the intervening years, you got social media in all terms, YouTube, Facebook, and Twitter, eventually Instagram, which came.

Actually, Instagram, I think, is really the moment when it cements itself.

I'll get back to that.

And then the smartphone much further.

So that was the moment for some kind of regulatory intervention, if that's what you're referring to.

That time came and went.

And the Obama administration was kind of a big booster of tech, actually, during that time.

So it's not as though the opportunity for regulatory intervention, which you might associate with that sort of administration being in power, that wasn't enough either.

We just completely missed it.

One of the things that happened during the actual viral moment, where an actual virus went viral, is that we had come to the internet assuming that the old rules of conversation would hold.

Specifically, that being an authority or an arbiter of the science would command a platform large enough to be able to drown out or otherwise communicate past a lot of the misinformation.

And what we found was that because of the algorithms that had been built in that 2004-2008 period and continued to hone later on, is that actually it was the conflict itself that drove engagement and that created an even platform between truth and full-on falsehood, which of course elevated falsehood.

And I guess I want to ask you, as we think about how we engage in this internet 2.0 moment and going into 3.0, how should we be thinking about the way in which this moment of the internet actually privileges certain kinds of speech versus others and how do you communicate in it?

We did.

Wow.

Yeah.

No, we really thought that, didn't we?

Yeah.

Yeah, we did.

We're like an earnest bunch, right?

We assume that good always wins.

And unfortunately, it's not the world we live in.

We know that antagonism, oppositionalism, bad vibes, that they reach further and faster than good ones.

And we kind of knew that already from television and from other forms of media, but it only got amplified in the internet age.

So, you know, in terms of like since we can't go back and recuperate that moment, we have to face the reality in which we actually live and work from that point forward.

I don't know what I would have done differently as a public health communicator had I been one during the early days of the pandemic.

But what was clearly crucial was to understand, okay, the channel is going to have an effect on the message.

And surely, didn't we learn that from like Kennedy and Nixon?

You know, like why did we have to learn that lesson now?

It's a very simple one, and it's that technologies change the messages that are delivered on them.

And so when you say one thing one week and you say another thing the other week, but now they've been compressed into little sound bites that are even smaller than the sound bites you can get on network television.

It is no wonder that that creates a space for that kind of argument that you're talking about, that kind of dispute to undermine the trust of a supposedly trustworthy actor and then to spread that mistrust further, whether for earnest or deceitful ends.

We knew that was the case already by 2020.

It was known.

Maybe this is a comforting thought to think.

Maybe at that moment in time, there was nothing we could have done better.

The battle had already been lost.

We got through it as best we could in that moment, which doesn't mean that we did a good job, that you did a good job, but now we have to move forward in some way.

Now, if I had to pick one thing to change, not an easy thing to change, one thing to change, it would be to turn down the volume, to downscale where everything had been upscaled.

People just aren't meant to be able to speak this frequently to this many people.

It is bad.

And no matter what they're saying, even if they're delivering expert public health information, in fact, I don't think you should be able to do that as often as you want.

It has to become more precious.

On the one hand, the whole advent of the Internet, you talked about the Vannevar Bush idealized moment.

The whole point here was that if we could connect faster to more people, that that should be a benefit for people.

And we've gotten to a point now where the cost of communication is virtually nothing.

Any of us can, in theory, communicate to everyone all the time.

In fact, I worry that because of that and because you're right, that our minds aren't great at processing information coming to us from everywhere all the time and understanding how to leverage that in a productive way.

That we've created a world that inhabiting is actually really quite hard, particularly so for people who engage it the most.

And I would argue that a lot of the teen mental health challenges that we face are a function of this weird information environment that we now occupy as a function of the Internet.

I guess my question to you is, as we think about what ought to be regulated or should have been regulated, what are the pieces that we should have pushed forward?

I'm asking this because we're about to hit another inflection.

And I swear we'll move on to AI.

I keep saying it.

But we're about to hit another inflection in which our information is not the only information that's being created.

What's at the intersection of what is currently possible and what is desirable?

There's a lot of talk about content-related, whether it's regulation or management.

So, you know, moderation.

How do we get all this misinformation offline?

Or how do we suppress it from being spread if it's false?

And that's also coming up with AI.

AI is sort of already self-censoring.

A lot of the stuff that I mess around with when I try out these AI systems, I'm not allowed to do because someone has intervened, right?

That's totally wrongheaded thinking.

I mean, some amount of it is going to be needed.

But to think that, okay, we can continue just barraging the universe with information as much as we want all the time.

And we will somehow figure out a way, a viable way of taking the false stuff.

And here, you know, false is unfortunately relative.

Or maybe fortunately so because we do have many perspectives to take on different positions.

We will somehow be able to control the quality of information.

It's just a pipe dream.

It's impossible.

So what can you control instead?

Well, you can control the flow.

You can control how much I can say how often to how many people.

These are simple ideas, but they've really never been tried.

They're also content agnostic.

It doesn't matter what I'm talking about if I can only say it every so often, right?

So those are the levers I would pull on if I had my druthers today.

But it also, it's kind of too late in the sense, not in the sense that, like, you know, power and wealth of tech companies have overrun us.

Or that our tolerance for any kind of regulatory or legislative intervention is low.

It's also that all of us have become acclimated to this way of living.

Like, do you want to be told, well, you know, maybe you've got your tweet for the day.

Actually, you're kind of cut off.

But most people, they would feel censored.

That's probably how they would describe it.

Why are you censoring me?

Or why is it that I can't do this thing that I was able to do a week ago?

It's a Pandora's box problem.

We're trying to stuff something back in.

But I still think it's the most promising way forward.

Just turn down the volume on everyone.

And if there were less stuff to see, then we'd have less information by definition because we'd have less information, too.

You know, I'm a father.

I've got a 6-year-old and an almost 1-year-old.

And I think about the ways my kids think about the Internet.

They have an incomplete picture of what this thing is.

I was like, absolutely not.

How do you know what Instagram is?

And she's like, oh, my friend.

Right?

My friend has an Instagram.

I was like, your friends are 6.

Do you think that there ought to be a clearer, more direct effort to limit Internet access?

In Utah, for example, there was, frankly, efforts to ban access to social media for kids.

Right?

And there are other approaches to thinking about this.

And, of course, every approach to this regulation is going to have some unintended consequence.

How do you think about the best way to engage?

Because I'll be honest with you.

I look at young people – young people these days.

Anyway, I look at – I think about younger folks in my life, and it's hard to feel like things are not okay.

And so much of it comes from this difficulty of trying to balance a life in real life, a life in digital life, and have your social interactions scored and cued and monetized by some company whose goal it is to keep you there.

Yeah.

Like, everyone has a phone, and so, therefore, everyone can kind of do the same things that everyone else can do.

And if you're a kid, then maybe you don't have a phone.

You probably have an iPad, though.

Is your six-year-old have an iPad?

You know, it's kind of the age-old problem of what are you going to do with your kids all the time?

But anyway, that flattening of experience now means that we all sort of see the same stuff.

We all have access to the same ideals, whereas you previously wouldn't have.

You would have had to have been in certain kinds of adolescent or adult spaces in which different kinds of topics and opportunities would have come up, whether that's being at school or at work or at the mall or whatever.

These things were embedded in social and physical structures more than they are now.

Now they're mostly symbolic.

And once they became symbolic, it becomes harder to say, well, you know, you shouldn't have access to this system of meaning that everyone else does and that they draw value and delight from.

So it's more of an uphill battle than it used to be.

But also we seem to be against limiting control of anything to anyone nowadays.

I mean, I'm familiar with the social media kind of proposed legislation that you mentioned.

But there's also been recent discourse about control of pornography online.

And it's been interesting to me that there's been a lot of pushback to any kind of limits or controls on accessing pornographic material online.

Like what would have previously in a different era seemed like fairly reasonable laws about access, you know, modulo certain details and their legislative and kind of meta legislative purposes as politicking rather than the politics.

But there's been a real kind of counter reaction to that.

So I think we may have left orbit on the opportunity to control children's experiences.

Or it's much harder to do than it used to be.

COPPA, the children's privacy regulation from the 90s, that is, you know, when you have to, like, check the box that you're 13, obviously did nothing.

Because what do you do? You check the box.

So one problem is that we failed at making good laws.

But the gates were already broken when we put them up.

You know, if you're a kid, if your six-year-old went and tried to buy a pack of cigarettes, like, what are you doing, right? Like, no.