An Apple a Day?

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By David Katz, M.D.

I am just back from attending the Apple Live Event in San Francisco, where I snapped the photo above from my seat near the stage, surrounded by a small group of fellow health “influencers,” and a sea of tech and business journalists rolling tape and flashing cameras. More on that momentarily.

Some years ago, I attended a fund-raising gala for a health education program I support, and for which I serve as an advisory board member. Among the hundreds who anteed up for seats and tables was the CEO of Coca-Cola. I came across him, surrounded by a group of acolytes, holding court. He was propounding his ambition for a world where everyone, everywhere had various Coca-Cola products in hand throughout every day. A “Coke-a-day” vision, in other words. I bit my tongue, and beat a hasty retreat. My Mother taught me what to do when I have nothing nice to say.

I heard a somewhat similar ambition in a far more promising context from Apple CEO, Tim Cook, at the event this week. Within that larger group of tech and business media people, I was right there as Tim and his senior staff introduced Apple’s innovations. Then, with only that small group of health and fitness invitees from around the world, I enjoyed a tour of Apple facilities, including some privileged peeks into the rarefied world of their R&D.

The particulars of the presentation and the new product offerings, most notably the imminent release of the Apple Watch, are available to all online now, and have naturally received extensive media attention as well. I will leave all that to the pros, and focus on the elements germane to what I do.

Which immediately invites the question: what elements are germane to what I do?

As the new and improved Mac was profiled, for instance, nothing much about my day job came to mind. Rather, I found myself suddenly loathing the nearly new, but now decidedly yesterday’s news Mac I had left in my hotel room. Just an hour prior, it had seemed perfectly fast and sleek. The next thing I knew, in comparison to the new Mac, it was old and slow and clunky. The life cycle of obsolescence gets ever shorter, and the relentless pace of invention begets ever more necessity, or at least the covetousness that can seem much the same.

Be that as it may, I am writing this on that same, old (about a year) Macbook Pro. For now, it will have to do.

I was privileged to find myself sitting next to Michael Pollan for much of the day — and he and I asked one another more than once: so why are we here? As most of you likely know, Mr. Pollan’s large following is a product of his uniquely insightful writings about food, health, and agriculture. Nothing in Apple’s presentation pertained to any of those topics. They did highlight their environmentally friendly, contaminant-free manufacturing methods — so we thought perhaps the new Mac would be edible? Consult your dentist.

There was, eventually, some clear relevance to my work. In particular, Apple announced its release of Research Kit, a platform of limitlessly modifiable applications to facilitate biomedical research. Among the early utilities is outreach to potential research study participants. As someone who has run dozens of clinical trials over the years, that is potentially very helpful. Recruiting study participants is often among the slowest, most difficult, and costly elements in our research. Some 700 million people worldwide now own iPhones — one person of every ten on the planet, more or less — so push-of-a-key recruiting to that large audience offers many potential advantages, including time, money, effort, and aggravation spared; and perhaps better representation of the population into the bargain.

Research Kit is intended to do much more, however, such as capture the measures that could serve as study data. I found this both intriguing, and a bit worrisome. It is intriguing because many such measures, notably those for gauging the severity of Parkinson’s, are quite subjective and amenable to the kind of improvements engineered by Apple. There is real opportunity here for both more, and better data.

Why, then, the worry? Whatever the limitations of our measures, historically we researchers have direct oversight of them, and responsibility for them — including such things as the calibration of our equipment. How will we know about the “calibration” of all those iPhones? If someone drops theirs a few times, or uses it in extreme heat, or cold, or wind, or humidity, will it work just the same? If we are subject to data distortions we can’t control, or even predict, there is some danger of the perennial research concern: garbage in, garbage out. The very smart people at Apple, and the biomedical researchers with whom they worked on Research Kit, are fully aware of this, of course. But whether knowledge of the concern is the same as power to overcome it remains to be seen.

The many potential applications housed in Research Kit may also facilitate medical diagnosis, and even disease management. Tracking the status of asthma, for instance, might allow for notifications about timely use of inhalers that could prevent serious exacerbations. There is real potential for exciting advances here.

But there is also some more cause for caution and concern, and it’s in a peculiar direction. Maybe an Apple (product, app, etc.) a day will, indeed, keep the doctor away — and maybe that’s not such a great thing.

Medicine, at its best, is much more than applied science. It is also intimate and human. There are subjective elements to medical decision-making, of course, the so-called “Art” of medicine. But there is also the opportunity for human beings to make eye contact, to read body language, and to empathize. At least there should be!

We already have evidence of declining levels of empathy in the population at large, with frequent recourse to technological interfaces rather than direct eye contact one of the reasons invoked. The doctor-patient relationship has degraded too much already in my opinion; I would hate to see it technologized out of existence.

I also have some concerns about ever more dependence on technology for the simplest of things, such as walking. As invention begets necessity, we seem to be drinking deeply of that particular Kool-Aid: if we go for a walk but don’t submit our step count to the Cloud, did it really happen? Actually, yes. The enviable health status of the world’s Blue Zones populations is courtesy of time-honored behavioral patterns and traditional cultural practices, not tech.

Maybe, though, we can’t go back to the future; maybe we can only go forward. And maybe we can’t make Ikaria, Greece (a Blue Zone) play in Peoria, Illinois. But maybe we can get everyone in Peoria to stand up and move every hour when their Apple Watch prompts them to do just that. And maybe Peoria — and all such real estate in the modern world — will be traversed by more footprints when those steps are goaded, and gauged by iPhone apps. Maybe the New-Age trends can’t be beat, and we all have to join them.

If so, an Apple product a day may contribute something to keeping the need for the doctor at bay. That would be a good thing. I am a bit less comfortable with ever more tech becoming a reason why the doctor and patient never make eye contact, and reaffirm the human bond that always has, and always should, matter most.

Time will tell which way tech takes us. For now, my thanks to Apple for a privileged look into that rarefied world where our future is not just being predicted, but engineered.

Which brings us back to big companies and their ambitions. Given a choice between a Coke-a-day, or an Apple-a-day future, it’s no contest. Pass the Apples!


David L. Katz, MD, MPH, FACPM, FACP

Director, Yale University Prevention Research Center; Griffin Hospital

Editor-in-Chief, Childhood Obesity

President, American College of Lifestyle Medicine

Founder, The GLiMMER Initiative

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