How long do you think it will take for authoritarian governments, dictatorships or tyrannies until they realize the vast potential in digital health technologies and until they learn how to harness their powers? Twenty years? Ten years? We have to warn you, the era of 24/7 surveillance and intrusion into the innermost secrets of human life is even closer than that. Watch out! Dystopic worst case scenario-alert!

Digital technologies are double-edged swords: they promised social change…

On 17 December 2010, a Tunisian vegetable vendor set up his cart on the street in Sidi Bouzid to sell goods that he obtained the day before from borrowed money. Police began to harass him as he didn’t have a permit to sell his wares and confiscated his products. Being deprived of his only chance to make a living, and not listened to by the authorities, he set himself on fire. Within a couple of hours, the tragic deed of Mohamed Bouazizi sparked protests in his home country, Tunisia, which spread around like wildfire in the entire Middle East.

The flames were fed by the dissatisfied populations and diffused by the power of social media. Back in 2011, news outlets around the world hailed how Facebook, Twitter, and the Internet promoted democratic uprisings in authoritarian regimes around the Middle East. For a moment, it seemed that in Tunisia, Egypt, Lybia, Syria, and Bahrain, average people were empowered by technology to change the course of their own lives and take control over the bigger political scenery. The Arab Spring carried the promise that social media and the Internet were going to unleash a new wave of positive social change.

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During the Arab Spring, Egyptians used their mobile phones to document unrest and celebrations. Source: USC News/Mohammed Abed/AFP/GettyImages

… but ended up in the net of restrictive governments

But the past seven years have shown that liberty isn’t the only end toward which these tools can be turned. Joshua Tucker, a principal investigator at the Social Media and Political Participation Lab at New York University, believes that activists were able to organize and mobilize in 2011 partly because authoritarian governments didn’t yet understand very much about how to use social media and didn’t see the potential.

Looking at the crackdowns on Facebook, Twitter or other online platforms in countries with authoritarian leadership, it seems that they learned the tricks of the trade by now. Several examples show how governments restrict access to social media sites, how they manipulate audiences or exert their power over the companies themselves.

In July, the Egyptian government announced it wants a greater share from the tech giants’ profit, and passed another controversial law placing popular social media accounts under media regulatory oversight. Turkish authorities banned the use of Facebook and Twitter several times, usually in the aftermath of events which might have resulted in widespread resistance. In mainland China, most of the Western social media sites, as well as the main news outlets, are blocked, and Google is said to be working on a censored search engine for Beijing. And there is certainly the issue around Russian meddling in the 2016 U.S. elections through the spread of fake news on Facebook and Twitter as well as the workings of Macedonian and Russian troll-farms under the auspices of the Russian Internet Research Agency (IRA) to rally people according to governmental interests.

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Should we worry about the fate of digital technologies in healthcare?

As the above examples show, governments and bureaucracies are certainly not early adopters. Democratic leadership is even less so than authoritarian regimes, as, in the former, political, social and economic interests clash while the latter is only ruled by the central political will so if they decide for the introduction of a new solution or for the crackdown on a technology that will most probably happen there faster.

At the moment, there are rather few governments with a digital health policy – Canada, New Zealand, Australia, Estonia – although there is already an abundance of digital health technologies out there ready to disrupt national healthcare systems. Early adopters are tech-savvy doctors, nurses and clinical practices – so far it has been a rather bottom-up process with regulatory bodies lagging way behind innovation. But it might turn around in a few years – just as it happened with restrictive governments and social media. Perhaps officials shaping healthcare policy do not understand how artificial intelligence, wearables, health sensors or virtual reality works or cannot see their potential at the moment, but that’s just temporary. The Medical Futurist believes there is a considerable risk that authoritarian political leadership around the world misuse digital health technologies in the future – and a chance of using our health and bodies for achieving centrally planned political purposes.

What if health insurance meant Dr. Big Brother?

The spread of electronic medical records, the connectivity of data systems and big data analytics help collect, store and analyze more and more health data. Moreover, piles of data will be augmented with information stemming from health sensors, wearables, and trackers – which enable data collection about lifestyle choices. What if a future authoritarian government instructed every single citizen to wear digital tattoos or other trackers to collect the most health data possible – and used it to operate a national health insurance system based on a centrally determined data-set that people had to reach?

The government would have access to data coming from sleep and fitness trackers, blood pressure and ECG they store and the gadgets they use to assess their general well-being. Based on this, the national health insurance holding would be able to either change patients’ premiums or notify them about replacing them soon based on lifestyle choices. Choosing a big steak instead of something more suitable for your customized diet or being too lazy to do sports would mean higher premiums. Insurance systems might discriminate against patients if they have medical conditions that are determined to be predominantly genetic and not lifestyle-related.

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What if your social companion robots surveilled your every move?

With the advancement of robotics and artificial intelligence, social companion robots started to take shape: these human or animal shaped, smaller or bigger mechanic creatures are able to carry out different tasks and have interactions with humans and their environment. In the future, they might become little helpers in the kitchen, might support the guard dog in keeping the house safe, might teach the children and support the elderly from reminding to take their medication until keeping them company when they feel lonely.

What if authoritarian governments found social companion robots appropriate tools for surveillance? They would be equipped with cameras or other recording devices – some already have cameras today – and they would transmit data to remote digital tools. Authorities just used the memory cards or chips as evidence in cases of alleged disobedient citizens. Going even deeper down the rabbit hole, they could also rewrite memory cards and thus events if they want to denigrate someone. Moreover, social companion robots could have access to the health information of their surveilled “hosts” and report back any data that might show discontent with the leadership. Elevated heart rate and stress after a news report of the achievements of the State? People might get into trouble! And if even the slightest possibility of a similar event arises, we would be truly at the heart of 1984 and the Thought Police.

What if authorities had access to the IoT system of your smart home?

Smart homes of the future might work as entire systems of connected devices communicating with each other and the users through the Internet of Things (IoT). Inhabitants could regulate the security system, the heating or electricity scheme of the house and make the entire ecosystem and the use of resources more sustainable and more environmentally friendly. For example, your smart fridge could let you know whether there’s enough fresh tomato inside and the smart shower could heat up the water precisely for the desired temperature.

Now, imagine a scenario where authorities have oversight of your smart home. They might have access to the heating, electricity or security system. How terrifying would that be if representatives of the central power punished disloyal or disobedient citizens by withdrawing fuels or cutting off electricity? However, if you think about Russia and its power game around natural gas or nuclear energy, the chance for authoritarian governments to translate the idea from the macro to the micro-level will immediately increase.

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Will Black Mirror get real through augmented or virtual reality?

Remember the episode in the British dystopian television series, Black Mirror, Man Against Fire? Soldiers are exterminating mutant humans called “roaches” in a countryside setting. Later, it turns out that each and every fighter has an implanted microchip which turns their targets into non-humans so it would cause them less moral and psychological issue to kill them. Moreover, technologies enabled soldiers not to sense any smells or hear any voices associated with bloodshed – for the very same reasons.

It is not far-fetched to imagine how authoritarian governments could misuse the potential in augmented, virtual or mixed reality. These technologies are perfectly capable of presenting the desired environment. Moreover, they can lift people out of their own worlds and meaningfully help them. For example, Bravemind, a VR Exposure Therapy developed by a research team at the University of Southern California, allows soldiers to fight combat-related post-traumatic stress disorder (PTSD). VR can help women get through childbirth with less pain, but medical education, surgery, rehabilitation medicine, psychiatry, and psychology could all benefit from VR. As a doctor, you could assist in the OR without ever lifting a scalpel or prepare for complex surgeries efficiently. As a medical student, you could study the human body more closely and get ready for real-life operations. Thus, going through all these examples – is it unrealistic to think that authoritarian governments might try to utilize VR, AR, and MR for their own benefit? That they might hide propagandistic messages in feel-good VR environments built by their own experts?

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Black Mirror: Man Against Fire. Source:

Would telemedicine become the doctor for the poor…

Providing clinical care via telecommunication services has the potential to transform how we think about primary care. With its spread in the future, patients would not necessarily need to visit their GPs, and in the long run, even artificial intelligence-powered chatbots could dispense medical advice in case of minor problems. Telehealth platforms allow people living in remote areas to still get proper care, and medical professionals in rural towns and remote areas can have access to specialty services, and patients can be treated in their own communities. It’s a win-win scenario. Or is it, really?

What if authoritarian governments, aware of scarce human resources regarding medicine and healthcare, only allowed the privileged, loyal circle to go to the doctor personally, and let ordinary citizens or members of the oppositional forces see a doctor only virtually?

…and biotechnology the medicine for the rich?

The creation of a two-tier citizenry with different biological chances for life might also arise using biotechnology. Remember the science fiction movie, The Island? Cloned humans were living in a colony not being aware of their actual identity: they were produced to provide auxiliary body parts or become surrogate mothers for the rich who wanted to live as long as possible, wanted to avoid diseases or the hardships of pregnancy.

With the advancement of 3D bioprinting, it is highly unlikely that in the future, we will create or clone human beings, trends show instead that technology allows us to manufacture tissues or at best organs. But what if authoritarian governments restricted access to the achievements of biotechnology for the privileged? What if only the chosen ones could receive 3D printed tissues, personalized treatment or medicine? The rationale might be that these people embody the backbone of the state and so the state should ensure their longevity and health above others. You might say that governments should do that for every single member of the community – and you would be perfectly right about that. But experience shows that authoritarian regimes don’t really have the best interests of the largest group possible in their minds.

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Population genomics and preventive community management

In April 2018, news outlets surfaced that one of the biggest state in India, Andhra Pradesh, will secure the DNA base of 50 million citizens through the blockchain. On 20 March 2018, Estonia launched the first stage of a national state-sponsored genetic testing and information service providing 100,000 of its 1.3 million residents with information on their genetic risk for certain diseases. Already in 2015, MIT Review reported that a genetics company in Iceland named DeCode Genetics collected full DNA sequences on 10,000 individuals. And since the population in Iceland totals around 320,000 citizens, and they are fairly closely related, DeCode said it could extrapolate to accurately guess the DNA makeup of nearly the whole population of the country, including those who never participated in its studies.

By 2025, between 100 million and 2 billion human genomes will have been sequenced, researchers said. The rise of population genomics is visible – and governments will assume more and more roles in managing this huge chunk of biological information. As genome sequencing could reveal the innermost secrets of human life – alongside with risks for the future -, this information is invaluable and incredibly sensitive. For example, pharmacogenomics studies drug response due to the genetic code and argues that medications do not have the same effect on people. Nutrigenomics looks at your genetic map and tries to explain your tendencies to react to food in your own unique way. These types of information could mean incredible power over people.

For centers of control, the acquisition of genomic data meant not only a grip over the present health state of citizens, alongside with the future. What if authorities had the chance to categorize people based on their health risks? What if the quality of health services depended on the health risks people carried in themselves? Would a society built up by genetically inferior and superior casts evolve? Would authoritarian governments push citizens towards this dystopia to be able to manage communities according to their interests?

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The atomic bomb of digital technologies – artificial intelligence

The amount of available digital data is growing at a mind-blowing speed, doubling every second year. In 2013, it encompassed 4.4 zettabytes, however by 2020 the digital universe – the information we create and copy annually – will reach 44 zettabytes, or 44 trillion gigabytes (!). We need specific algorithms to make sense of these incredible chunks of information. And it seems that the method of machine learning and deep learning can create such smart programs that are not only able to make sense of data but also predict outcomes that humans would never be able to catch. Nigerian start-up, Ubenwa has developed an A.I. algorithm able to diagnose childbirth asphyxia based on an infant’s cry. On the other end of the spectrum, the U.S. Food and Drug Administration (FDA) has recently approved the use of an algorithm which monitors vitals of patients suffering from a severe illness to help predict sudden death from heart attacks or respiratory failure. The algorithm, named the Wave Clinical Platform, was developed by the medical technology company ExcelMedical.

Thus, it seems that although there are limited fields – especially computer vision and natural language processing – where A.I. has proved its worth, in those areas, its achievements are mind-blowing and undeniable. And what if autocracies, dictatorships, and tyrannies discover the potential in A.I. for themselves?

Acclaimed Israeli historian, Yuval Noah Harari, believes that the conflict between democracies and dictatorships lies at the heart of their abilities for data processing. Throughout the 20th century, democracies were better at gathering and making sense of information through their distributed sources of data – as opposed to authoritarian leadership as they have more limited sources. However, artificial intelligence may soon swing the pendulum in the opposite direction. A.I. makes it possible to process enormous amounts of information centrally. In fact, it might make centralized systems far more efficient than diffuse systems, because machine learning works better when the machine has more data to analyze, Harari said. That centralization is the key to the possibility to create digital dictatorships.

Imagine a society where you are surveilled through millions of cameras, your every move is recorded in a central database alongside public records, health information, achievements in school or at your workplace. Your online activities are recorded effortlessly, and your data is placed next to your family’s and friends’ accounts. How easy would it be to influence citizens through means like that? How easy would it become for the government to discern information about our lifestyles, mood, priorities and predict our behaviors? Would docile people with the ability to blend in with the system be rewarded and persons with dissenting opinions or even different tastes be punished?

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Do you think it’s science fiction? There is a country where 200 million CCTV cameras ensure that nothing remains hidden. It becomes child’s play to judge or track anyone’s moves. In some pilot programs, the state assigned “social credit” to its citizens based on track records, their families and friends, their past actions, their online activity, job, healthcare status – every single step they do. The “social credit” is undoubtedly built up according to the government’s expectations, and docile subjects get high points – with more options, better school, and job prospects or better healthcare. People, who have done anything against the interests of the state get low points – and the gates will close before them everywhere. In the worst cases, they are condemned to house arrest without actually being convicted.

No, it’s not from the screenplay of the next episode of Black Mirror.

It’s China.

No, it’s not happening in the far future.

They have already introduced the pilot system in several cantons and plan a nation-wide roll-out in 2020. Yes, you’ve read that right.

Within less than two years.

So, how much time do you think we have until democratic governments understand the potential in digital technologies and start to build in the necessary checks and balances to maintain our way of life? How much time do we have until the positive outcomes of digital (health) technologies could be cemented in our societies?