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The place of WhatsApp in the ecology of care

Marilia Duque E S26 August 2018

Author: Marilia Duque

Dr. Gusso uses WhatsApp Business at Amparo Health Clinic (Photo: Marilia Duque)

In 2015 a PwC research report suggested that the Brazilian m-health market would reach $ 46.6 million while a GSMA report forecasted that 45.7 million Brazilians would benefit from mobile health projects (see here). In 2017 the scenario was even more optimistic. According to Statista, Brazil was expected to become the largest m-health market in Latin America with revenues of around $ 0.7 billion. These numbers explain the impressive amount of m-Heath startups and startup Incubators I’ve seen in Sao Paulo (see Eretz.bio, for example). But they don’t explain why after 7 months of fieldwork I still couldn’t find the people who are actually using these m-health apps. Instead, I found an intensive use of WhatsApp among my informants, filling the gaps in communication and making a huge impact on the ecology of care which we address in this project.

For example, every day early in the morning, Ms. M (54) sends a good morning message through WhatsApp to four lady-friends older than her. “It is like volunteer work because I know they are lonely and that message will make them happy and socially connected”, she explained. Ms. D (66) also starts her day sending a WhatsApp message. But in her case, the message is sent to her only daughter who lives in France, as a sign that she spent the night well. She is supposed to send this message every day before 10am otherwise her daughter will call a friend to check on her. “Some people say my daughter abandoned me, but the truth is that she is closer than many of my friends’ children who just live nearby”.

That is the same in the case of Dr. J., a physician who works in Sao Paulo and uses WhatsApp to take care of his 93 year-old father. After having a stroke, his father moved to Dr. J. brother’s house located two hours away.  Dr. J. created a WhatsApp group to talk to his brother and to his father’s caregiver. He gives her all the instructions she needs, and she updates him with information such as what his father ate, how he slept, how much water he drank, how much he exercised and how he was feeling. After a few months, he could tell how improved his father was and he explained how WhatsApp helped him and his family to feel safe and engaged.

Dr. K. also uses WhatsApp to provide care at distance. He works in my field site as a generalist providing ambulatory care to old people. WhatsApp allows him to give orientation about what to do when patients don’t feel well, and he can also ask them to go to his office if necessary. In many cases, he said, he can solve problems providing only care at distance. Dr. K. believes that the simple fact that the patients know they can use WhatsApp to contact him makes them feel safe and comfortable.

WhatsApp is also helping clinics to manage people’s health. Amparo Health, for example, is a clinic that uses WhatsApp Business to connect patients to doctors. The patient pays a monthly fee to have access to low-cost exams and to specialists like ophthalmologists, gynecologists, dermatologists, nutritionists and psychologists. What is new here is that all procedures and exams are coordinated by a generalist, who is available on WhatsApp. Dr. Gusso, the head physician at Amparo Health, explains that because the clinic business model is based on membership, they have no interest in demanding unnecessary exams or appointments. Doctors are paid by the hour and not by performance and that includes time to answer WhatsApp messages during the morning and afternoon. At the end of the day, he said, they are using WhatsApp to provide care at a distance, helping people to stay healthy, to feel safe and to save money. Prevent Senior, a health insurance company, also uses WhatsApp to make patients’ lives easier. In cases where treatments require on-going medication, patients can use WhatsApp to ask for new prescriptions. They can receive their prescriptions at home or they can go to the doctor office to get them, but with no need to schedule an appointment.

WhatsApp is the primary method of communication for 96% of Brazilians with access to smartphones. And among my informants older than 60 years old, that is also the app they use the most. Now imagine what can be achieved if WhatsApp features are explored to make the communication between health insurance companies, doctors, patients, caregivers, family and friends healthier too.

What is a smartphone?

Daniel Miller1 June 2018

Author: Daniel Miller

Photo (CC BY) newkemall

I have spent the last two months in my Irish fieldsite trying to answer a simple question: what is a smartphone? Actually, it’s a fiendishly difficult question. Several older people started our discussion by insisting that the only things they use their phones for are voice calls and texting. Once we looked at the phone in more detail, it turned out that just the most common functions include WhatsApp, maps, voice calls, camera, alarm/time, Facebook, text messages, calendar, weather and news. Once we add a variety of more specialist apps such as sports, music, airlines, banks etc. we easily reach the most typical result which would be that an individual uses between twenty-five and thirty different functions of their smartphone.

In the newspapers, the personalisation of the smartphone is understood as the advances in algorithms and artificial intelligence, which allow smartphones to learn from people and predict their behaviour. But, just as in our previous Why We Post project, for the ethnographer, these corporate developments pale into insignificance compared to the personalisation represented by the diversity of usage that will arise from the way an individual configures this multitude of apps.

Indeed, it may be the personality of the user that comes across most. A man expresses a particular version of masculinity in demonstrating how all his usage is based on need and pragmatism. He mentions more than once how, now his daughter is no longer in Australia, he will never use Skype again. By contrast, a woman, aged 69, has every last detail of her life, from the steps involved in paying each particular type of bill, to the slide decks from workshops she has attended, all carefully classified in nested hierarchies of icons on her iPhone. About the only thing she doesn’t like is the clumsy and intrusive Siri. In both cases the smartphone effectively expresses their personality. Sometimes a particular activity dominates an individual’s phone life; a phone where everything is geared to a retirement spent playing and teaching the banjo, or a phone that contains seven apps all associated with sailing.  It’s not that a woman is addicted to her phone, or even to YouTube per. se., it’s just that she can’t stop spending two hours a day following US politics on YouTube. More commonly the phone will revolve around three or four key activities and concerns such as a combination of family, sports, holidays, and photography.

Working with people in their 60s and 70s, I come to appreciate that they are not elderly, but that much of their life may be devoted to caring for an elderly parent in their 90s. For some of these people everything about the phone is connected with this responsibility of care, whether mobilising family care through WhatsApp, showing pictures of great grandchildren through Facebook, using maps to get to a hospital appointment, employing phone and text to negotiate with the local council and never turning the phone off, because you never know…

An equally important component of what makes the phone is people’s lack of knowledge. An older person is told to download an app, but she has never heard of Google Play and so attempts this action using an icon labelled ‘Downloads’. A man won’t buy a new Samsung Galaxy because it doesn’t have an inbuilt radio and he doesn’t know he can download radio as an app. Many users do not know the distinction between Wi-Fi and data that they have to pay for, so they won’t watch video while on Wi-Fi because they think it will cost them. Many can’t understand that a phone which ‘doesn’t work’, is not a broken phone, rather they just need to go about something in a different way. This is because the smartphone has so little in common with traditions of machines and tools. There is no manual they can actually use. Trying to work out precisely why one 80-year-old finds every little step impossible and another seems entirely comfortable in using these phones may give us many clues as to what, in effect, a smartphone is.

In the newspapers the smartphone appears as the constant development of new capacities – articles about the latest thing you can do with your smartphone are commonplace. For the ethnographer the smartphone is the myriad constellation of new actualities – we strive for an appreciation of what ordinary people create with or cannot understand about these devices.