Power to the people: on double trouble

 In 1970, I was a first year medic al student. Oil was $6 a barrel. The Beatles had yet to break up. But looking back, the thing that brings change most sharply into focus is the memory of my statistics lectures.

At the start of each lecture we were given a mechanical calculating machine. To multiply 1,254 by 64 you set the input digits by hand and then turned the handle 64 times and read off your answer. 

On a good day I was executing maybe one instruction per second. Today, thanks to Moore’s Law and the doubling of computing power every two years, the kit that I can actually hold in my own hands has gone through around 10¹¹ orders of magnitude change.

Everything changes

OK, so you already knew all that Moore’s Law hoopla. But what is important is just how far we have come. Counting from the invention of the transistor in 1954, we have had 30 doublings. This means that we are entering the second half of the chess board.

That’s the chess board in the old story of the Chinese emperor who agreed to reward his sage for solving a problem by paying him one grain of rice for the first square of a chess board, two for the second, four for the third on so on – until, on the 64^th square, he would pay 2⁶⁴ grains of rice.

Such doubling myths only get really hairy after 30 doublings or so. That’s when payback suddenly goes from tiresome to crippling. It’s when the non-log graph inflects and in a few short squares points to the sky.

In the real world, it’s the point when either the doubling process beaks down or the world is utterly transformed. 

So right now we are beginning to live life in the second half of the chess board. That’s why everything seems to be more hectic than it used to be. The world seems to be going faster because it is going faster.

Tough on incumbents

Being on the second half of the board effects every aspect of technology in mutually reinforcing ways: advances in computing drive robotics and imaging; voice recognition drives interaction with machines; the challenge of handling massive amounts of data from CERN feeds into the world-wide mega-databases tracking genetic advances.

All of which makes prediction particularly tough. So what can we possibly say about how medicine might look after even a few more squares?

One of the key conclusions of The Second Machine Age by Brynjolfsson, McAfee  and Cummings is that life in this new world is tough on incumbents.

It’s much easier for a start-up to hack the future from the 30th square than it is for incumbents, weighed down as they always are by the legacy of all the systems, software and snafus that they have accumulated over the previous 30 squares.

The curse of the incumbent applies in spades to the NHS. Over the last six months, I have asked the chief executives of five, innovative, health-related start-ups where they intend to do business.

Without exception they all started out with high hopes of selling to the NHS; but now see overseas as a much better place on which to concentrate. Good for the balance of payments but a dire commentary on the NHS’s chances of survival as the world speeds up.

So, don’t look to the NHS for radical change. Indeed, don’t look to the North and the OECD but to the South and the BRICS for the first glimpse of medicine’s future.

Just as M-Pesa, a mobile phone-absed money transfer and micro financing business, is more instructive than the Co-op Bank, so Aravind Eye Care Hospital’s $35 cataract operations in India have more to teach 2020 than the NHS.

A different version of incumbency is that citizens have much less invested in the status quo than professionals and organisations. So the digitally adept are often way ahead of professionals.  Just look at bio sensors, FitBit wearable health trackers, and the quantified-self movement to see this happening right now.  

Painful not accidental

Developments in education, the world’s other universal and largely publicly-funded knowledge system, are also instructive.  MOOCs (Massive Open On-line Communities) show the potential of web-enabled communities of citizens and professionals.

MOOCs are already disrupting teaching and learning by disintermediating universities; while giving rock-star status to professors at MIT.

Will we soon get ‘MO-DOCs’ (Massive Open Disease Orientated Communities) in which patients’ requirements and experiences blend with system-wide data feedback, professional expertise and crowd-sourced capital to develop new forms of care?

Perhaps – forerunners of MO-DOCS already exist in Patients Like Me disease focused communities and CellSlider’s categorisation of cancer cells by untrained citizens.  

A final thought: perhaps really crap reforms (thank you Mr Lansley) or terrible implementation (pace Obamacare) are more than just accidents. Maybe they are better seen as the twisting and turning of dinosaurs caught in the tar pit of very high rates of change.

Perhaps the move from hierarchies to networks, and the shift from command and control to distributed, chaotic, citizen-led knowledge and action, becomes toxic to bureaucracies as we transition to the second half of the board.

Scream if you want to go faster

The possibilities anticipated after the 32^nd doubling are summed up in the more general concept of a possible ‘singlularity’ (in geometry, the singular point of a curve, in maths and sciences the point at which things cease to be defined and at which behaviour can no longer be predicted). They often feel unreal and far-fetched – and maybe they are.

Maybe Moore’s Law will bump up against the quantum limits of chip fabrication sooner than we think. Perhaps Ebola will get us. Or global warming.

But I think a lot of the sense of unreality comes from this being the first time that we have been so far from home.

My generation is indeed unique in having lived through 11 orders of magnitude of computing power. And – as in so many other ways – we have had a comfortable ride of it because we have just been travelling through the foothills.

Only now are we getting close to the inflection point of really profound change.  If Moore’s Law persists your generation may live through the same number of doublings; but the effects will be many times more spectacular.

Maybe this thinking only appears outlandish because we are indeed entering the ‘out lands’, the ‘here be dragons’ world of the second half of the board.  

Faced with all this it feels as if all we can really do is muddle through. And maybe this is true, maybe muddling through is our best and only option.

But Chinese tradition tells two different outcomes to the story of the emperor and the sage. In one the emperor breaks his word, so calling a halt to the doubling process. This is the equivalent of Moore’s Law failing.  

In the other version, the emperor kills the sage. In this version, neither the emperor nor the universe will tolerate such hubris and the sage loses everything as the asymptote comes crashing lethally to earth.

The digital world has many fewer inherent limits to the possible than anything as corporeal as rice. So the future is more open for us than the sage.

Just don’t be surprised by anything as the world cracks open under the rapidly multiplying possibilities and disasters inherent in the transition to the second half of the board.

Paul Hodgkin

Paul Hodgkin is founder and chair of Patient Opinion, a website on which patients, service users, carers and staff can share their stories of care across the UK. Patient Opinion is a not-for-profit social enterprise based in Sheffield.

Until 2011, Paul also worked as a GP and has published widely including in the BMJ, British Journal of General Practice and the Guardian and the Independent. Follow him on Twitter @paulhodgkin.