My wife and I visited a will-and-trust lawyer after our first son was born. Everything seemed simple and clear until the lawyer asked, without missing a beat, "So, what about your social media management?" My wife looked at me and, even though I'm more tech savvy, I felt as confused as a Luddite.
One can imagine chatbots becoming the next generation of care management alongside funeral services, and will and testaments.
"Social media management?" I laughed, making a joke about my wife spending more time on Facebook than I do. But the lawyer's question was serious, as were the legal documents asking for our profile page links, passwords, and related information.
What do you want to happen to your Facebook, Twitter, and other social media platforms after you die? Your grandfather may have wanted his cremated ashes poured into the Ganges, or a burial in a prepaid plot. But unlike earlier generations, whose personas ended with their last breath, your bits and bytes could live on across multiple servers, holding a space for you online like a digital obelisk. Or, if you desire, your relatives can do the equivalent of a DNR: Delete account.
"It is the future of 'Get your affairs in order,'" says John Havens, Executive Director of the IEEE Global Initiative on Ethics of Autonomous and Intelligent Systems. He remembers being pulled aside when his father was being put into the ICU and realizing that his dad wasn't going to come back.
Havens says if we are lucky enough to know that we are wrapping up our time, then we have the opportunity not just to bow out of the digital world gracefully, but to have our digital persona carry on beyond us. This persona could go beyond today's static memorial pages on Facebook and Instagram; it could be an interactive computer program designed from your specific speech patterns, memories, and personality – a chatbot.
"I could have an algorithm trained to hear what I say and how I say it," Havens told me. "You can say, 'I'm Damon and I'm going to pass in the next few months, but, you know, over the past six months, I've created a chatbot to continue our conversations. In the upcoming months, my partner or loved ones will let you know when the chatbot will take over and be involved.'"
The chatbot could become an extension of you on platforms like Messenger or WhatsApp, for example. One can imagine this becoming the next generation of care management alongside funeral services, and will and testaments. You can see the future in Eugenia Kuyda, an entrepreneur who successfully created an interactive chatbot of her late friend, Roman Mazurenko, just based on his text messages. Her new program, Replika, may eventually give us the same technology so we, too, can all potentially do the same with our loved ones. Expect other tech companies to follow suit.
There is now no real separation between IRL and online – just as there may be an increasingly blurred line between our personas before and after death.
Chatbots offer us an irresistible decision: They are artificial intelligence programs built to have conversations with people, usually within a service capacity like canceling a shipping order or getting to the right help desk. You can view it as a modern-day helpline and, no doubt, you've interacted with chatbots when you've made purchases online. Chatbots are now becoming verbal, too, managing phone calls you make to your credit card company, local utilities, and other daily operations.
We witnessed our future this spring when Google showed off Google Duplex. It is a voice-driven system that will call people on your behalf with the intention, Google says, to manage your life. At the Google I/O conference, Google CEO Sundar Pichai showed Duplex calling a hair salon and interacting with the human receptionist – with nearly all the pauses, mmm-hmms, and colloquialisms as its female counterpart. "The amazing part is the assistant can actually understand the nuances of conversation," Pichai said to the rapt tech audience.
Recode's Kurt Wagner explained the immediate problem with the Google Duplex demo, which is the same problem technologists so often overlook: What if someone uses your technology in ways you didn't intend? "The major concern with that demo was that Google Assistant never said it was a robot or told the salon that the call was being recorded. When pressed by members of the media in the days after the demo, Google declined to comment, leading some to believe the company had simply overlooked this privacy element altogether."
"This is why disclosure will be so huge," Havens says. "When people call, they will begin with, 'Hello. I am a human.'"
This conflict between the physical and the digital is now coming to a head, though it isn't the clichéd man against machine Skynet conspiracy theories, but rather us against us. Today, it is as if we are split into two or, perhaps more accurately, two personas – our "real-life" persona and our online persona – and we're now experiencing fatigue trying to hold center.
It is a new phenomenon reflective of our social media: Media forerunners like MySpace and Friendster as well as classic websites like LiveJournal and Tumblr allowed us to explore the online world – and, in a sense, the physical world beyond our physical reach – using avatars as close to or as far from our real selves as we desired. On the Internet, nobody knows you're a dog.
Facebook truly eliminated the powerful choice of anonymity, as its extensive verification process required people to give up anonymity to participate in the biggest social network in the world. This was a willful, purposeful decision by Facebook: Founder Mark Zuckerberg has been an advocate of being yourself online, and the former Director of Market Development Randi Zuckerberg infamously said, "I think anonymity on the Internet has to go away… People behave a lot better when they have their real names down."
This was Facebook's intention and, whether or not its theory of people behaving better is true, especially in light of the 2016 U.S. Presidential election, the effects on us are real. Sex workers and other high-risk, anonymity-driven entrepreneurs are being outed via social media. The parallel rise in online addiction clinics isn't a coincidence, as the blur between the physical self and the digital self has never been hazier. There is now no real separation between IRL and online – just as there may be an increasingly blurred line between our personas before and after death.
Chatbots represent a tempting form of convenience: A way to remove our cognitive load to an assistant that will manage our relationships.
We have Carrie Fisher starring in the next Star Wars movie, potentially winning the first truly post-humous Oscar thanks to technology that can help transition older footage into live-recorded footage. Similar, more subtle turns occurred with Paul Walker in the Fast and the Furious 7, which used a combination of CGI and stand-ins. But a key difference is that we actually know they are dead before the movie is even released. As not-famous individuals, we have the ethical choice (duty?) to disclose that information to our social media followers after we die.
While we're still alive, though, chatbots represent a tempting form of convenience: A way to remove our cognitive load to an assistant that will manage our relationships. The rub is that our online relationships are our personal relationships, so we're not just potentially automating, say, our social media feed or our online postings, but our responsibilities in the real-life relationships that we've built. There is no line.
"It's naïve to think that the Google Duplex that was designed to make your hair appointments won't be used to do more difficult things like break up with a girlfriend," Havens says. "Record 50 words, use different inflections, and put in phrases like 'It's not you, it's me.' Why wouldn't people do that?"
Well, it really depends on the person. My wife and I ended up leaving the social media management section of our will blank for now. I even took a long social media sabbatical to connect with people more in person. If my online relationships and my in-person relationships are all becoming the same, then maybe it's OK to let them die – just like I will.
The Friday Five covers five stories in research that you may have missed this week. There are plenty of controversies and troubling ethical issues in science – and we get into many of them in our online magazine – but this news roundup focuses on scientific creativity and progress to give you a therapeutic dose of inspiration headed into the weekend.
Here are the promising studies covered in this week's Friday Five:
- Research on a "smart" bandage for wounds
- A breakthrough in fighting inflammation
- The pros and cons of a new drug for Alzheimer's
- Benefits of the Mediterranean diet - with a twist
- How to recycle a plastic that was un-recyclable
Sexually transmitted infections (STIs) are surging across the U.S. to 2.5 million cases in 2021 according to preliminary data from the CDC. A new prevention and treatment strategy now in clinical trials may provide a way to get a handle on them.
It's easy to overlook the soaring rates of gonorrhea, chlamydia, and syphilis because most of those infections have few or no symptoms and can be identified only through testing. But left untreated, they can lead to serious damage to nerves and tissue, resulting in infertility, blindness, and dementia. Infants developing in utero are particularly vulnerable.
Covid-19 played havoc with regular medical treatment and preventive care for many health problems, including STIs. After formal lockdowns ended, many people gradually became more socially engaged, with increases in sexual activity, and may have prioritized these activities over getting back in touch with their doctors.
A second blow to controlling STIs is that family planning clinics are closing left and right because of the Dobbs decision and legislation in many states that curtailed access to an abortion. Discussion has focused on abortion, but those same clinics also play a vital role in the diagnosis and treatment of STIs.
Routine public health is the neglected stepchild of medicine. It is called upon in times of crisis but as that crisis resolves, funding dries up. Labs have atrophied and personnel have been redirected to Covid, “so access to routine screening for STIs has been decimated,” says Jennifer Mahn, director of sexual and clinical health with the National Coalition of STD Directors.
A preview of what we likely are facing comes from Iowa. In 2017, the state legislature restricted funding to family health clinics in four counties, which closed their doors. A year later the statewide rate of gonorrhea skyrocketed from 83 to 153.7 cases per 100,000 people. “Iowa counties with clinic closures had a significantly larger increase,” according to a study published in JAMA. That scenario likely is playing out in countless other regions where access to sexual health care is shrinking; it will be many months before we have the data to know for sure.
A decades-old antibiotic finds a new purpose
Using drugs to protect against HIV, either as post exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP), has proven to be quite successful. Researchers wondered if the same approach might be applied to other STIs. They focused on doxycycline, or doxy for short. One of the most commonly prescribed antibiotics in the U.S., it’s a member of the tetracycline family that has been on the market since 1967. It is so safe that it’s used to treat acne.
Two small studies using doxy suggested that it could work to prevent STIs. A handful of clinical trials by different researchers and funding sources set out to generate the additional evidence needed to prove their hypothesis and change the standard of care.
Senior researcher Victor Omollo, with the Kenya Medical Research Institute, noted, “These are prevention interventions that women can control on their own without having to seek or get consent from another person,” as is the case with condom use.
The first with results is the DoxyPEP study, conducted at two sexual health clinics in San Francisco and Seattle. It drew from a mix of transgender women and men who have sex with men, who had at least one diagnosed STI over the last year. The researchers divided the participants into two groups: one with people who were already HIV-positive and engaged in care, while the other group consisted of people who were on PrEP to prevent infection with HIV. For the active part of the study, a subset of the participants received doxy, and the rest of the participants did not.
The researchers intentionally chose to do the study in a population at the highest risk of having STIs, who were very health oriented, and “who were getting screened every three months or so as part of their PrEP program or their HIV care program,” says Connie Celum, a senior researcher at the University of Washington on the study.
Each member of the active group was given a supply of doxy and asked to take two pills within 72 hours of having sex where a condom was not used. The study was supposed to run for two years but, in May, it stopped halfway through, when a safety monitoring board looked at the data and recommended that it would be unethical to continue depriving the control group of the drug’s benefits.
Celum presented these preliminary results from the DoxyPEP study in July at the International AIDS Conference in Montreal. “We saw about a 56 percent reduction in gonorrhea, about 80 percent reduction in chlamydia and syphilis, so very significant reductions, and this is on a per quarter basis,” she told a later webinar.
In Kenya, another study is following a group of cisgender women who are taking the same two-pill regimen to prevent HIV, and the data from this research should become available in 2023. Senior researcher Victor Omollo, with the Kenya Medical Research Institute, noted that “these are prevention interventions that women can control on their own without having to seek or get consent from another person,” as is the case with condom use, another effective prevention tool.
Antibiotic resistance is a potentially big concern. About 25 percent of gonorrhea strains circulating in the U.S. are resistant to the tetracycline class of drugs, including doxy; rates are higher elsewhere. But resistance often is a matter of degree and can be overcome with a larger or longer dose of the drug, or perhaps with a switch to another drug or a two-drug combination.
Research has shown that an established bacterial infection is more difficult to treat because it is part of a biofilm, which can leave only a small portion or perhaps none of the cell surface exposed to a drug. But a new infection, even one where the bacteria is resistant to a drug, might still be vulnerable to that drug if it's used before the bacterial biofilm can be established. Preliminary data suggests that may be the case with doxyPEP and drug resistant gonorrhea; some but not all new drug resistant infections might be thwarted if they’re treated early enough.
“There are some tradeoffs” to these interventions, Celum says, and people may disagree on the cost of increased resistance balanced against the benefits of treating the STIs and reducing their spread within the community.
Resistance does not seem to be an issue yet for chlamydia and syphilis even though doxy has been a recommended treatment for decades, but a remaining question is whether broader use of doxy will directly worsen antibiotic resistance in gonorrhea, or promote it in other STIs. And how will it affect the gut microbiome?
In addition, Celum notes that we need to understand whether doxy will generate mutations in other bacteria that might contribute to drug resistance for gonorrhea, chlamydia or syphilis. The studies underway aim to provide data to answer these questions.
“There are some tradeoffs” to these interventions, Celum says, and people may disagree on the cost of increased resistance balanced against the benefits of treating the STIs and reducing their spread within the community. That might affect doctors' willingness to prescribe the drug.
Turning research into action
The CDC makes policy recommendations for prevention services such as taking doxy, requiring some and leaving others optional. Celum says the CDC will be reviewing information from her trial at a meeting in December, but probably will wait until that study is published before making recommendations, likely in 2023. The San Francisco Department of Public Health issued its own guidance on October 20th and anecdotally, some doctors around the country are beginning to issue prescriptions for doxy to select patients.
About half of new STIs occur in young people ages 15 to 24, a group that is least likely to regularly see a doctor. And sexual health remains a great taboo for many people who don't want such information on their health record for prying parents, employers or neighbors to find out.
“People will go out of their way and travel extensive distances just to avoid that,” says Mahn, the National Coalition director. “People identify locations where they feel safe, where they feel welcome, where they don't feel judged,” Mahn explains, such as community and family planning clinics. They understand those issues and have fees that vary depending on a person’s ability to pay.
Given that these clinics already are understaffed and underfunded, they will be hard pressed to expand services covering the labor intensive testing and monitoring of a doxyPEP regimen. Sexual health clinics don't even have a separate line item in the federal budget for health. That is something the National Association of STI Directors is pushing for in D.C.
DoxyPEP isn't a panacea, and it isn't for everyone. “We really want to try to reach that population who is most likely going to have an STI in the next year,” says Celum, “Because that's where you are going to have the biggest impact.”