Hybrid bodies and the materiality of everyday life: how people living with pacemakers and defibrillators reinvent everyday routines and intimate relations.

Technologies inside bodies pose new challenges in a technological culture. For people with pacemakers and defibrillators, activities such as passing security controls at airports, using electromagnetic machines, electrical domestic appliances and electronic devices, and even intimate contacts with their loved ones can turn into events where the proper functioning of their device may be at risk. Anticipation of potentially harmful events and situations thus becomes an important part of the choreography of everyday life. Technologies inside bodies not only pose a challenge for patients living with these devices but also to theorising body-technology relations. Whereas researchers usually address the merging of bodies and technologies, implants ask us to do the opposite as well. How are we to understand human-technology relations in which technologies should not entangle with bodies because they serve other purposes? Based on a study of the daily life practices of people with pacemakers and defibrillators in the Netherlands and the US, I argue that disentanglement work, i.e. work involved to prevent entanglements with objects and people that may inflict harm upon implanted devices, is key to understanding how hybrid bodies can survive in today's densely populated technological landscape.

How diversity gets lost: Age and gender in design practices of information and communication technologies.

This article adopts an intersectional approach to investigate how age, gender, and diversity are represented, silenced, or prioritized in design. Based on a comparative study of design practices of information and communication technologies (ICTs) for young girls and older people, this article describes differences and similarities in the ways in which designers tried to cope with diversity. Ultimately diversity was neglected, and the developers relied on hegemonic views of gender and age, constructed older people and young girls as an "other," and consequently their input was neglected. These views were thus materialized in design and reinforce such views in powerful yet unobtrusive ways.

Sustaining cyborgs: sensing and tuning agencies of pacemakers and implantable cardioverter defibrillators.

Recently there has been a renewed interest in cyborgs, and particularly in new and emerging fusions of humans and technologies related to the development of human enhancement technologies. These studies reflect a trend to follow new and emerging technologies. In this article, I argue that it is important to study 'older' and more familiar cyborgs as well. Studying 'the old' is important because it enables us to recognize hybrids' embodied experiences. This article addresses two of these older hybrids: pacemakers and implantable cardioverter defibrillators inserted in the bodies of people suffering from heart-rhythm disturbances. My concern with hybrid bodies is that internal devices seem to present a complex and neglected case if we wish to understand human agency. Their 'users' seem to be passive because they cannot exert any direct control over the working of their devices. Technologies inside bodies challenge a longstanding tradition of theorizing human-technology relations only in terms of technologies external to the body. Cyborg theory is problematic as well because most studies tend to conceptualize the cyborg merely as a discursive entity and silence the voices of people living as cyborgs. Inspired by feminist research that foregrounds the materiality of the lived and intimate relations between bodies and technologies, I argue that creating these intimate relations requires patients' active involvement in sustaining their hybrid bodies. Based on observations of these monitoring practices in a Dutch hospital and interviews with patients and technicians, the article shows that heart cyborgs are far from passive. On the contrary, their unique experience in sensing the entangled agencies of technologies and their own heart plays a crucial role in sustaining their hybrid bodies.

How places matter: telecare technologies and the changing spatial dimensions of healthcare.

Dominant discourses on telecare technologies often celebrate the erasure of distance and place. This paper provides a critical intervention into these discourses by investigating how spaces still matter, despite the move from physical to virtual encounters between healthcare professionals and patients. I argue that science and technology studies (STS) research on telecare, as well as other technologies, can be enriched by including a focus on place to understand the dynamic interactions between people and things. Adopting insights of human geographers, I show how places in which technologies are used affect how technologies enable or constrain human actions and identities. Whereas some spaces may facilitate the incorporation of technologies, others may resist technologies. A focus on how places matter is important for understanding how telecare technologies reorder and redefine healthcare. Although other healthcare technologies are also important actors in transforming healthcare, telecare technologies do this in a very specific way: they redefine the spatial dimensions of healthcare. To capture and further explore this changing spatial configuration of healthcare, I introduce the notion of technogeography of care. This concept provides a useful heuristic to study how places matter in healthcare. Although telecare technologies introduce virtual encounters between healthcare providers and patients, the use of telecare devices still largely depends on locally grounded, situated care acts. Based on interviews with users of several cardiac telecare applications, including healthcare professionals and patients in Germany and The Netherlands, the paper shows how patients' homes and public spaces are important for shaping the implementation and use of telecare technologies, and vice versa. Last, but not least, telecare devices are implicated as well. The paper emphasizes the place-dependency of the use and meaning of technical devices by showing how the same technological device can do and mean different things in different places.

Physical and digital proximity: emerging ways of health care in face-to-face and telemonitoring of heart-failure patients.

The introduction of telehealth-care technologies profoundly changes existing practices of care. This paper aims to enhance our understanding of these changes by providing a comparative study of health-care services for heart-failure patients based on face-to-face contacts in a policlinic (department of a health care facility treating outpatients) and remote consultations at a telehealth-care centre. I will show how changes that take place when care moves from physical to virtual clinical encounters cannot be understood in terms of a replication of existing health-care services. Instead, it is more useful to conceptualise these health-care provisions as practices that create and value other kinds of care, incorporating different forms of proximity to patients. The physical proximity created at the policlinic facilitates contextualised, personalised care in which responsibilities for monitoring are delegated to nurses and patients and heart failure is constituted as an illness. The digital proximity that characterises the telehealth-care centre supports individualised, immediate care in which responsibilities are largely delegated to technological devices and heart failure is constituted as a disease. A major policy implication of these differences is that telehealth-care cannot simply replace physical consultations without changing the nature of health care.

Diagnosis at a distance: the invisible work of patients and healthcare professionals in cardiac telemonitoring technology.

Although patients are often absent in discourses on telemedicine, many telemonitoring applications constitute a new medical practice in which patients are expected to play an active role. The paper is based on a study of the use of one specific telemonitoring device, an ambulatory ECG recorder introduced to diagnose infrequent irregularities of the heart rhythm. It seeks to examine all the invisible work it takes to produce patients who are active and responsible as participants in the diagnosis of their heart problem. In particular, I address the question of how we can understand that individuals who are anxious about their heart function manage to adopt the role of 'diagnostic agent'. This research shows that, although many patients managed to become competent users of the new technology, there are important patterns of selective use patients invented to integrate the technology in their daily life. In conclusion, the paper suggests that most patients were able to adopt the role of diagnostic agent not only because of their individual motivation but because of their location in the socio-technical network of this technology, in which the invisible work of home-care nurses and physicians at the telemedical centre made all the difference.