An excerpt from Nobody’s Driving: A Neurologist on the Self-Driving Century, and Why One Company Can’t Be Allowed to Own It.
The numbers vary by study, but somewhere between a third and two-thirds of stroke survivors are back behind the wheel within a year. Driving is one of the most demanding things an ordinary brain does: It requires cognition, perception, emotional control, and motor control, all at once, and a stroke can take a piece out of any of them. So a good many of the people who resume driving are doing it with deficits they cannot perceive: a slice of visual field that is simply gone, a reaction time that is slowed by a few hundred milliseconds that they would swear is normal. I have had patients argue with me about their driving while failing the test that would tell them why they should not. It is not stubbornness. The brain that would notice the deficit is the brain that has the deficit.
Then there is the list, which is long. Amyotrophic lateral sclerosis, where the hands go and then the legs and then the breathing, in an order the disease chooses. Parkinson’s, where the reflexes slow and the medications wear off in the middle of the afternoon. Epilepsy, where a single seizure costs you six months of driving in most states and you never really know when the next one is coming. Multiple sclerosis. Neuropathy. Macular degeneration. The ordinary attrition of being eighty-five.
For every one of those people, losing the ability to drive is not an inconvenience. In most of this country, it is the end of independent life. There is no bus in Laredo that will take you to a neurology appointment in San Antonio. There is a daughter, if you have one, who takes a day off work. Or there is nothing, and you do not go.
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Ask any neurologist who runs a follow-up clinic how many appointments are missed each year because the patient could not get there. It is not a small number. Missed follow-ups turn into missed medication adjustments, which turn into second strokes, which turn into nursing homes. Transportation is not a soft variable in stroke care. It is a hard one. It shows up in outcomes.
The best assistive device nobody is marketing
Here is what I wrote the week I saw the gold car, and I still think it is the most important sentence I have written about it: This is the most significant assistive technology I have seen in my career, and it is not being sold as one. Think about what we do sell. Hand controls for cars, which cost thousands and require a working upper body. Wheelchair vans, which cost as much as a house in some towns. Paratransit, which requires booking a day ahead and will get you there in a window of two hours. Ride-hailing, which is a person in a car, and a person in a car costs what a person costs.
The Cybercab is a car that has been redesigned around the assumption that the occupant is not going to do anything. Not because the designers were thinking about stroke patients. They were thinking about robotaxis, and cost, and utilization rates. But an object designed so that nobody has to drive is, by accident, an object designed for people who cannot. The two are the same shape.
That is why the video of the blind man got me. It was not the technology. It was the look on his face, which I have seen the inverse of four hundred times. Everything else in this book, the cities, the economics, the fight over who owns the software, is downstream of that face. I want that man to be able to summon a car in Laredo, and in rural Oklahoma, and in Lahore, and I want him to be able to afford it, and I do not want it to depend on whether one company in Austin decides his town is worth serving this year.
Which is where things get complicated.
Osama Jamil is a neurologist.
