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Is Slack Good for Anyone?

Illustrations by Maria Chimishkyan

In 2014, the executives at a brand-new start-up called Andela made a decision whose consequences they would only understand much later. Andela’s model was to recruit and train promising African engineers, then place them at Western tech firms, which meant its employees and clients were scattered across time zones; it desperately needed a way for its distributed workforce to share information and make decisions easily and asynchronously, ideally without subjecting anyone to a deluge of emails. So the company started using Slack.

The maker of the chat software had recently become one of San Francisco’s trendiest new companies, based on a promise to make work communication more transparent and fluid. And at Andela, it did. As the company grew, Slack became its central nervous system, the place where business was conducted and where the company’s culture was formed.

Over time, it also became the site of a workplace revolt, as the company’s fellows—engineers in training—began to agree that they were being mistreated. The complaints started in private messaging groups, where they’d discuss priorities before big meetings, in order to act as a sort of bloc in front of senior leadership. But when the fellows stopped being invited to those meetings, they created a private Slack channel where they’d air their grievances, especially about pay.

In the summer of 2019, a glowing BBC article misrepresented how much the fellows were paid, saying they made a third of what clients paid Andela, when in fact the amount varied and was sometimes lower. First, the #general Slack channel lit up with complaints, mostly from employees who had been talking among themselves about the issue for months. “I would like to know, did Andela at any point in time tell any news source we get 1/3?” wrote one. “This info has been flying around for a long time and it does not seem to bother Andela.” In a private employee-only Slack, they took to calling Andela “The Plantation.” Eventually, the fellows circulated a petition asking for higher pay—an effort organized over Slack. But by late 2019, the issue was moot: The company—citing “market demands for more senior engineering talent”—had laid off 400 people and shut down its fellowship program.

What became clear was that Slack was never just another piece of software at Andela. Instead, it was a whole new way for workers to talk to one another, and to demand answers from their bosses.

Thanks in large part to the coronavirus pandemic, Slack has now seeped out of start-up land and into all corners of corporate America, with more than 169,000 organizations—including 65 of the Fortune 100—paying for its services. Lyft, Airbnb, Venmo, Tumblr, and a raft of companies with names like Splunk and Deliveroo all use Slack—but so do Target, The New York Times, 1‑800‑Flowers, Harvard, AstraZeneca, and The Atlantic. So do Liberty Mutual, IBM, NASA’s Jet Propulsion Laboratory, and countless local businesses and nonprofits. Donald Trump, Elizabeth Warren, Andrew Yang, Cory Booker, and Pete Buttigieg all paid for Slack during their 2020 presidential campaigns. The Taylor Creek Church, in rural Washington State, uses it to coordinate prayer requests. Arizona State University has more than 140,000 individual Slack accounts in its system; the IT department considers it a tool that students should become acquainted with in school, like Excel or PowerPoint, because they will likely be using it for their entire professional lives.

It’s a safe bet: Last year, it was announced that Salesforce would acquire Slack for nearly $28 billion, in an ostensible bid to edge out Microsoft as the working world’s digital center of gravity. For millions of people, Slack is a verb, a utility, and a way of life. It has spawned competitors from Facebook, Microsoft, and Google; all told, chat is now the second-most-common computer activity, after email, according to RescueTime, productivity software that tracks users’ screen time.

But even if you don’t use Slack, or something like it, you live and work in the world Slack helped create. It’s a world where openness and transparency are prized; where work is something we are always kind of doing; where who we are at the office and who we are outside it are closer than ever before; where all of these dynamics mean that sometimes things go very wrong, especially for people in power.

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Slack is probably the first enterprise software in history to convince people that it’s cool. Its founder, Stewart Butterfield, became famous in Silicon Valley after starting the beloved photo-sharing site Flickr, which he and his partners sold to Yahoo for more than $22 million in 2004. He vaped and swore and majored in philosophy and had been born on a commune in British Columbia. He was funny, but the way he talked about software was almost tender. The tech press absolutely loved him.

In 2012, Butterfield and some friends were working on a video game, Glitch, that never really took off. But the team had become so enamored of the chat platform they’d built in the process that they decided to spin it off into the company that would become Slack. In an industry that fetishizes constructive failure so much that it repurposed a word for it, this was a spectacular pivot.

“We were like, ‘Well, we like working this way,’ ” Ali Rayl, a Glitch alum who is now Slack’s vice president of product, told me. “ ‘And maybe other people would like working in this way too.’ That was it: ‘Let’s try to make something that makes money so we can keep doing this thing that we like together.’ ”

Slack was explicitly an antidote to email—the formality, the clunkiness, the crush of useless messages, the bottomless reply-alls, and the chirpily false I hope this email finds you well! s. It organized information by subject (like a message board), not conversation (like email), and its architecture encouraged users to share knowledge broadly. Everything was saved by default, so all the flotsam and jetsam of daily work was captured in a sort of running ledger. It worked on desktop and phone, and made switching between the two seamless.

[Read: What Slack does for women]

“As soon as you were in, it was like, ‘Oh, this is better. This is what it’s going to be for everybody in five years,’ ” says the tech executive Anil Dash, whose company at the time, ThinkUp, was one of Slack’s very first customers. “I was pretty evangelical about it.”

Part of the appeal was the way the software felt. The company’s name was a wink, a self-aware joke, a sensibility: a hint at the kind of casual, effortless culture the companies that adopted it early seemed to be hoping to cultivate. The product itself was bubbly and bouncy, with a kindercore color scheme and a little cartoon robot that showed you the ropes. New messages announced themselves with a swoosh-tap-tap-tap that was inspired by jazz percussion and is, as the sound designer Josh Mobley told me when I called to ask about it, “Pavlovian,” “iconic,” and “very clever.” He added, “I wish I’d made it.” The interface supported GIFs and emoji and offered upbeat, cutesy messages as it booted up.

“It just felt like it wasn’t something made by, like, Microsoft,” Dash told me. “It just had a soul to it.”

Slack was the beneficiary of good press and word of mouth—when its preview version debuted in 2013, 8,000 companies signed up within 24 hours—but also of a larger trend. From the dawn of the office to the mid-2000s, the tools people used to do their jobs were largely dictated from the top down. But as technology became a consumer product—and especially after the first iPhone was released, in 2007—rank-and-file employees began doing work on their personal devices, using whatever software they wanted.

And so workers installed Slack’s free, low-feature version on their work-issued laptops and started chatting, until eventually they converted enough people that leadership had no choice but to pay for a professional license. Soon enough, and without advertising at all, Slack was a perk, if not a shibboleth, for a certain kind of employee and a certain kind of company.

Illustration of stacks of fire and heart emojis, notifications, @s, #s, and envelopes on purple background

Eight years, more than 10 million users, and an acquisition bigger than the GDP of El Salvador later, Slack has managed to mostly hold on to the cachet of its early days. “All of the other messaging apps that we tested just felt sort of corporatey,” says Melanie Pinola, who wrote the Wirecutter review that declared Slack “by far” the best team-messaging app. “And the ones that were fun were really just imitations of Slack.” The user-experience researcher Michele Ronsen, who has done work for Slack and other global brands, told me that she’s seen no other product evoke such uniformly positive reactions among consumers. “When I recruit and conduct studies, over half of the people volunteer their love for the product and the platform and the benefits, completely unsolicited,” she said. “That does not happen very often.”

[From the November 2016 issue: The binge breaker]

This is great for Slack, and also a little ridiculous: Enterprise software is meant to blend in, silently and only semi-effectively wringing more productivity out of us before we can call it a day. It is not supposed to create zealous brand loyalists. But Slack so thoroughly permeates companies’ culture that it changes them. It changes the language of the office and the texture of the workday. It enables a sui generis kind of communication, one that’s chatty, fast, stream-of-consciousness, and always on; one that often feels less like an email than a group text. It is work software that insinuated itself into our lives precisely by feeling unlike work software—and, in turn, it has made work feel less like work.

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I first encountered Slack in 2015, when I went to work at BuzzFeed. I’d come from a tiny magazine where “workplace communication” meant volleying one-line emails over Outlook, and where chatting was something you did at the bar after work, not while you were in the office. This new way of working was a revelation. I loved talking to my new colleagues. Thanks to Slack I could spend hours sitting in an office, on a work-issued laptop, chatting away on work-sanctioned productivity software and not get a single thing done. This is what the writer John Herrman has called “a novel form of work-like non-work,” with all the superficial trappings of labor—thinking, typing—but very few actual results.

Indeed, Slack’s original motto was “Where work happens,” but the platform is also where quite a bit of nonwork happens. Especially in an officeless office, Slack is the cubicle, the boardroom, the hallway, the watercooler, and the bar. It’s where you talk about your performance with your manager, and where you then talk about your manager with your friends. It’s where you flirt; where you joke around; where you complain; where you, in some sense, live. During the darkest days of the pandemic, Slack was where I felt most embodied, trading ideas with people I hadn’t seen in months, engaging in an activity that sort of resembled conversation, being seen and being heard.

Slack is where office culture is performed, codified, and amplified, often through an ever-evolving lingua franca of custom emoji, inside jokes, and hyper-specific references. It’s also where the characters and plotlines of the office emerge. Every Slack has oversharers and class clowns and bullies and try-hards and popular kids. It has people who love to ostentatiously keep their little green “active” light on as long as possible as proof that they’re working late, and people who abuse the feature that lets you notify an entire channel when you’ve sent a message.

In-person work has its own archetypes too. But Slack can feel like a sitcom you are writing together. Sometimes, in a big channel, employees can get so riled up that Slack will inform you that several people are typing, which of course riles people up even more.

On Slack, anyone can create a group channel. These can be for projects (#salesforce-acquisition) or events (#winter-carnival) or teams (#HR). But depending on your workplace, you can have a channel for just about any affinity group, ranging from the genuinely meaningful to the entirely frivolous. Many companies have established Slack channels in which employees from underrepresented groups can find community and support; Stormy Jackson, a product designer, told me she “really heavily relied” on Lyft’s Slack channel for Black employees in the months after George Floyd was murdered. BuzzFeed had channels for parents, queer employees, and women, but also for Rihanna fans, media gossip, exceptionally funny tweets, and people with the first name Matt.

[Read: Slack doesn’t want people using it for romance]

Slack’s setup also provides spaces for employees to gather out of view of the big bosses. Technically, management can access private messages and channels under certain circumstances. But craftier employees move them onto Slack’s free version, where they can really speak freely. Side Slacks are a place for workers to commiserate, gossip, and offer minute-by-minute color commentary on all-hands meetings, or the drama unfolding in the main Slack. All of this makes Slack even more irresistible: If you enjoy your job, Slack is like a party you get paid to attend. If you don’t, you’re probably in a side Slack, which is also like a party you get paid to attend. But parties have a way of getting out of hand.

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A few years ago, Fatima was working as an engineering manager at a small education-tech start-up. (I am omitting their last name, because their current employer did not authorize them to speak to the press.) This was the kind of place with in-office happy hours, a game room, and a culture rife with inside jokes. Explaining any office’s dynamics to an outsider is impossible in the same way that explaining a dream or a mushroom trip is. These things are private, all-encompassing, and very specific. But in an interview with me, Fatima tried: For reasons lost to time, the employees of this firm had developed an extended gag about ham. Then some started a Slack channel whose name was a pun on the word. And then they started using the term The Ham as sort of a dunce hat, or a kick me sign. Every week, a new person was designated “The Ham,” sometimes with their consent and sometimes without.

Fatima didn’t really think it was funny. “It was a fraternity-like mentality, like a ‘Let me go pick on the pledge’ kind of a thing. But in this instance, it’s your co-workers, and you’re doing it in a company-owned communication platform.”

And although this is the kind of game you’d probably want to keep private, the channel was public, its chat history accessible to anyone who knew where to find it. “You could literally go look at that Slack channel,” Fatima said, “and be like, ‘Oh my God, these are all the things that they are saying about me.’ ”

People did look, and then HR looked. Two employees were fired, and the channel was archived. “There was a reckoning at the company where we were like, ‘Oh crap,’ ” Fatima said. “You feel like you have some semblance of safety and privacy, like, ‘I can say whatever I want in here.’ We sort of forget that we’re in a professional workplace.”

A lot of people seem to be forgetting that. In 2016, three teachers resigned from a Rhode Island high school after someone leaked a Google Doc containing screenshots of a private Slack channel in which they mocked students by name (“Here’s how Hudson spelled Ta-Nehisi Coates: Tonahese quotes.” “Fucking idiot”). This summer, three senior Netflix executives were fired after management saw a public channel in which they criticized their colleagues, sometimes while those colleagues were speaking in meetings. One CEO told me he had to step in after “a lot of man-bashing was occurring” in a women-only channel at his company. “It began as political, at which point it was like, ‘Great.’ And then it began to veer into specific employees.” HR wanted to shut the channel down altogether; the CEO declined out of respect for “women needing a sense of solidarity in an environment where, you know, men can be shitheads.” But the company did issue a reminder to the staff that “as a general policy, Slack is not a place to talk about your co-workers.”

I have heard about employees being accidentally sent porn, of performance reviews being posted to public channels, of leadership bickering in front of their employees, of sloppy fingers and absent minds making for all kinds of horrifying accidents. Or horrifying nonaccidents: In her memoir, Uncanny Valley, Anna Wiener, a former tech-start-up employee, recalled that at one company she worked for, employees had set up Slack so that whenever someone typed “/giphy metronome” into the chat box of an all-company channel, an animated GIF of a swinging penis would appear.

[From the January/February 2020 issue: A review of Anna Wiener’s Uncanny Valley]

If these incidents feel like something that would never happen on email, that’s because Slack is more akin to social media than email. Proponents of Slack will point out that unlike social media, it is not algorithmically driven, and its profit mechanism isn’t engagement. These things are true, and important: Facebook makes money every minute you spend arguing with your cousin about climate change; Slack makes money every time a CEO tells his buddy he found software that has made employees more productive. But in practice, Slack evokes many of the same feelings that, say, Twitter and Reddit do, most saliently the feeling that what you are saying is categorically different, somehow less real, than what you’d say in another context.

“In a real-person meeting, at some point you’re going to say, ‘Stop it here,’ ” Maria West, a copywriter from Florida, told me. “But on Slack, you’re like, ‘Heh heh heh, this is juicy.’ ” Like many other people, West has found remote work much more bearable because of Slack. But, she conceded, “it also provides these festering pools of what CEOs are afraid of.”

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Stewart Butterfield prefers a different metaphor. Slack “makes people more powerful at communicating,” he told me, not unlike the way a backhoe makes people more powerful at digging holes. “They can dig a lot more ditches than they do if they only have a shovel,” he said. “But you can also accidentally knock over a building.”

On Zoom at his home in Aspen, Colorado, Butterfield is candid, wry, and uncommonly reflective for a CEO. He is a lot richer than he was in 2013, but he’s still charming. (He still vapes, too.) He sees Slack as inevitable—not in an egotistical way, but kind of the opposite.

“People were already chatting at work and with their friends. Something like Slack would have happened anyway. Maybe it would have taken longer. Maybe it would’ve felt very different. But [chat] is so much more efficient and so much more effective as a means of communication that I feel like it’s going to happen no matter what.”

Some hope that Butterfield is wrong. “I talk to other CEOs and they all hate it,” Anil Dash said. (Butterfield: “I enjoy a rich tapestry of feedback from all kinds of people.”) Part of that, Dash thinks, is because Slack largely came to them from the bottom up. “They would never articulate it this way, I think, but it has a radical architecture. They can feel it: Slack lets people collaborate, organize, communicate in ways I did not expect [them] to and I did not choose.”

Illustration of towering stacks of +, fire, and heart emoji, red notifications, and other symbols/emoji used in Slack reactions on purple background

“Photoshop doesn’t do anything radical to your organization,” Dash continued. It’s just another technology license. CEOs “think of [Slack] in that category, because the same person in the organization approves the purchase. But it’s not at all like that. It’s something that changes the culture of your organization.”

On Slack, everyone has the same size megaphone, regardless of hierarchy or chain of command. And between the jokes and the special channels and the spontaneity and the freewheeling way of talking to your colleagues—who are also kind of your friends—it encourages a type of personal expression that is new to the American workplace.

A decade or two ago, identity formation, friendship, meaning-making, and political agitation were much more likely to be the things we did on nights and weekends. Now they’re central to work. If you’re an entry-level grunt, this might be thrilling. If you’re a boss, it can be scary. In August, Apple blocked employees from starting a Slack channel devoted to discussing pay equity, citing a policy that Slack activity “must advance the work, deliverables, or mission of Apple departments and teams.” (Channels about dad jokes, pets, and gaming were left alone.) In April, Basecamp, which makes software with a function similar to Slack’s, banned “societal and political” discussions on its own Basecamp account. And in 2018, employees at the luggage company Away were fired after creating an unsanctioned private Slack channel where employees—particularly those identifying as LGBTQ and people of color—talked freely about what they felt was an inhospitable work environment.

Slack’s inherent flatness means that anyone can emerge as a leader. In fact, the most influential person on Slack is almost never the boss, in part because in many organizations the more powerful you are, the less you use Slack. Being good at Slack is a skill, and it’s a different one from being well liked, or effective in meetings, or even good at your job. It’s more like being a social-media influencer. “People can amass power in the organization by being good at this tool,” Dash said. “They are not elevated by an institution; they just happen to have mastered a technology. And that is a thing that people can find threatening or find upsetting or that can be misused.”

Stephen Miles, an author and a consultant who has been coaching Fortune 500 CEOs for decades, sees this as “the really ugly side” of Slack: “In the workplace, you kind of garner your equity through the course of work and through the course of time, and you earn the right to weigh in at a certain level on various topics,” he said. “This is sort of taking all that away.”

Part of Slack’s tremendous capacity to build culture is its ability to rapidly homogenize views, and police what’s acceptable. “This is a struggle every day for every CEO that has a full-blown Slack environment,” Miles said. “There’s an amazing, powerful, positive side to Slack. The negative side is that you create an us-and-them dynamic in the context of your company across multiple dimensions. You create conflict and tension.” Whether you view this as an opportunity or a threat probably depends on your place in the hierarchy.

Slack can make reaching consensus very easy. Sometimes that consensus is about where to go to lunch, or about how to solve a problem. Other times it’s about exploitation or unfair treatment. Still other times, it’s about a colleague, or a manager, or a corporate decision; in a very large channel, you can get piled on in the same way you can on Twitter—even if you’re the boss. In June, CNBC ran a story that BuzzFeed would be going public. Almost immediately, employees gathered in a company-wide, 1,100-person channel called #aja, for “Ask Jonah”—as in CEO Jonah Peretti—“Anything.”

They had a lot to say. “We would have liked to hear it directly from you first, Jonah, as most of us found out via CNBC,” one person wrote; she quickly received a chorus of assent from her colleagues in the form of “point up” emoji reactions. Another employee then asked whether CNBC had simply scooped BuzzFeed. Another speculated about whether the company’s partners had demanded confidentiality. “We like to hold our bosses accountable,” the first employee responded, to more affirming emoji. “Opacity is not cute.” Ultimately, Peretti said that the deal had been leaked to the press and that Securities and Exchange Commission rules had prevented him from informing employees before the public.

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Slack isn’t to blame for everything that goes wrong on the platform. People have been distractible and insensitive and insubordinate and hungry for better conditions at work for as long as we’ve been going to work. If you’re a jerk in real life, you’re probably one on Slack too. If your job is stultifying, or oppressive, or lonely, your Slack probably is too.

Andrew Braccia was one of Slack’s earliest investors, back before it was Slack. He acknowledges the software’s downsides. “You can get like-minded people that want to be destructive. You can get people driving discussions in negative directions,” he told me. “So I think it can take a lot of work at the company level to control these things. It’s an important evolution and maturation cycle that companies are going to need to go through.” In other words: Slack gave every company a message board. Now those that want to hold on to their authority are hiring moderators.

Last summer, The New York Times published an op-ed by Senator Tom Cotton calling on then-President Donald Trump to “Send In the Troops” to quell Black Lives Matter protests. The Times’ Slack quickly erupted as employees took to a channel called #standards to voice “serious concerns in the newsroom,” as one put it. With the plus-sign emoji piling up, a Times standards editor stepped in to assure employees that the newspaper’s top brass was addressing the matter. At least two editors would eventually step down.

“It was very clear in that moment what Slack was to each party,” Charlie Warzel, a technology writer for the paper at the time, told me. “And it was different for everyone: Management thought it was a place for them to message. And a lot of employees were like, ‘Here’s where I’m going to vent and whip up support.’ ” Six months later, the Times posted a job listing for a vice president for culture and communications, tasked in part with developing “the way people at The Times give feedback to leadership.”

As companies scramble to manage fallout from incidents like these, Slack Slacks on. The company is getting new client interest every day; Butterfield briefly shared his screen with me to show me Slack’s #sales channel, which was lit up with good news and thumbs-up emoji. Slack advertises, but maybe it doesn’t have to: The product has become embedded in our psyches. This summer, when the company ran TV ads during the Olympics featuring its distinctive notification sound, people took to Twitter en masse to complain about being reminded of work while trying to watch men’s gymnastics. RescueTime has found that the average Slack user in its data set checks communication tools much more often than the average non-Slack user: every five minutes.

[Read: The Slackification of the American home]

Slack is always there, in your pocket—but then again, so are emails, and text messages, and everything else. What makes Slack insidious is also what makes it appealing: It’s the bottomless scroll, the jokes, the drama, the emoji exploding like confetti cannons after every banal dispatch from a life under wage drudgery. It’s the itchy pull of something that was purpose-built by the cleverest minds in tech to feel essential. Slack is fun. Sometimes, when I am watching television or standing in line at the grocery store, I find my thumb absentmindedly moving over to Slack, the same way it does with Instagram and Candy Crush. I assure you it’s not because I’m a hard worker.

A fun workplace is one you want to spend time at, and also one that contributes to your sense of identity. “We’re like sharks who are sleeping with one eye open,” says the design researcher Simone Stolzoff: never fully invested in leisure or in work. The problem with that state, he said—other than the fact that it is completely exhausting—is that “it doesn’t give us containers to figure out who we are when we’re not working.” Kyle Mullins, who uses Slack in his capacity as the editor in chief of Dartmouth’s student newspaper, told me he’s already struggling against the feeling that “work is on all the time.” He’s 22 years old.

And when who you are at work and who you are outside of work blur—when work is your paycheck, but also your community and your source of purpose—you treat it a little more like the rest of your life, with all the stakes and all the messiness that implies.

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Adopting any new technology is an act of ferocious optimism and deep stupidity. You don’t really know what the thing is going to be—for you or for the world. How could you? How could anyone?

In September, I called Jeremy Johnson, Andela’s CEO, to ask if he ever regretted installing Slack. What I heard surprised me.

“Honestly, no,” he said. “Not at all.”

“There are lots of days when I come home and say, ‘This is a giant challenge,’ ” he continued. But Slack “forces companies to be more transparent, forces companies to be more thoughtful about policies; it forces them to think about how these things will be interpreted. But these are all things that a good company should be thinking about anyway … And yes, that makes running the company harder. But it’s not a bad thing.” Since ending its fellowship program in 2019, Andela has become more like an outsourcing operation for engineers. It has thousands of employees and works with hundreds of clients in more than 80 countries, remotely and during a global pandemic. Without Slack, it wouldn’t be the company it is today. Regretting Slack isn’t an option.

Toward the end of my conversation with Stewart Butterfield, he returned to a thought he’d left unfinished earlier: “Before, I said the adoption of something like Slack is inevitable. I don’t mean that, like, if we didn’t make Camel-brand cigarettes, people would buy Winstons instead. I just mean it’s a general-purpose technology. And people do mostly good stuff with computers generally, but people also use computers to do bad stuff, like put ransomware on hospitals. There’s a fundamental kind of moral reckoning with technology right now that if a technology has a bad use and also many good uses, should we take it away in order to prevent the bad use?”

No, but it’s an irrelevant question. Entire organizations have rearranged themselves around Slack. Slack isn’t a backhoe, as Butterfield suggested—it’s a Trojan horse. We installed it on our computers because it was cool, and because it was easy, and because we looked around and everyone else was using it. A generation of workers has bought into this wholly new way of working—one that feels good enough, often enough; one that is interesting and addictive and natural. If companies took Slack away, they’d need to reorient their processes, contend with angry employees, and generally put a great deal of toothpaste back in a pretty big tube.

Whether Slack is better or worse than email, good or bad for workers and bosses, liberating or oppressive or dangerous or delightful or all or none of those things, it’s here.

This article appears in the November 2021 print edition with the headline “Several People Are Typing.”

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A pair of realities: This week, Colin Powell, the former secretary of state whose service under President George W. Bush is most prominently associated with the American invasions of Iraq and Afghanistan, died at 84 due to complications from COVID-19, despite having been fully vaccinated. And: There are conditions under which any generally healthy person would most likely have a seizure.These facts, as strange as they seem in juxtaposition, are related—neither describes events at all out of the ordinary, and yet both arrive as a kind of shock, with the sense that something must be amiss. They share this: They’re matters of probability, and probability is a fact of life in medicine, and a chaos agent in discourse.Powell’s passing sparked a fresh round of social-media venom from vaccine critics, with the general’s death serving as ammunition for their claims. The onslaught of told-you-so’s sent news networks scrambling to invite experts to explain why the death of a single vaccinated person did not prove the overall worthlessness of the COVID-19 vaccines.[Kori Schake: What working for Colin Powell taught me]In Powell’s case, there is plenty of evidence to point to: The man was 84 years old, having lived, in other words, a very long life and having arrived at the highest risk category for death from COVID-19. Over time, bodies simply break down—our defenses become frail, our organs fragile—and no amount of medical intervention, no matter how heroic or generally efficacious, can forestall the end we all eventually meet. Nor was Powell in sterling health by the time he became infected with COVID-19. According to Powell’s family, he was in treatment for multiple myeloma, a cancer that affects white blood cells. These cells play a crucial role in protecting the body from infection; without them, even the most effective vaccines cannot perform their role. (A vaccine, after all, is more or less a highly skilled agent training your immune system to fight invaders; it doesn’t matter if the vaccine spends 20 years expertly whipping your macrophages into shape if, when the time comes, they simply don’t fight.)To which the vaccine skeptic will likely say: “Blah, blah, blah. That’s all just a long-winded way of saying vaccines don’t work. If you get your shots and you still die of COVID-19, that means the vaccine didn’t work. Case closed.”That this implicitly misstates the promise of vaccines is perfectly understandable. This is where a healthy person’s hypothetical seizure—and my real ones—comes in.If you are fortunate, you will live the majority of your life without ever having to think too much about medical decision making. (In fact, this is my hope for you, whoever you are: that you enjoy good health, and that if and when you do fall ill, your medical problems are straightforward, well researched, and easily treatable.) If you, like me, are a little less lucky, then you will become familiar with the way medical decision making actually works: probabilistically.When I was 14, I was diagnosed with epilepsy. What this broad blanket term for dozens of syndromes means is that a person has unprovoked seizures, in my case both grand mal seizures—that is, the convulsive ones most commonly associated with the word—and myoclonic jerks, which are short, repeated, electric-shock-like contractions of specific muscle groups, typically in my hands, arms, and shoulders. This array of symptoms is categorized as Janz syndrome. For me, the disorder will be lifelong. It has no known cure.When you are diagnosed with epilepsy, one of the things you learn is that a seizure is a burst of sudden, uncoordinated electrical activity in the brain that can be prompted by all kinds of disruptions—even in perfectly healthy, non-epileptic people. An ordinary person without any neurological abnormalities whatsoever may have a seizure if, for instance, they sustain a serious head injury, develop a significantly high fever, go into shock, suffer blood loss, or use particular prescription or illicit drugs. All of those factors lower what neurologists refer to as a person’s “seizure threshold,” the barrier between the average brain and a full-on electrical meltdown. For most people, the threshold is relatively high, and lowering it such that their likelihood of having a seizure comes to match, say, mine takes quite a disruption. That’s not the case for me. My seizure threshold is naturally quite low: It simply doesn’t take much to scramble the grid in my part of town. That doesn’t mean I’m constantly having seizures, or that anytime I run into a factor that could trigger a seizure, I will have a seizure; it just means my odds of having a seizure are higher than the average gambler’s.Thinking in terms of odds helps patients with illnesses like mine consider treatments. Through one lens, no epilepsy medication works—at the end of the day, you’re still epileptic, and your life is still circumscribed by limitations that do not apply to the lives of others. But that implicitly misstates the purpose of treatment: Epilepsy medications aren’t intended to cure epilepsy, or to guarantee that an epileptic never again has another seizure. They’re meant to lower the odds that, on any given day, in any given situation, an epileptic person will have a seizure. Or to put it another way: They raise your seizure threshold to something closer to a non-epileptic person’s.[Read: Why some doctors purposely misdiagnose patients]A windy day in an apple orchard with my kids is a roulette wheel, red and black. By nature’s accounting, my wheel is two-thirds black, and I can bet only on red. With anticonvulsant medication, I can reshuffle the pockets to 50–50; with a good adjunctive therapy, I can cut the black down to a quarter of the game or less, and mostly forget that I’m even placing a bet, though I always am.And so it goes for medicine in general. In order to live, we need to forget that we’re placing bets, though we always are. So many of our treatments are so efficacious and well established that their benefits are never really called into question, and we take for granted that they simply work, when the reality is that they mostly work, most of the time, for most people.The COVID-19 vaccines are no different. Elderly people living in states with higher vaccination rates during the Delta surge were more likely to survive than elderly people living in states with lower vaccination rates; unvaccinated Americans are 11 times more likely to die from infection with the Delta variant than vaccinated Americans; fully vaccinated Americans 65 and older are 94 percent less likely to be hospitalized than their unvaccinated counterparts, per a CDC assessment published in the spring. In any of those categories, there are undoubtedly outliers; there always are. But medicine isn’t about playing the outliers. It’s about playing the odds.
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