Introduction: Book Forum on ‘The Doctor Who Wasn’t There’ and ‘The Distance Cure’

In this forum, five scholars from different but intersecting fields of historical research engage with Hannah Zeavin and Jeremy Greene’s recent books on telehealth and telemedicine. As all of the contributors highlight, Zeavin and Greene’s books provide inspiring analyses of the potentials and limitations of electronic technologies in medicine and healthcare. In the following, I will first provide a very brief and necessarily very selective summary of the two books and then sketch some of the major themes that run through this Book Forum’s discussion.

Jeremy Greene’s The Doctor Who Wasn’t There: Technology, History, and the Limits of Telehealth (The University of Chicago Press, 2022) chronicles the history of physicians’ infatuations with new electronic technologies based on case studies of the telephone, radio-technologies, cable television, and early computer systems. Greene’s studies follow a chronological but temporally and thematically overlapping order. The first chapter examines the history of physiological and clinical applications of the telephone from the late nineteenth to the late twentieth centuries, highlighting the anxieties and expectations that accompanied new uses of the technology. Greene points out that hopes and fears about telephone medicine often badly matched its unintended social and clinical consequences. For example, in the mid-twentieth century, the telephone tended to create not less but more labor for both doctors and patients, demanding the former to be constantly available and the latter to frame their concerns in the language of algorithms of medical decision-making. In chapters 2 and 3, Greene turns to various mid-century radio-telemetric devices such as radio-transmitted ECG, the radio pill, and the radio pager. Greene situates these devices in a growing corporate and financial investment in the public health and medical market. In this context, he argues that, just as the telephone, radio devices were transformative for medicine but often in ambiguous and unanticipated ways: while the “wireless body” can improve individual and public health, “it is also a space of surveillance and control” of both patient data and physicians’ bodies allowing to track their movements over time and space (78). Ambiguity and unfulfilled promises are also at the center of Greene’s assessment of television in chapters 4 and 5. Discussing early applications of closed-circuit TV and cable television in the 1960s and 1970s, Greene shows that TV technologies offered powerful means for providing healthcare in underserved rural and urban communities. However, these technologies ultimately failed to resolve health disparities because they could not address underlying financial, commercial, and professional interests such as a lack of political will to finance public health infrastructure on the long term. In the last two chapters, Greene traces the introduction of computers into medical information management and automated diagnostic check-up, respectively. Greene points out that, in contrast to the early enthusiasm about electronic knowledge management, paper remained the dominant medium of medical practice for most of the twentieth century. Similarly, early systems of automated check-up failed to inaugurate a new era of public health prevention. Rather, they stand as a reminder for “our limited ability to perceive which promises of new technologies will and which will not transform the practice of the present” (239).  Indeed, one insight that sticks out in both Greene’s book and this forum’s discussion is a political call for caution. Throughout his book, Greene emphasizes that “the medium of care is not neutral” but depend on the power dynamics of professional endorsement, political will, and financial support (243).

Hannah Zeavin’s The Distance Cure: A History of Teletherapy (MIT Press, 2021) also scrutinizes real and imagined transformations of healthcare due to communication technologies but brings us from somatic medicine to mental health. The Distance Cure explores the media history of psychotherapy from Sigmund Freud’s epistolary exchanges and British psychoanalytic wartime radio to suicide prevention hotlines and tele-therapy apps. Zeavin’s book provides a complementary perspective to Greene’s: akin to Greene, Zeavin contends that media technologies have been planes of projection for “fantasies, concerns, and panics”; yet, her main emphasis is on how these technologies have enabled “medium-specific forms of relating that allow for unexpected and new kinds of human-to-human communication” (5). The Distance Cure traces these media-specific forms of relating in five chapters over a period of a hundred and thirty years. The first chapter invites us to rethink the history and practice of psychoanalysis form the point of view of mediation and communication. Zeavin points out that Sigmund Freud’s famous self-analysis and early psychoanalytic theory and practice, more generally, relied on both the use of traditional media (speech, handwriting, letters) and the metaphoric of new media (telephone, phonograph, radio). In Zeavin’s reading, the ‘talking cure’ thus turns out to be a “communication cure” (58); and the widespread anxiety of psychotherapeutic practitioners to extend the analytic scenario beyond the room has had more to do with professional safeguards than with the nature of the therapeutic encounter. Chapter 2 examines the long history of therapeutic broadcasting from Donald Winnicott’s wartime radio to present day podcasts. Zeavin carefully analyzes radio shows’ evolving strategies of scripting, pacing, and curating, and demonstrates how these strategies have allowed individual listeners to identify with case stories and transfer their own emotions and fantasies on the radio hosts. Just as the radio, Zeavin shows in chapter 3, suicide and crisis intervention hotlines have offered new ways of therapeutic relating since the mid-twentieth century. The first crisis intervention hotlines blended pastoral care with Freudian psychoanalysis, and sought to save lost souls with the telephone as a new and easily accessible medium of confessional help. Zeavin argues that many of these and later hotlines have, indeed, provided users with new forms of anonymity and agency as they shifted “the power dynamic of the psychodynamic encounter” (110) and made it easier for people in crisis to seek help. In chapter 4, Zeavin explores therapeutic computer programs since the mid-1960s, and engages with the counter-intuitive phenomenon that many users have described their therapeutic interactions with computers as pleasurable. Zeavin suggests that we may think of algorithmic therapy as a form of self-therapy, or “auto-intimacy,” akin to a young child’s self-soothing with the help of the thumb. Importantly, Zeavin writes, these modes of automated therapy reveal that, in the triad of therapist, medium, and patient, “the most disposable element is not the medium through which the therapy is communicated, but the human therapist” (175). The final chapter explores the growing market of online therapies and therapeutic apps since the 1990s. Zeavin shows that online therapies also come with their own modes of communication, such as the integration of elements of orality into written language. At the same time, she criticizes the increasing commercialization of the mental health app market that runs the risk of undermining the very privacy and intimacy that distance therapy can offer. In Zeavin’s assessment, tele-therapy offers a real opportunity for mental health care but, as in Greene’s study, its potentials are confined by economic, professional, political, and ideological interests.

In their respective essays, Kirsten Ostherr and Katja Guenther explicitly engage with the political dimensions of Greene and Zeavin’s books. Ostherr observes that both “Greene and Zeavin explore the tension between telling stories of individuals and telling a larger structural story of power and inequality as vectored through technology.” Both books highlight “the role of economic incentives to promote or abandon technologies in health care” and thus provide a corrective to stories focused on technological progress. Importantly, Ostherr emphasizes, the books demonstrate that the failure of technologies to “live up to their fullest potential [is] not due to technical problems but rather due to failure of political will and financial commitment.” As Guenther further details, the politics of media use are not restricted to specific facilities or practices but reach into “all forms of medical interaction, even the seemingly immediate [ones].” Along the lines of Greene and Zeavin, Guenther invites us to focus not so much on the inherent ideology of media but rather on “mediatic possibilities” that may be recuperated through a study of the past.

On a more personal note, Jaipreet Virdi reflects about technological access to care from the perspectives of disability studies and social justice. Virdi reminds us that “telehealth is not accessible for all people” but limited and shaped by “socio-economic disparities, lack of insurance, and unfamiliarity with technology.” Drawing on insights from both Greene and Zeavin, Virdi elegantly points out that the “cultural obsession with the new and the innovative” tends to obscure these structural aspects of healthcare. In Greene’s terms, these technologies function as “thought-saving devices.” Similar to Virdi, Mar Hicks stresses how technologies have been used to obscure structural inequalities. Hicks reads Greene and Zeavin’s book as two complementary stories of expertise and power: while Zeavin’s book narrates how “the expertise of the psychologist is largely eroded by […] amateur forms of counseling,” Greene’s book shows how “generations of mostly white, male, middle class internists alternately adopted, developed, and derided technologies” to maintain “their claims to professional expertise.” Hicks seconds as a central lesson from the books that “the medium of care is not neutral” but shaped by structural determinants of health.

Carmine Grimaldi draws attention to the historiographic questions that Greene and Zeavin’s studies raise. Grimaldi notices that both authors worked with particular kinds of archival records: audio-recordings, videotapes, transcripts of telephone calls, logs of suicide hotlines. Grimaldi critically remarks that historians are mainly trained in textual exegesis and thus badly equipped for the ethical and technical challenges that these sources pose. In Grimaldi’s view, Greene and Zeavin’s books offer models for a “historiographic practice that both accounts for privacy and creates a generative distance from the media and its subjects” — in part, through radical historicism. Yet, Grimaldi also points out that much is still to be done, not least due to a lack of interest in curating and preserving electronic records of our medical past.

In their responses, Jeremy Greene and Hannah Zeavin take up the calls to reflect about both the historical archive and the broader historiographical questions that their respective books raise. Greene points out that the history of “media and mediation of care” has not yet been properly understood as an area of scholarship in its own right. For Greene, this “incipient field” offers many opportunities. “Attending to media history” not only allows, as Grimaldi has pointed out, to attend to the infrastructure and ethics of “our own normative practices as historians” but also enables scholars to “move laterally, to other places, other practitioners, other voices, and reframe so many other forms of care in terms of a constellation of media medica.” Zeavin draws attention to the centrality and ambivalence of “distance” as both an object of study and a historiographical device. According to Zeavin, “the kinds of records and data of much of teletherapy are incomplete yet overly revealing” — be it Wilhelm Friess’s burning of Freud’s letters, or “the impossibility of fully accounting for the listener’s experience of Winnicott’s radio shows.” The scattered and yet, at times, highly private nature of the archival record asks for creative ways of negotiating distance in historical writing itself. Indeed, a central theme that runs through both the contributions to this forum and Greene and Zeavin’s books concerns the self-referential capacity of media that has, perhaps, become all too obvious in a post-COVID-19 society: whether telephone or tele-app, the medium of care is always present in technologically-mediated encounters.Zeavin and Greene remind us that this mediation remains profoundly historical: it cannot be understood outside of the social, economic, and political texture of its time. It is from this perspective that we can see the contours of a media history of medicine and health as an exciting field of future scholarship.  

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