Learning from the History of Experimental Telehealth

The increased demand for distant cures amid heightened concerns about infection in healthcare facilities, coupled with the “great resignation” in medicine since the COVID pandemic, have together created the unfortunate circumstances in which we find the American healthcare system in 2024. This is a moment, like many we have seen before, in which new, unproven technologies are being promoted as cures for the social, political, and ideological problems facing medicine in the United States. In this context, two recent books – Jeremy Greene’s The Doctor Who Wasn’t There and Hannah Zeavin’s The Distance Cure – bring fresh critical histories and viewpoints to debates about the role of technology in medicine. While contributing to a body of scholarship that looks at how technologies have changed medical practice in clinical settings, these timely works also fill an important gap on the impact and significance of telehealth technologies outside of clinical settings.

In their respective works, 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. Zeavin’s account shows how compassionate, service-minded clergy, social workers, and civilian volunteers found ways to use existing technologies like telephones and radios for therapeutic purposes. Guiding readers through a tour of twentieth-century devices that shaped public responses to private mental health crises, Zeavin introduces us to a series of creative people who adapted somewhat blunt, mass-mediated tools to do the highly sensitive and intimate work of distant care for people in need. By contrast, Greene’s account brings us the vantage point of individual doctors who grappled with technological interventions that seemed capable of extending the reach of modern medicine, but rarely succeeded in doing so to the satisfaction of both the doctors and the managers of the healthcare system. While Zeavin’s account presents a narrative of non-expert individuals outside of medicine who found ways to use technology to provide potentially life-saving care, Greene’s account presents a narrative of expert individuals inside of medicine whose ability to realize the promise of technology in their care of patients was perpetually deferred. 

Many of the technologies discussed in The Doctor Who Wasn’t There failed to live up to their fullest potential, not due to technical problems, but rather due to failures of political will and financial commitment. Put differently, medical technologies failed when those with the power to ensure the creation of a viable marketplace for the devices or services remained unconvinced that those investments were worth sustaining. Both Greene and Zeavin highlight the role of economic incentives to promote or abandon technologies in healthcare; in this way both books offer a much-needed corrective to a prevailing techno-determinist progress narrative in medicine. As Greene points out, hospitals often invested large sums of money to try out the latest technologies, yet their efforts to use telehealth to reduce disparities in underserved communities never seemed to pan out. These unfulfilled promises and the “failures of communications technologies,” Greene explains, “do not limit the allure that the next technology just might hold the key to short-circuit long-established socially structured forms of health inequity in the United States” (255; emphasis in original). Looking at Greene’s and Zeavin’s books through the lens that some technology developers call “need finding” prompts us to ask a seemingly obvious but potentially anachronistic question: what health or medical problem was the new technology attempting to solve? I say anachronistic, because the expectation that a new technology would only be adopted within healthcare if it solved a pressing problem is not a requirement to this day, so there is no reason to expect that rationale to have prevailed in the historical cases recounted in these books. Yet, both Greene and Zeavin do trace out the reasoning of their early adopters and users, and by doing so from the perspective of sometimes-failed experiments, they allow us to see the logic of technological healthcare through a clearer, albeit ethically cloudier, lens. 

The question of the marketplace for medical and health technologies is never far from the surface in both books, appearing at different moments as the pressures of commercialization, the insurance industry, and popularization through consumer culture. This points to an implicit question in both books: what is the difference between “patients,” “consumers,” and “users” in these histories, especially as medicine becomes ever more technologically mediated? And further, to what degree does the commercial marketplace inherently limit the transformative potential of healthcare technologies? For The Distance Cure, the technologies under consideration had the potential to lead in both radical and mainstream directions, as in the case of radio: “Whereas Fanon and Guattari theorized that radio was essential to producing revolutionary subjects at distance, in the United States, psychological radio and its listeners would become a major market” (78). Tracing parallel ideals among some early promoters of telehealth, Greene points out that early cable television “was hailed as a disruptive, community-based technology,” with the potential to “empower and integrate isolated and marginalized populations into a more inclusive American society” (146). Yet, Greene goes on to place that idealism into context, noting, “[i]n retrospect, it seems extremely naïve to suggest that an information technology could reverse the accelerating vector of postwar urban segregation, a process whose origins can be traced in racially restrictive covenants, federal redlining maps, and brutal policies of urban renewal that systematically circumscribed and denied services to the Black communities they pathologized” (148). Both Zeavin and Greene highlight this tension between utopian views of new technologies that could transcend existing structures of oppression, and the barriers posed by long-standing infrastructural inequities in America. By tracing this polarity across the histories of teletherapy and telehealth, these books point to the need for meaningful dialogue between contemporary critics and techno-optimists, before – not after – investments in new healthcare technologies are made.   

Both books provide insights about the bounded constraints of techno-mediated medicine and the limits of scripted dialogues between doctors, computers, algorithms, and patients. In the long arcs of medical media history that both books trace, those boundaries have a tendency to naturalize and make invisible their own limitations, transposing the affordances of the technology onto the scope of care. As Zeavin explains in a discussion of computer-based therapy, “On the one hand,” mechanizing the human therapist “would free mental health care even further from a dependency on expert labor, making it cheaper and more widely available; on the other hand, efforts to generate these natural language programs, algorithmic therapies, and diagnostic tools necessarily narrow the scope of what is treatable to what computer scientists and psychiatrists seek to treat, what the computer can do in its moment, what it can read, and what its programmer can code” (132). In his discussion of experiments with the IBM 1400 at Kaiser Permanente, Greene observed similar results: “as the machine learned, person by person, its input was limited to the measurements and yes/no answers of a collection of atomized patients” (219). The end result was the same: automation resulted in a paradoxical blend of standardization (the inability to account for the unique particularities of individual patients) and individualization (diagnoses and cures were focused solely on the quantifiable aspects of a single patient’s physiology, no social or behavioral factors could be addressed).

So, did mediation push healthcare toward or away from personalization? These books – unlike the computer algorithms they examine – do not offer neat yes/no answers. Reading The Distance Cure alongside The Doctor Who Wasn’t There offers balance and historical ground-truth to the cynics and the optimists around medical media hyperbole. At the conclusion of these books, it is clear that more innovation won’t solve our healthcare crisis; we’ve already tried that. Technology isn’t the solution, but it isn’t the root cause of our problems, either. As Zeavin observes, “The convergence of human-to-human interaction and algorithmic-human interaction is so extensive that these ways of understanding and making the subject overlap and inform each other” (173). Through their new books, Greene and Zeavin have helped us to see that the only way to truly understand and move forward productively with new technology in healthcare is to see that mediation is already at the center of all of our complex constellations of care. Before we embrace another new technology as a fix, we would be wise to consider it alongside all of the failures that came before.

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