10/1/20: Interview with Sawyer Seminar’s Dr. Jeremy Greene

This interview with Sawyer Seminar Director Dr. Jeremy Greene is based on the recent publication of his co-authored article, “Innovation on the Reservation: Information Technology and Health Systems Research among the Papago Tribe of Arizona, 1965–1980”.  We provide the abstract below but the full article can be accessed here. The interview has been edited for clarity and brevity.

Abstract: “In May 1973 a new collaboration between NASA, the Indian Health Service, and the Lockheed Missiles and Space Company promised to transform the way members of the Papago (now Tohono O’odham) Tribe of southern Arizona accessed modern medicine. Through a system of state-of-the-art micro- wave relays, slow-scan television links, and Mobile Health Units, the residents of the third-largest American Indian reservation began to access physicians re- motely via telemedical encounters instead of traveling to distant hospitals. Examining the history of the STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care) project from the perspective of NASA and its contractors, from the perspective of the Indian Health Service, and from the perspective of O’odham engineers and health professionals offers a new focus, emphasizing the American Indian reservation as a site of medical research and technological development in the late twentieth century, with specific attention to the promise of information technology to address health disparities and the role of American Indians as actors in the late twentieth-century history of science, technology, and medicine.”

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How did you come across the STARPAHC archive, and how did the different authors of this article come to work together after initially accessing this archive independently of one another?

I first became aware of the archive through the work of Charles Doarn, who works in the telemedicine division at NASA and who is interested in history of STARPAHC. I also came across the archive when I was beginning a project on the history of telemedicine. I was surprised to find out that this field which we now associate with private telemedical providers and app developers pitching new interfaces for telemedicine to Silicon Valley investors, received its most significant investments in the 1970s through federally funded research projects; not just the Department of Health, Education and Welfare (HEW) but NASA as well. I looked in further detail at the documentation of STARPAHC reports within  NASA, the Indian Health Service (IHS), and the Lockheed Missile and Space Corporation. It was fascinating to see that foundational moments for developing telemedical platforms emerged from an unlikely partnership between an underfunded IHS, a jeopardized space agency that would see its funding cut unless it could prove domestic terrestrial value for space technology, and defense contractors trying to find peacetime markets for their technology.

I also learned that there was a well preserved archive around STARPAHC at the University of Arizona. The university wanted to make sure this legacy of telemedicine origins was locally archived. From Doarn I learnt that NASA also had a collection of documents on STARPAHC in Washington DC. In the IHS archival materials, it became clear that the infrastructure that was set up to create the electronic health basis of the then Papago Nation, now Tohono O’odham tribe, had been laid out well before STARPAHC came about, through the actions of the IHS. I then also had a chance to meet up with Rosemary Lopez, the current Secretary of Health and Human Services of the Tohono O’odham tribe and the first community health worker to staff the STARPAHC Mobile Health Unit. Somewhere in these intersections, I realized that there was a story that looked very different depending on which archival source was used to tell it – and yet, at the intersection of these sources the story that I might have expected, of simple extraction and exploitation, didn’t resolve any of these narratives. I then met up with Victor Braitberg at the University of Arizona’s Anthropology department, who had also found his way to these archives and we started working collaboratively. Through our own research, we found the senior thesis of Gabriella Maya Bernadett, who is a member of the Papago tribe and wrote a senior thesis on STARPAHC at Yale University, coming to the same conclusions as us. We met and decided to work together, given that we had found our way to the same archive through different paths.

You draw from many different sources and bring many different voices to the forefront in this article. As you said, the unlikely collaboration of the IHS, NASA and Lockheed is not something you expect to see in the archive.

Exactly. It’s an unexpected story. So if I were to say that I’m going to tell you a story about how in order to have a medical bay in a space shuttle, NASA needed to take a Winnebago and stuff a version of that medical bay inside it, drive it around the Sonoran Desert picking up sick Tohono O’odham passengers and then treating them as if they were sick astronauts – it’s not a speculative future that any of us would generate on our own. It raises one of the core questions of social and cultural history: How do we explain something that seems so improbable but was impelled by logical forces at the time of its inception? I will add that that Doarn, who I mentioned earlier, did go on to collaborate with Steven Palmer and Andrew Simpson, the three of them publishing an article on STARPAHC and this unlikely collaboration in the Journal of Policy History. The focus of their article is, how do you get the Department of HEW, the IHS, and different federal agencies to collaborate successfully? The question for us was a different one. How do we, in this surprisingly well documented episode, find a moment to rethink Indigenous Science and Technology Studies? How do we rethink the reservation as a space for science, surveillance, data generation, analysis and calculation, while also being attuned to the possibility for exploitation and the asymmetries of political economy? How do we rethink the reservation as a space for sovereign indigenous subjects having scientific selves as well? That sense of creating one’s own person and one’s own population as a voluntary form of trading surveillance for other forms of capital and agency is surprisingly well documented in this case. We thought that’s something we don’t hear enough about in the 21st century intersection of science, technology, History of Medicine and American-Indian lives.

In the article you point out that Cold War technologies have been tested before on American-Indian land. With the STARPAHC project, we see a more complex relationship between Cold War technoscience and an American-Indian tribe, in contrast to the devastating effects of the Manhattan Project for example. Yet there remains a sense of technological innovation brought in from the ‘outside’ to the ‘inside’ of the reservation. Should we see this binary as a clear-cut one, or does the presence of Papago Nation bureaucrats, technicians and healthcare workers make this a more symbiotic process? Should these roles be seen as oppositional to otherwise extractive colonization processes?

It’s hard to answer that with a simple “yes” or “no”. Any late twentieth century historian needs to call attention to the continuing disappointment of failed treaty agreements, aggressions, and violations that constitute ongoing settler colonialism. There’s a danger in painting too rosy a picture in this analysis. It’s also clear who holds the purse strings in this process of bringing telemedicine to the Papago tribe. The budget that NASA had for this telemedical demonstration dwarfs all other federally funded telemedical demonstrations  during the 1970s combined, and that’s not an accident. Nor is it an accident that Lockheed’s participation in this is encouraged not simply to receive income through federal funding, but also via the possibility of accessing substantial markets by selling this prototype to “out of the way” places, especially markets understood to be in the developing world. So there is necessarily an extractive development here, bound up in a flow of capital and an asymmetrical flow of resources, that we need to read the story through.

At the same time this is not simply a case of Lockheed and NASA developing these technologies in laboratories in Silicon Valley, or Sunnyvale in California, and then bringing them out from “the center” to “the periphery” in the Sonoran Desert. Looking at the movements of people involved, it’s also clear that the Executive Health Board of the Papago tribe plays a substantial role – such as Rosemary Lopez and Peter Ruiz, an air force engineer communications expert who signed onto the STARPAHC project and went to Sunnyvale to help design and physically fabricate circuit boards. Lopez toured existing telemedical sites in other parts of the country so she could have a sense of the practical advantages and pitfalls of using telemedical services to connect urban and rural areas. Then, she and other Executive Health Board members named the project STARPAHC. It’s hard to square the involvement of capital and clear asymmetries of power with the substantial role that the Executive Health Board members had in designing and building a system. This is not to say their involvement erases those power hierarchies, but rather that it creates a space where sovereign Indian technoscientific agency can be articulated as an act of self-determination in this time period.

The many different American-Indian voices reflected in this article often don’t see eye to eye with each other. Yet, all are committed to the modernization project inherent to the Cold War zeitgeist. Have their views on this changed over time? 

I think one of the challenges for me, and the other authors of this article, is that talking about what the Tohono O’odham wanted in this moment is limited by those voices which are available to us. Preserved in the various archives and any archive in the Himdag Ki (cultural center) on the reservation itself, are moments of conscious deliberation on what exactly the Executive Health Service board wanted the STARPAHC project to accomplish. There was pushback from opposition, specifically from Michael Rios, who runs an oppositional tribal newspaper. And yet, in this process, we can’t claim to capture the voice of the Papago in an abstract or coherent way. That being said, what fascinates is me is that when resistance is documented, it’s done carefully and is remediable. In the years before STARPAHC, when the IHS  starts to envision the Papago reservation as its own “population laboratory” for imagining new cybernetic visions of public health surveillance and intervention, there’s documentation of meetings where there is strong opposition to this. It seems this initial opposition was listened to and resolved by suggesting that if, as part of this arrangement, it could lead to more direct training of Papago public health officials and community health medics, it would resolve a lot of the reservations around the tribe making itself available for data surveillance. Similarly, we see later when Michael Rios is expressing his indignation of the characterization of the Papago as “guinea pigs” for massive electronic surveillance through STARPAHC, his demands are not that NASA be sent packing or the erasure of data, but rather that if the Papago are taking part in this arrangement, the technology be used to improve public health, set up more roads, and a fund to train more Papago doctors for the IHS. There is a self-conscious, if limited, agency in trading participation in a widescale data monitoring project for enhancing scientific, technological and medical agency for the Tohono O’odham as a people.

Going back to something you said earlier: We often tend to think of telemedicine in terms of Silicon Valley and 21st century health care. Much like contemporary critiques of Silicon Valley solutions, a question that arises about the STARPAHC project is how it provides stop gap measures rather than addressing the root causes of health disparities on the reservation. Can you speak further on this proximate approach to healthcare provision?

What I find compelling about the STARPAHC project and the different perspectives on how the Tohono O’odham became positioned as an ideal “test site” for technologies of telecommunications, data systems, and medicine is this lineage of what might be seen as the limits of technological liberalism coupled with an understanding of the fallacies of the “tech fix”. There is an inescapability to the allure of technological solutions for seemingly intractable social problems. A simple version of this would be to say that naïve people at the IHS, NASA and Lockheed believed they could use a new form of technology and cybernetics, thereby short-circuiting the otherwise intractable structural health disparities that had been layered on by centuries of settler colonialism, dispossession and socio-political marginalization. Yet when you start looking at the details of the story, all the folks at the IHS engaged in STARPAHC, and even people at Lockheed and NASA, were aware of just how deep-set these problems were. They saw themselves as part of a liberal “agenda” to restore rights at a key moment for American Indian self-determination and could cite almost chapter and verse the dangers of the “tech fix” narrative – yet they felt it was a lever they could use.

As anthropologists and historians, it’s important to figure out how to lay judgment on these actors for self-conscious decisions to take actions which they knew were unlikely to resolve all the problems they were dealing with, while nonetheless being hopeful that it could be a point of limited leverage. So much of this is wrapped up in what it means to do a demonstration project. STARPAHC was a demonstration project. It’s a limited moment in time to generate  resources and funds to help show that something works and that perhaps that platform will become the future – most likely it will not, but in the interim good work can be done. And so I think it’s really quite shocking to look at the documents of the Executive Health Board or those left by IHS officials who were so keenly aware of what they were up against. Taking an RV and stuffing in some telecommunications materials is not going to undo the terrible statistics for health disparities. At the same time, this paradoxical vision of a hi-tech future that is immediately transposed onto the perception of the Papago reservation as an “out of the way place” nonetheless promised to at least offer better access to biomedical care, as limited and downstream as that care was understood to be. 

You highlighted just now that the STARPAHC project can’t be read in  purely cynical terms; there’s an optimism running through on all sides. You also point out in the article that already existing data and infrastructure allow for the land of the Papago tribe to be the appropriate field site for the STARPAHC project, rather than any essentialist characterizations of a “cooperative people”. Yet it’s not quite clear why, in the end, it is decided that this project can’t be implemented elsewhere. Can you tell us why it was so?

We’re not left with a good explanation for exactly why STARPAHC fell apart. I think one part of it is to say that the promised hand off between NASA/Lockheed on the one hand, and the department of HEW, on the other, just fell apart halfway through the project. James Justice, who was the medical director of the STARPAHC project, told us that the department of HEW was supposed to do a series of analyses about how the project was working,  to help capture the public health impact as well as the logistical biomedical feasibility of the project. This quickly fell apart and was never honored. That’s one of his greatest regrets and a source of anger about the project. There was already a tenuousness to the process of how a less well funded entity like the Department of HEW was going to take over from a much better funded aerospace defense contractor and agency. Even this initial veneer of possibility was stripped away early on. So by the time NASA’s own very strict timetable of involvement came to an end, the writing was on the wall.  I think another piece of this story, from the perspective of the IHS, was that people like Stu Rabeau built cybernetic resources for the IHS Office of Research & Development (ORD),  but it was not a frictionless process to convince other IHS  sectors and the tribal leaders of other Indian Nations that the Papago experience of surveillance and data generation was translatable or relevant for their own experience. There’s all these documented export models for STARPAHC which are generated initially, but they quickly fall by the wayside as it starts to seem like this data is not generalizable. A third angle to this answer is an international one. At its height, this creation of the ORD at the IHS, overlapped with a sense that the IHS could shift from being a “backwater”, poorly funded health agency to a forward-leaning part of soft power in Cold War US foreign relations, especially through the roles of technology, international health, and development. So there’s a hope that on a broader level, this technology is going to be exportable and Lockheed is interested in that. Effectively, that doesn’t come to pass either – these are all speculative ventures.

What is fascinating is finding how little anger there is on the parts of these various actors that these things don’t come to pass. If anything James Justice, the IHS program lead on STARPAHC, is probably the most frustrated in what we see in the record. Most of the Executive Health Board seem to have anticipated that this was going to happen with a demonstration project, but feel that at least they had the support during these years; they got some roads built, shored up clinics in substantial ways and helped build a training process for Papago public health officials and medics. This is something that I find fascinating in the story, the sense that again, what we might initially call a naive technological optimism isn’t necessarily naive at the beginning or the end. There’s a hopefulness that’s built into it but there’s also a resignation, and a sense that perhaps this kind of engagement is worthwhile even though the things that are promised do not actually arrive. 

You make an important point in the article about the political economy of the STARPAHC project, and of the funding of scientific and public projects more generally. If the funding was never meant to truly improve public health, was the closure of the project inevitable?

The question you’re asking here is; to what extent can we write off the participation of various actors in STARPAHC as deliberately cynical? In other words, is it simply a matter of the purported public relations benefit that makes it appear that a defense contractor is aiding an impoverished American Indian population but is in effect a cover for building a medical bay at a space shuttle? I think that from a distance that’s certainly what it looks like to a casual observer and I think this is what Lisa Cartwright speculates in her brief treatment of STARPAHC. And yet I think closer engagement with the archives and oral histories of the people involved doesn’t really sustain a  fully conscious cynical take on this. All of them could point to the unlikeliness of tech fixes in actually resolving social problems. It’s as if they all were willing to hold their breath though, and say, well maybe this time it will be different. That’s not the same thing as cynicism to me. It is very instructive to the extent that we continue to consider this, in the present telehealth moment, in the COVID pandemic, in how we talk about wearables, or our iPhones collecting data on us, to help us achieve better health individually or as a public. There’s a continued willful suspension of disbelief in the inevitability of the collapse of any program that doesn’t immediately come in line with financial sustainability as prescribed in an increasingly neoliberal healthcare space both in the 1970s and in the present day.

I’d say one last thing here, maybe related to one of your earlier questions, part of what fascinates me about the story of STARPAHC is not simply what takes place in the 1970s, but that that moment is only understandable as the product of a series of several different earlier moments of the voluntary production of an entire Indian nation as a database, which is not resolvable to simply an action by outsiders. Rather, it is also the result of the deliberate decisions of the tribal council and its representatives on how participation in scientific projects that created the Papago nation as a database were seen as the best of a series of limited options to help achieve both political and economic goals for the Papago tribe.  

At the time the STARPAHC project was conceived, there was a great deal of promise and hope in using Systems Analysis as a paradigm for thinking through public health problems. It seems you and your co-authors point out the limitations of this paradigm as they become apparent by the end of the STARPAHC project. Can you speak further on the role of Systems Analysis in the birth and development of STARPAHC?

The STARPAHC project is simultaneously saturated in the tacit relevance of Systems Analysis that needs to be evident to all parties involved, and provides a language which systems analysts at Lockheed, NASA, and the cybernetically revamped office of the ORD, can speak along with systems analysts in the Papago tribe. It forms a common language and yet at the same time it also performs a critique at a moment when a critique of the ideology of Systems Analysis is becoming evident in the 1970s. If you take a figure like Charles Erickson, who was  an anthropologist and systems analyst living in Tucson and helping convene the meetings of the Executive Health Board, part of Erickson’s excitement about the dynamic quality of how the Papago Executive Health Board puts together its “stew pot” model of organization is that he perceives this as a critique of the limitations of rigid, boxy Systems Analysis. So I agree that there is a paradox here in the story of critiquing Systems Analysis present within the STARPAHC project, which itself is only possible because Systems Analysis has become a common language across such disparate groups. Part of this moment collapsing and the end of STARPAHC may have to do with the life course of Systems Analysis no longer being able to sustain the energy to continue aligning all these diverse viewpoints. This is very relevant for the present day as well, except that we don’t call it Systems Analysis anymore. Right now the common animating dream is Big Data, and Artificial Intelligence – with similar problems of aligning diverse groups held together for a bit but likely to disperse again once the magic of that alignment starts to fade. 

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