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Interagency Cooperation in the Twilight of the Great Society: Telemedicine, NASA, and the Papago Nation

Published online by Cambridge University Press:  30 January 2020

ANDREW T. SIMPSON ,
CHARLES R. DOARN  and
STEPHEN J. GARBER
ANDREW T. SIMPSON
Affiliation:
Duquesne University
CHARLES R. DOARN
Affiliation:
University of Cincinnati
STEPHEN J. GARBER
Affiliation:
NASA History Division
Rights & Permissions [Opens in a new window]

Abstract:

NASA has put people in unique and extreme environments for over six decades. Supporting these individuals with a comprehensive health-care system has evolved over this period. As the Apollo program ended and NASA began to contemplate a space shuttle and space station program, societal pressures in the late 1960s and early 1970s caused federal agencies such as NASA to reconsider how to link the needs of the space program with a growing pressure to address societal needs by forging interagency partnerships. The Space Technology Applied to the Rural Papago Health Care (STARPAHC) project provides an example of how NASA sought to balance these two imperatives in an age of diminishing federal support. This project can provide lessons for today’s uncertain budgetary future for agencies such as NASA, which are once again being asked to find creative and innovative ways to support their missions while demonstrating their larger value to society.

Keywords

TelemedicineNASASTARPAHCNative American HealthPublic-Private Partnerships

Information

Type
Article
Information
Journal of Policy History , Volume 32 , Issue 1 , January 2020 , pp. 25 - 51
Copyright
© Donald Critchlow and Cambridge University Press 2020

Only a few months after the triumph of the Apollo 11 mission, the National Aeronautics and Space Agency (NASA) found itself at a crossroads. For much of the previous decade, the Agency and its staff had tirelessly worked to fulfill the 1961 pledge of a lunar landing by the late President John F. Kennedy. With that goal achieved, bureaucrats, elected officials, scientists, representatives from private industry, and citizens all jockeyed to advance their positions on NASA’s future priorities. Many of these stakeholder groups were particularly interested in refocusing at least a part of NASA’s energy away from the stars and toward a pressing set of social problems back on Earth.Footnote 1 NASA’s involvement during the 1970s in interagency health programs such as the Space Technology Applied to Rural Papago Health Care (STARPAHC) built off the intertwined Great Society ideas of health, economic justice, and social equity, as well as seeking to demonstrate the agency’s value to American society far beyond its traditional focus on space exploration.Footnote 2 Recent aerospace historians have enriched our knowledge of how NASA both sought out and reluctantly accepted a larger social role, but NASA’s influence on health equity, however, has not received as much attention.Footnote 3

This article focuses on how efforts to improve health among the isolated Papago people of Arizona became an important point of intersection between NASA, the Department of Health, Education and Welfare (HEW)’s Indian Health Service (IHS), private defense contractors, and Native Americans.Footnote 4 While much of the federal government’s health care research after World War II focused on funding treatments and cures for specific diseases through grants administered by the National Institutes of Health, programs such as STARPAHC represented a complementary effort to improve the delivery of health care to help make the results of disease-specific research available for the public.Footnote 5

Building off a long tradition of public-private cooperation in both space-related and health science research, officials at the White House and administrators at NASA and HEW understood that a robust cooperative effort with the private sector was necessary to improve health-care delivery, especially around new areas like telemedicine, in order to build and maintain capacity through the creation of communications networks, mobile health clinics, and the training of health professionals. At NASA, this multistakeholder partnership enabled the agency to advance its own technology development goals while helping to serve a broader national interest. Thus, the STARPAHC story highlights cooperative efforts among the federal government, citizens, and private industry to improve health-care delivery for a vulnerable Native population during the twilight of the Great Society. The Papago are now known as the Tohono O’odham people, but we have chosen to use the Papago name to keep the terminology consistent with how our historical actors would have described themselves and the tribe.

We also hope the STARPAHC case study of multistakeholder cooperation helps to inform the present. Currently, NASA is once again in a time of institutional change after the end of the Space Shuttle program, with the agency’s reliance on Russia to transport astronauts to the International Space Station, and eagerly awaited commercial crew capability. The way NASA leaders previously thought about its mission and potential larger contributions to society may offer its current leaders a new set of ways to think about NASA’s terrestrial contributions for the twenty-first century. Ultimately, STARPAHC illuminates a key feature of these multi-stakeholder partnerships that made for successful public policy—each was driven by a blend of altruistic goals and immediate self-interest that shaped the project outcomes in ways that were wholly unpredicted by participants and are still being felt today.

Native American Health and Space-Related Health Technology

Beginning in the 1940s, a perceived shortage of health care facilities and health care providers encouraged the federal government to pass legislation such as the Hill-Burton Act in the hopes that an increased supply of both would mean better health for all Americans.Footnote 6 By the mid-1960s, this model reached its fullest expression under President Lyndon Johnson’s Great Society.Footnote 7 Increasing the supply of hospitals and medical professionals was politically viable, but it was also costly and labor intensive, especially when extending better facilities and care to traditionally underserved populations such as rural and Native Americans. Uneven health outcomes undermined the promises of equity and opportunity that underpinned the growth of the liberal state. Thus, a variety of different federal agencies including the Office of Economic Opportunity, HEW, and the IHS focused on providing more and better health care to underserved populations.Footnote 8

Native American health was especially challenging, since it was intimately linked to the larger question of how the relationship with the federal government would be defined in its policy toward Native American tribes; a policy that, while frequently oppressive, also struggled to reconcile tribal demands for political independence and cultural respect. Health care was an important ground on which this complex relationship was articulated. After the Civil War, the federal government built a number of hospitals for the tribes.Footnote 9 The 1934 Indian Reorganization Act tried, with limited success, to balance the “conflicting goals of Indian autonomy and assimilation.”Footnote 10 In 1953, the U.S. Congress passed Public Law 280, which aimed to integrate Indians into broader U.S. society and forced Native Americans to be ruled by state laws. Neither the individual states nor the tribes were enthusiastic about this “termination” policy; since no additional funding was provided to the states for Native peoples, it removed federal recognition of the tribes, and it minimized the trustee role of the federal government.Footnote 11 This policy was eventually replaced by self-determination under the Nixon administration in an effort to find a middle path between termination and excessive dependence.Footnote 12 Even in the midst of termination policy, Native American health care still was an area of federal concern. In 1955, the IHS was established within HEW. This agency built on earlier efforts by the Public Health Service and the Social Security Administration to address Native Americans’ medical needs.

Even though the IHS assumed a primary role in providing health care on reservations, its mission was often complemented by efforts from a range of other federal agencies concerned with health and antipoverty efforts.Footnote 13 Dr. James Shaw, the first IHS director, who served from 1955 to 1962, focused on improving clinical-care and prevention programs as well as reducing the gulf between patients and medical facilities. From 1962 to 1965, Dr. Carruth Wagner, the second IHS director, emphasized training and management skills for all IHS personnel. Under Dr. E. Stuart Rabeau’s leadership from 1966 to 1969, the IHS instituted an innovative training center for Native Americans to take on more health-care responsibilities in their communities. Rabeau also believed in the use of scientific data in decision-making and created the IHS’s Office of Research and Development (ORD), which took on an important later role with STARPAHC.Footnote 14

By the late 1960s, Rabeau and other IHS officials understood that interagency cooperation was essential. IHS’s 1970–75 strategic plan claimed that “it is no longer possible or realistic for a single agency to develop broad-based program plans within a vacuum for the Indian community. An agency must take into consideration the entire spectrum of federal, state, local, and tribal governmental resources, along with those of the private sector, that have relevance to its program efforts.” This same plan also argued: “The mission is to assure a total health services system for meeting the needs of Native American and Alaska Natives. The goal is to raise the health level of the Native American and Alaska Native people to the highest possible level. The objectives for achieving this goal are to be accomplished emphasizing Indian [and] Alaska Native involvement and participation to the fullest extent with full utilization of available public and private resources.”Footnote 15 In recent years, the literature on IHS history and the often-contested Indian-federal relationship has expanded.Footnote 16

Despite the creation of the IHS, health disparities remained far more pronounced for Native peoples. In 1969, for example, the rates of accidental injury and death were substantially higher among Native Americans and Alaska Natives than among the general population, infant mortality after leaving the hospital was higher than the general population, and life expectancy was nearly six years lower. High rates of infectious diseases such as tuberculosis also posed a continuing threat to Native American and Alaskan Natives’ health.Footnote 17 Health disparities and improving health care for Native Americans more generally became important rallying points for tribal activists and more radical groups such as the American Indian Movement (AIM).Footnote 18 Both groups understood that the linkage of health and economic opportunities was essential for Native peoples to build social and economic equality.

Efforts to improve the health of Native Americans intersected with a larger push to share technology and management structures across the federal government and throughout private industry that reached a crescendo during the final years of the Great Society. The Federal Council for Science and Technology brought together a range of agencies including NASA and HEW to “promote cooperation in planning Federal R&D (research and development) programs by the agencies, and to assist in advancing and strengthening the scientific efforts of the U.S.”Footnote 19 The embrace of systems planning offered tribal leaders and federal health officials another potential path for helping to narrow these health disparities. This also opened the door for the federal government to outsource some of the technical work of creating these new types of solutions to private-sector partners such as Boeing, General Electric (GE), and Lockheed Missiles and Space Corporation (LMSC), since each of these companies had extensive experience with systems planning and project management that complimented the efforts that agencies such as NASA and HEW had with managing public outreach and citizen participation.Footnote 20

In September 1969, another high-level coordinating body, the Space Science and Technology Panel of the President’s Science Advisory Committee, submitted a report titled “The Next Decade in Space.” This report, which was made public the following year, noted that NASA was facing two key questions: (1) “how shall the Nation use these new space capabilities?” and (2) “in which direction shall these capabilities be expanded for the future?” The answer, at least according to this group, was to recommend that “the Nation’s program for the next decade in space focus on the advantages that space abilities can bring to the peoples of the world. Emphasis should be placed on reaping the rewards in terms of basic new scientific knowledge and applications of value to man’s life on earth.”Footnote 21

How effective advisory bodies such as the President’s Science Advisory Panel and the Federal Council for Science and Technology were for sharing information is unclear, especially for a complex issue such as health care. For example, as part of the annual budgetary process, members gathered to hold “preview days,” which allowed White House officials to get a sense of what projects or areas were important for each agency. Preview days also provided an opportunity for agencies to get a sense of what other parts of the government were working to find areas of potential collaboration. However, in a 1971 memorandum for the record written after observing the FY 1973 Office of Science and Technology Heath Services Preview Day, General J.W. Humphreys, M.D., NASA’s Director of Life Sciences, noted that simply bringing groups together did not mean they always shared the same definition of how to advance a singular idea. “It became apparent,” he noted, “that there is no health care system in the context that NASA uses the term within the civilian sector in the United States. Each agency is dreaming up components and testing them mostly without any measurement of the effectiveness except subjective ones.” This lack of uniformity meant, lamented Humphrey, that “R&D in health services delivery terms really means to think up an idea and then demonstrate it.”Footnote 22

Humphrey’s observation about the understanding by many federal agencies, with regard to the new meaning of R&D, was particularly important for building health system capacity. The use of numerous small-scale demonstration projects, designed to test a particular piece of technology or management idea, was an important way that private and governmental actors advanced medical knowledge. A project-based approach to research and development had several advantages over a high-level interagency cooperation. One of the most important was that it provided a tangible link between federal agencies, the private sector, and the on-the-ground constituency that was looking for specific services. Moreover, a project-based approach provided measurable outcomes and the opportunity to hone specific technologies. When all of these were taken together, especially when projects or technologies brought jobs or measurable health improvements to specific congressional districts, they provided an impetus to continue to develop certain areas over others.

After setting NASA on a path to the successful Apollo lunar landings, NASA Administrator James Webb resigned in 1968 and was succeeded by Thomas Paine. Paine was in charge when the Space Task Group submitted its report in September 1969 outlining three potential major new directions for NASA in human spaceflight (Space Shuttle, space station, and an expedition to Mars), but there was only funding for the Space Shuttle Program. But even immediately after the triumph of the July 1969 Apollo 11 lunar landing, NASA officials realized that they would no longer have a bottomless checkbook. Turnover in the Administrator’s suite (Paine was succeeded by James C. Fletcher in April 1971), combined with some institutional soul-searching, meant that NASA was surveying a variety of options for its next major program.Footnote 23

Telemedicine as a Solution to Terrestrial and Space-Based Health Issues

The focus on telemedicine as a shared solution for health issues in remote rural areas and in space started with several successful demonstration projects in the 1950s and 1960s in Nebraska, Massachusetts, New Hampshire, and Vermont—all of which gained national attention for their use of television and/or microwave communications technology to provide medical education, remote diagnosis, and consultations.Footnote 24 The limited size of these demonstration projects, however, meant that none by itself became an important node for developing the type of scale needed for a larger national demonstration of the potential of telemedicine.

While NASA did not have a large interest in the improving the health of underserved populations during the 1960s, the agency did enter the 1970s with a long-standing interest in remote health monitoring and satellite communications, much of which was a legacy of several successive human space programs. Promoting telemedicine activities on Earth, while planning for future human spaceflight, appeared to be one of several ways that the agency could meet both its own future program goals and the challenge laid out by the Space Science and Technology Panel and other actors within the Nixon Administration who were encouraging a more practical return on investment for space science.Footnote 25 In other words, NASA’s interest in telemedicine in the early 1970s was twofold: improving remote health care for crews in space and to retain societal relevance by contributing to health care for underserved populations.

With the launch of the Applications Technology Satellite (ATS) communication satellite (ATS-1) by NASA in 1966, and the subsequent experiments conducted cooperatively by the agency and HEW to improve rural health, the potential scale for telemedicine projects were greatly enlarged. At first, it was not clear what role this satellite would play in telemedicine promotion—it was not until 1971 that ATS-1 was used to connect nine isolated Alaskan villages with physicians located far outside the range of the two-way radio communications system that had been previously used.Footnote 26 This meant that tribal community health aides could gain access to cutting-edge health knowledge and specialist services. According to telemedicine scholars and practitioners Rashid L. Bashshur and Gary W. Shannon, the ATS experiment, despite “its limited capacities,” nevertheless resulted in more contact between the villages and doctors and more “episodes of illness” being diagnosed than in the four villages (control group) where satellite ground stations were not installed.Footnote 27

The launch of ATS-6 in the spring of 1974 intensified the interagency commitment to satellite-oriented telemedicine. Much larger than the ATS-1 satellite, ATS-6 allowed for the transmission of video and spawned the Health Education Technology (HET) experiments. This package of experiments included a strengthened commitment to the ongoing Alaska projects, as well a range of other experiments, including the use of video for medical education in Appalachia on the West Coast.Footnote 28 Later in 1974, NASA announced that ATS-6 would also participate in the joint U.S. and Soviet Apollo-Soyuz mission helping to “provide data, voice and television coverage from Apollo for more than half of each orbit.”Footnote 29

There was also a public relations benefit that came with these programs, which helped each agency to appeal to appropriators. Elected officials and the general public praised NASA and its partners for the ATS-6 and the HET experiments. On March 21, 1975, Senator Hubert Humphrey (D-MN) entered a brief statement and article about the ATS program into the Congressional Record. Humphrey was not the only member of Congress to call attention to the relationship between ATS, interagency cooperation, and telemedicine. Senator Frank Moss (D-UT), Senator Walter Mondale (D-MN), and Representative Olin Teague (D-TX) all made mention of it in the Congressional Record during 1974 or 1975. Often accompanying these mentions were reproductions of articles designed to inform the public about the program.Footnote 30

A critical reason why the HET experiments were greeted with enthusiasm by elected officials, agency staffers, and the private sector is that they reinforced the role of the state as a provider of services for Americans left outside the rising tide of prosperity, while simultaneously paralleling the rethinking of the federal–state private-sector relationship that occurred as the Creative Federalism of the Johnson years transitioned to the New Federalism of the Nixon Administration.Footnote 31 By bringing together federal, local, and tribal actors into a shared conversation with the private sector, new solutions to the nagging health-care inequalities that marred full citizenship were not just possible but were actively being created. Moreover, a cooperative model that spread out the costs and the benefits was attractive in an age when budgets were being cut and missions were being shrunk as the postwar exuberance of the 1950s and 1960s started to meet the harsh realities of the changing global economy of the 1970s.Footnote 32

The HET experiments were not the only way that NASA was interested in utilizing telemedicine during the 1970s. The Integrated Medical and Behavioral Laboratories and Measurement Systems or (IMBLMS) program was evolving along a separate track and was designed to test how to transmit health information back to Earth during human spaceflight. IMBLMS was developed and managed at NASA’s Manned Spacecraft Center (later the Johnson Space Center) in Houston and had evolved in several phases since 1965.Footnote 33 With much of the hardware development work moving along at a sufficient pace during the late 1960s, NASA and its contractors were anxious to move forward with the third phase of IMBLMS—finding a terrestrial test bed. However, the process of creating a proposal to move to this phase took several years. By the early 1970s, when the formal plans to create an external request for proposal were being finalized, the political and social climate surrounding programs such as IMBLMS had evolved away from one that simply sought technical solutions to one that sought to link the development of new technologies to social progress.Footnote 34 And while ATS, and IMBLMS in its earliest iteration, was not tied directly to Papago health, nevertheless it helped to demonstrate the way that interagency partnerships could address the health of vulnerable populations—an important goal for Great Society health programs while at the same time helping to develop the technology needed for continued space exploration (See Figure 1).

This direct tie between NASA’s telemedicine efforts and the health of the Papago would soon change as the agency sought to find a terrestrial test bed for the technology. In fact, IMBLMS soon became an important point of cooperation between NASA and other agencies concerned with the potential of telemedicine. Like the ATS program, which involved sharing NASA technology (in this case satellite access) with HEW to address rural health needs, testing IMBLMS technology in a terrestrial setting could also help to improve potential health outcomes for underserved populations. Moreover, as a member of high-level technology transfer bodies within the federal government and the private sector, NASA’s plans to develop telemedicine capacity were well known, and while this occurred several months before formal pressure from the Nixon White House emerged to document interagency cooperation, it is likely that senior staff at both agencies knew that this would be a priority of the president.Footnote 35

Following a January 1971 National Academy of Engineering (NAE) meeting, NASA and HEW attempted to define their working relationship around IMBLMS. Making these relationships work among different agencies, private contractors, and Native Americans required a delicate balancing act. The transition between the technology development phase and the terrestrial testing phase of IMBLMS makes this clear. In 1971, NASA issued a Request for Procurement Approval Plan, which was designed to start the process of site selection. In this document, procurement officers noted that “the performance of the Phase B contracts the above firms [GE and LMSC] has placed them in a preeminent position as they are the only firms to have conducted development on the systems concept of IMBLMS.”Footnote 36

In April 1972, NASA and HEW representatives developed a general framework for what type of data they should collect on each site. The extensive list was divided into four main categories: (1) Geographic Data, (2) Population Characteristics, (3) Existing Health Facilities, and (4) Area Facilities. Each category included breakdowns of climate features, population demographics, existing hospitals, and economic development data.Footnote 37

At a higher policy level, on June 9, 1971, Deputy Administrator George Low directed Edgar Cortright, the director of the NASA Langley Research Center, to conduct a study on what nonaerospace technological problems NASA might best tackle and to report back within a month.Footnote 38 Cortright finished his study in late June and concluded that NASA could indeed contribute to many nonaerospace technology areas, including environmental monitoring, health-care services, transportation needs, and urban needs.Footnote 39 NASA chose to direct attention to high-technology and system design in the arenas of health care and housing. The next month, NASA Administrator James Fletcher sent an internal NASA report, entitled “Applying NASA Capabilities to National Goals,” to Donald Rice, the head of the Office of Management and Budget, to pass along to Nixon adviser John Ehrlichman.Footnote 40

The next year, a June 1972 letter from NASA Johnson Space Center Director of Life Sciences Richard Johnston noted, “In attempting to develop our relationship with the Department of Health, Education, and Welfare, I am suggesting that we invite them to take the lead in site selection activities.”Footnote 41 A joint site selection board with representatives from the two agencies was convened in late 1972 with a “final decision by the Administrator, Health Services Mental Health Administration,… expected about February 5, 1973.”Footnote 42 This meant that HEW would act as “a single point of contact for IMBLMS site selection” and should “designate a preferred site.” Moreover, MSC proposed that HEW personnel chair the site-selection working group and serve as a co-chair, along with Dr. Charles Berry from NASA, of the full site-selection board.Footnote 43 Thus, the White House, NASA, and HEW were able to point to ATS satellites as an example of interagency cooperation in a cost-effective manner to expand health-care access for vulnerable populations. Moreover, NASA was also able to use its success in telemedicine to make a case for why testing IMBLMS mattered for the future of the agency.

While early documents specified that GE and LMSC were going to do the site-section work, several more companies became involved, including IBM and Boeing. LMSC and Boeing emerged as the primary contractors for site selection with Boeing conducting preliminary identification of potential sites and LMSC helping to create the evaluation process for a “a joint NASA/DHEW site selection board,” which “was chosen in June, 1972.”Footnote 44 By November 1972, a HEW-led model for site selection was in place. Wilson was named the chair of the site-selection working group, which “developed detailed requirements for a test site,” presumably with the input of the Boeing and LMSC report. Regional HMSA offices were responsible for distributing the criteria to potential communities of interest. NASA retained an important role, with representatives on both the site-selection working group and on the final site-selection board, including both Berry and Richard Johnston from NASA.Footnote 45

One of the key questions that emerged was what criteria would be used to select a terrestrial testbed. Since both NASA and HEW were involved, the site had to meet both agencies’ operational goals, which included not just a remote location where telemedicine could be of actual service, but one where health disparities existed and a demonstrated case for improving health outcomes could clearly be made. Even though Boeing was not responsible for the final location decision, its report did spell out many of the criteria that the site selection board would eventually use to choose the Papago Reservation in southern Arizona as the terrestrial test. Boeing’s criteria for effectiveness in a potential test site included robust community cooperation with both patients and health-care providers, and the community’s willingness and ability to absorb the project’s costs after two years. The company’s ideal site would have moderate weather year-round, with existing roads and utilities. A minimum population of approximately ten thousand residents was deemed necessary to ensure the validity of the pilot project, with about twenty daily patients for the mobile unit and forty for the satellite clinic. Trained medical and information technology professionals needed to be already available, of course, as well as a hospital with an emergency room. Further, line-of-sight communications with a minimal number of relay stations was a technical requirement. Not least, under the “mores and folkways” heading, the Boeing report called for a population that was “generally desirous of western medical care.”Footnote 46

On the Ground with STARPAHC

In the 1960s and early 1970s, the Papago reservation in Arizona was approximately 4,300 square miles, with a population of about eight to ten thousand people spread among seventy-five small villages (see Figure 2).Footnote 47 There was no public transportation on the reservation and only a small number of residents owned cars or trucks.Footnote 48

Fig. 1.

IMBLMS mission logo (Source: NASA).

Fig. 2.

Papago Indian Reservation, Southern Arizona (Source: Google Maps).

The Papago tribe had gained a special reputation for addressing its own health care needs. This was attributable largely to tribal chair Thomas Segundo. Based in part on his initiative, the tribe and the IHS established a Community Health Representative (CHR) program nationally in 1968.Footnote 49 The CHR program also drew on a prototype effort involving the Northern Cheyenne, which provided that tribe with its first full-time staff of health professionals. It was designed to go beyond a transfer of responsibility for health care and reflected the larger goal of Native American self-determination, also in keeping with AIM.Footnote 50 These CHRs “served as guides or cultural interpreters,” given the rather different attitudes toward health and medical care among Native American and “Western” cultures. This blending of traditional and Western medicine dramatically helped to improve health outcomes on the reservation including public health indicators such as increased life span and decreased infant mortality.Footnote 51 It was also a success in that hundreds of CHRs from more than sixty-five tribes were rapidly trained and employed in their communities. The CHR program helped HEW to counter its reputation as imposing policy from the top down by showing that the agency could embrace culturally relevant care processes.

The CHR program was only the start of a concerted effort by the Papago to address health disparities. For the next several years, the tribe built health programs that focused on nutritional improvement, mental health, alcoholism, and ear infections (later expanded to a more comprehensive program focused on “on identifying and attacking endemic and epidemic diseases”). Each of these programs eventually established a cooperative framework “based on the traditional Papago group decision-making process, whose primary objective was consensual agreement of all concerned parties. It was called the Bith Haa, literally clay or cooking pot.” According to Rashid Bashshur, the tribe’s Executive Health Staff owes at least part of its genesis to the Bith Haa model.Footnote 52 Moreover, it was the presence of this strong health staff, overseeing existing programs aimed at improving the tribe’s health, that provided at least a partial justification for NASA’s decision to locate STARPAHC on the reservation.Footnote 53

Even before STARPAHC, the Papago already had some experience with telemedicine. In 1971, the University of Arizona had conducted a short-lived telemedicine project that was funded by the U.S. Office of Economic Opportunity.Footnote 54 From January 1972 to June 1973, this project was to link five of nine reservations throughout Arizona to a hub in Phoenix, and eventually to the medical facilities at the University of Arizona in Tucson. The goals were to demonstrate the feasibility of telemedicine in Arizona and to apply advanced communications technology to problems of health in rural and geographicallly disperse areas.Footnote 55

Boeing had identified the reservation as one of several potential sites of interest in its report, and it appears that representatives from NASA did visit in the spring of 1972.Footnote 56 The response to the site by Boeing appeared to be lukewarm. The site-selection report cautioned, “It is technically feasible to test IMBLMS… at this site. It should be noted, however, that due to the remote location and limited local facilities such as telephone, power, and other supporting facilities normally available in the civil sector, additional expenditures are required if this site is chosen.”Footnote 57 That fall, the head of the IHS’s Office of Research and Development and the Papago chairman jointly submitted an application to be considered as an IMBLMS test site.Footnote 58

Papago tribal leaders visited sites in Boston and NASA MSC in Houston as a step in solidifying the tribal leaders’ decision. In late March 1973, NASA and HEW managers notified Papago tribal leaders that their site had been selected.Footnote 59 IHS head Emery Johnson believed that ORD’s track record of good cooperation with the Papago made those groups key.Footnote 60 While the area was quite remote, physician assistants were already available and were legally and culturally accepted. There was a definite medical need, and thus potential to improve significantly the overall public health of the Papago. Basing the project there also seemed financially feasible.Footnote 61

On April 17, 1973, HEW Secretary Caspar Weinberger announced that the Papago site had been selected for this telemedicine partnership and the project name became STARPAHC. Within a few weeks, the Papago Tribal Council passed a formal resolution to implement STARPAHC. It took some time for the project to be staffed and trained appropriately, and to get its technology up and running, so the project did not begin operations until May 1975.Footnote 62

STARPAHC was planned to have two years of design, assembly, and testing and then two years of operations and evaluation. Officials initially envisioned terminating the STARPAHC experiment at the end of 1976, but it lasted another four months to the end of April 1977, when NASA transferred responsibility to IHS OR&D. Rabeau had previously written to Norm Belasco, the NASA STARPAHC Project Officer, promising to pick up funding.Footnote 63 Compared with other, much larger aerospace projects, the funding for STARPAHC was a relatively modest $4.2 million. NASA agreed to spend $3.35 million, IHS ORD contributed $868,000 for medical equipment, and a $37,000 grant from HEW. (HEW intended to augment that with an additional $400,000, which would have brought the total to $4.6 million).Footnote 64

The project promised a more substantial involvement by specific federal agencies toward building a durable health infrastructure on the reservation. LMSC’s original concept was to create Area Health Services Field Units (AHSFU) for local use, and then combine these in a national network.Footnote 65 While the AHSFU concept was never fully implemented, it did, however, result in the IHS training more Native Americans to fill health-care roles in the field.

As built, STARPAHC consisted of four main physical components on the ground: (1) the control center at an IHS hospital in Sells, Arizona, (2) a clinic in Santa Rosa, Arizona, (3) the Mobile Health Unit (MHU), and (4) a referral center at an IHS hospital in Phoenix. A relay station was also constructed on Mount Quijotoa. Built in 1960, the Sells hospital had approximately forty beds to serve the Papago community, spread over about 3 million acres. Equipped with an emergency room and an outpatient clinic, hospital staff also referred patients for more specialized care or to nursing facilities. It also had an established, solid working relationship with the IHS Office of Research and Development.Footnote 66 Santa Rosa is approximately thirty-five miles north of Sells, both within the reservation, while Phoenix is about one hundred miles North of Santa Rosa. Sells had a population of less than three thousand but was considered the tribal capital.Footnote 67

The heart of STARPAHC was the MHU, which the Papago Executive Health Council helped design (see Figure 3) and which a Papago Community Health Medic (CHM) typically staffed. The MHU was a large mobile home that was specially outfitted with equipment such as an exam table, x-ray machine, basic laboratory instruments, including a microscope, and refrigerator that was driven around the reservation as needed.Footnote 68 It also changed the relationship between patient and provider—now the provider could come to the patient, helping to make routine screenings and preventative care a more important part of the patient’s overall health. In addition, the frontline provider was a native Papago, ensuring cultural sensitivity with more specialized medical expertise available remotely. One of the first two Papago CHMs became the first provider to run the MHU; STARPAHC provided a modicum of professional health care training and career opportunities for the Papago.Footnote 69 Moreover, the technology did not fully keep pace with the expectations. For example, in the mid-1970s, it took approximately 90 seconds to send an x-ray via the phone line, but it was clear.Footnote 70 As a presentation from NASA medical officers noted, “The projected level of health care available from the field unit may be favorably contrasted with that now generally available to the average citizen of our country. It far exceeds that available to most persons in rural or remote areas and that available to many of those in the inner cities.”Footnote 71

Fig. 3.

STARPAHC Mobile Unit (Source: NASA).

The deployment and operation of STARPAHC had both positive and negative outcomes. For example, NASA gained significant understanding of how the telemedical technology could be deployed and used, which was extremely valuable to NASA’s efforts to push the boundaries of human space flight. The lessons learned served as a platform for future telemedicine initiatives domestically and internationally. But, as with any large-scale project, STARPAHC also had some downsides. Detractors claimed that it was too costly and complicated. In fact, several years after the project had concluded, Higgins et al. noted that the costs based on the initial investment were higher per visit—34 percent higher—when using the Mobile Health Clinic.Footnote 72 In addition, some providers felt the equipment was unreliable and interrupted the normal workflow.Footnote 73

Among the Papago, there were other complaints. A 1975 letter from the tribe’s new vice chairman, Michael Rios, to NASA’s Richard Johnston echoed the “guinea pig” language used by the press. In a disheartened closing paragraph, Rios claimed: “But STARPAHC is here, thanks to ORD, and the proud Papago people are here. I guess to be used as ‘guinea pigs’ in the interest of science and mankind. So we’ll have to learn to live with it for 2 years or more, just as we have learned to live with (Dr. [Stuart] Rabeau) the famous ORD [Indian Health Service Office of Research and Development] and its INTERESTING projects.” Earlier in the letter, Rios had made additional “demands” from NASA: that the agency pay for more ambulances and train the Papago health professionals; and, at the Sells hospital, purchase updated technology for project ambulances, and set aside 10 percent of the total “project cost… toward the establishment of a Papago Health Services Education Program.” Part of Rios’s concern was that the program was not providing adequate economic mobility for members of the tribe that would last beyond the STARPAHC. Another part of his concern was that more Papago health professionals, trained on NASA dollars, could help provide a legacy of culturally competent care.Footnote 74

Johnston’s response to Jacob Escalante, the tribal chair, about Rios’s letter was sympathetic but firm—the agency was doing everything it could to promote Papago health, and while several tribal members had been hired to staff various parts of the project, “funds were and are limited.” STARPAHC was an opportunity for the tribe, argued Johnston: “All of the equipment in STARPAHC has been tested and used successfully in medical/health settings prior to STARPAHC. The new aspect of STARPAHC is that no other telemedicine project is so extensively equipped and geographically dispersed. The Papagos, for a change, will be the first beneficiaries of a system of communication to support improved health care.” As for the issue of employment and its lasting impact, Johnston deferred, noting that national legislation on health-professional training was being considered by Congress.Footnote 75

Medical privacy was another concern, one that foreshadowed more current issues about electronic health records in the digital age. ORD worked with the Bell Aerospace Company to set up an early Health Information System (HIS) that enabled IHS medical practitioners to maintain more comprehensive medical records for Papago patients, an advantage for the providers, but the Papago were concerned that their medical histories would become virtual open books.Footnote 76 Another broader concern was that Rabeau and ORD often instituted programs that were technically solid but that did not necessarily meet tribes’ needs per se. In this light, STARPAHC was a prime example of a “technology push” effort that was overkill and not cost-effective.Footnote 77

In February 1976, Ralph Antone, a member of the Executive Health Staff, responded to charges that the tribe was being treated like a “guinea pig,” or were being “ripped off” by NASA and HEW: “Those ‘bleeding hearts,’ he chuckled. ‘If there is anyone getting ripped off, it sure isn’t my people, it’s the government. We are getting the best health care available for free. How is that a ripoff?”Footnote 78 Antone’s sentiments were the result of a planning process that worked hard to integrate the tribe at each step. In fact, as Bashshur’s evaluation of the project notes, tribal representatives had a substantial amount of control over the planning, and even the administration of the program, including controlling access of nontribal members of the project team to the reservation itself. Tribal representatives worked to help protect sacred sites on the reservation and to blunt the physical impact of the technology by being involved in the road-construction process and infrastructure maintenance. The tribe also had final sign-off on public relations efforts, including photos and press pieces promoting the project.Footnote 79

Conclusion

While STARPAHC was a notable, little-known example of telemedicine research, it was also a significant, early attempt to utilize interagency cooperation to improve health outcomes for a minority population, as well as to justify NASA’s continued investment in technology designed to support new frontiers in human spaceflight. From a policy-history perspective, perhaps the key feature of STARPAHC was the innovative interagency and intercultural collaboration among NASA, IHS, the Papago, and LMSC. The STARPAHC case study has particular resonance to NASA’s current situation. In 2011, the Agency ceased Space Shuttle operations and currently has no way to launch humans into space from U.S. soil (NASA relies on the Russian Soyuz launch vehicle to send astronauts to the International Space Station). With the lack of this high-profile capability, some analysts decry the lack of a clear mission for NASA, just as the early 1970s was a time of extended transition for NASA.Footnote 80

Assessing the benefits and costs to its individual partners is more complex. For the Papago, the program provided a modicum of access to modern scientific medicine in a remote location, jobs, and infrastructure investment. However, many Papago found the attitudes of IHS, NASA, and LMSC personnel to be patronizing and culturally insensitive. From the NASA perspective, a relatively small amount of funding enabled some early telemedicine research and some initial forays into going beyond its “core mission” of aerospace research and development to technology transfer that served other social purposes. STARPAHC may well have been seen by many NASA personnel as an opportunity to “kill two birds with one stone.” NASA biomedical personnel understandably wanted ways to monitor astronauts’ health remotely, but the agency’s capabilities to do so before the digital revolution were decidedly limited. The remoteness of the Papago community represented a good technical opportunity to test such systems on the ground. Second, the opportunity to provide a tangible benefit to the Papago also was appealing. Thus, STARPAHC indeed may be considered a case of technology push with good, although not altruistic, intentions.

For IHS, it was a “resounding success” in delivering health care to remote populations that lacked physicians. STARPAHC set the stage for forty IHS telemedicine programs as of 2007, making telemedicine one of its most important contributions to Native American health.Footnote 81 And for private contractors, this relatively small project turned out not to be a gateway to other projects outside its aerospace and defense traditional area of expertise. Of course, STARPAHC participants could hardly have imagined how telemedicine would expand tremendously with the advent of the internet in the late twentieth and twenty-first centuries.

Even before the Apollo Moon landings concluded in 1972, NASA personnel and others were reassessing the agency’s raison d’être and looking for compelling new missions. The Nixon Administration’s notion of “applying NASA capabilities to urgent national needs” gained favor within Washington, DC, and was a partial precursor to the notion of “technology transfer” approximately two decades later. Thus, the political and cultural times presented a “policy window” that could be a “win, win, win” for NASA, the IHS, and the Papago.Footnote 82

STARPAHC is also a notable and early case study in what is now termed “stakeholder engagement.” Again, cooperation with the Papago was particularly attractive because they were and remain a small minority population (a tribe of approximately ten thousand people) within another minority (Native Americans). Since the 1970s, NASA and the federal government writ large have gradually prioritized “outreach” and improving relations with all sorts of minority populations. Moreover, NASA has a long history of engaging international partners and this necessitates sensitivities toward different cultures.Footnote 83 Working with the Papago on STARPAHC, NASA personnel soon encountered a whole set of different attitudes toward nature, science, and medicine. This has particular resonance for NASA personnel who have collaborated with Russian colleagues after the end of the Cold War on the International Space Station, an achievement of international cross-cultural cooperation perhaps even more than a technological success. Similarly, public administration scholar W. Henry Lambright notes that while the ambitious goals of the Apollo lunar landing program were certainly technically feasible, achieving these goals was not a given, and the real reason for this program’s success was the successful management of the necessarily large and diverse organizations by NASA administrator James E. Webb.Footnote 84

STARPAHC was neither the bold new frontier of health care that some people envisioned, nor a purely negative example of federal paternalism that its detractors asserted. Ultimately, its policy legacy is best viewed in terms of cooperation with diverse groups of stakeholders more than aerospace research and development, telemedicine, or Native American history. Given declining federal nondefense budget challenges, continually increasing U.S. spending on health care, and increasing interest in “leveraging” federal investments through teaming and cooperative public-private partnerships, the STARPAHC story is worth considering as a small-scale case study that offers some larger instructive insights on creating innovative partnerships when resources are scarce.

Footnotes

The authors recognize the University of Arizona Archives and Drs. Jeremy Greene and Victor Breitberg for their contributions in their efforts in reviewing STARPAHC historical records and oral histories. In addition, we extend our thanks and appreciation to those who participated in STARPAHC and who have studied it over the past five decades. We thank Jeremy Greene for his comments on this article.

Disclaimer: The opinions expressed here are the personal views of the authors and do not represent the views of Duquesne University, University of Cincinnati, or NASA.

References

Notes

1. For a comprehensive overview of how NASA managed the transition post-Apollo, as well as a detailed discussion of stakeholder politics inside and outside of the agency, see Logsdon, John M., After Apollo? Richard Nixon and the American Space Program (New York, 2015)Google Scholar.

2. Paul, Richard and Moss, Steven, We Could Not Fail: The First African Americans in the Space Program (Austin, 2017)Google ScholarPubMed and Maher, Neil, Apollo in the Age of Aquarius (Cambridge, Mass., 2017)CrossRefGoogle Scholar. Some of the most extensive writing about the program has been by Rashid Bashshur, who has not only studied the program but was involved in its assessment for the Indian Health Service. Many of Bashshur’s works are cited in this article’s notes. More recently, the project has received attention from anthropologist Victor Breitberg and historian Jeremy Greene. Both are acknowledged as collaborators and have been helpful in framing some of the arguments presented in this article.

3. For examples, see Glen Asner “Space History from the Bottom Up: Using Social History to Interpret the Societal Impact of Spaceflight,” chap. 20 in Societal Impact of Spaceflight (NASA SP-2007-4801), ed. Steven J. Dick and Roger D. Launius; Laney, Monique, German Rocketeers in the Heart of Dixie: Making Sense of the Nazi Past during the Civil Rights Era (New Haven, 2015)CrossRefGoogle Scholar; Shetterly, Margot Lee, Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race (New York, 2016)Google Scholar; and the proceedings of “NASA in the ‘Long’ Civil Rights Movement Conference,” 16–17 March 2017 (see https://www.nasa.gov/centers/marshall/history/nasa-in-the-long-civil-rights-movement-conference.html).

4. A significant body of practitioner-focused literature on NASA and telemedicine already exists, but there is a dearth of literature with an explicitly historical focus. For recent works on aerospace medicine, see Space Physiology and Medicine—from Evidence to Practice, 4th ed., ed. A. Nicogossian, C. L. Huntoon, R. S. Williams, C. R. Doarn, V. Schneider, and J. D. Polk (Springer, NY, 2016); Williams Sims Bainbridge, “Societal Impact of NASA on Medical Technology,” chap. 2; and Whalen, David, “Societal Impacts of Applications Satellites,” chap. 7, in Historical Studies in the Societal Impact of Spaceflight, ed. Dick, Steven (Washington, DC: NASA SP-2015-4803, 2015)Google Scholar. The history of the relationship of the agency to issues of health was also not a primary focus of the old aerospace history. Two of the earliest books on the subject are Link, Mae Mills, Space Medicine In Project Mercury (Washington, DC: NASA SP-4003, 1965)Google Scholar and Pitts, John A., The Human Factor: Biomedicine in the Manned Space Program to 1980 (Washington, DC: NASA SP-4213, 1985)Google Scholar.

5. See, for example, Starr, Paul, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York, 1982), 343Google Scholar.

6. This legislation provided federal funds to build hospitals as part of a larger effort to increase access for all Americans. See Hospital Survey and Construction Act (Hill-Burton Act, Public Law 725, 79th Congress); Perlstadt, H., “The Development of the Hill-Burton Act Legislation: Interests, Issues, and Compromise,” Journal of Health and Social Policy 6, no. 3 (1995): 77–96CrossRefGoogle Scholar; and “The Hospital Survey and Construction Act: An Editorial,” Journal of the American Medical Association 132, no. 2 (1946): 148–49.

7. Lyndon Baines Johnson, “Special Message to Congress: Advancing the Nation’s Health,” 7 January 1965, https://www.presidency.ucsb.edu/documents/special-message-the-congress-advancing-the-nations-health) accessed 1 February 2019).

8. Harry S. Truman, “Special Message to Congress Recommending A Comprehensive Heath Program,” 19 November 1945 available at https://www.trumanlibrary.org/publicpapers/index.php?pid=483&st=&st1= (accessed 11 January 2019). For several book-length studies of the evolution of the American health insurance and health-care system, see Quadagno, Jill, One Nation, Uninsured: Why the U.S. Has No National Health Insurance (New York, 2005)Google Scholar, and Chapin, Christy Ford, Ensuring America’s Health: The Public Creation of the Corporate Health Care System (New York, 2015)CrossRefGoogle Scholar. For an important overview of the government’s role in providing health, see Shonick, William, Government and Health Services: Government’s Role in the Development of U.S. Health Services, 1930–1980 (New York, 1995)Google Scholar. See Bailey, Martha J. and Danzieger, Sheldon, eds., Legacies of the War on Poverty (New York, 2013)Google Scholar, for a comprehensive overview of the ways that Great Society policies intersected with efforts to build the welfare state. Chapters by Barbara Wolfe, “Health Programs for Non-Elderly Adults and Children,” and Katherine Swartz, “Medicare and Medicaid,” provide helpful overview of health programs, along with Jonathan Engel, Unaffordable: American Health Care from Johnson to Trump (Madison, 2018). An important government program to expand health-care options during this same time period was the Regional Medical Programs, which grew out of efforts to combat chronic disease. See, for example, https://profiles.nlm.nih.gov/RM/ (accessed 11 January 2019). For a more general overview of the American welfare state, see Hacker, Jacob, The Divided Welfare State: The Battle over Public and Private Social Benefits in the United States (New York, 2002)CrossRefGoogle Scholar.

9. Thanks to an anonymous peer reviewer for making this salient general point. In 1888, only four Native American hospitals existed, but by 1922, the total was up to seventy-three. See Rife, James P. and Dellapenna, Alan J., Caring and Curing: A History of the Indian Health Service (Landover, MD: PHS Commissioner Officers Foundation for the Advancement of Public Health, 2009), 5Google Scholar.

10. Walch, M. C., “Terminating the Indian Termination Policy,” Stanford Law Review 35 (1983): 1183CrossRefGoogle Scholar.

11. See, for example, http://www.nativepartnership.org/site/PageServer?pagename=airc_hist_terminationpolicy, and S. E. Ruckman, “Nixon’s Role in Self Determination Focus of Talk,” Native Times, 25 May 2012, available from http://nativetimes.com/index.php/life/people/7232-nixons-role-in-self-determination-focus-of-talk?tmpl=component&print=1&page= (both accessed 3 February 2017).

12. Richard Nixon, “Special Message to the Congress on Indian Affairs,” 8 July 1970, available from http://www.presidency.ucsb.edu/ws/print.php?pid=2573 (accessed 6 February 2017).

13. Department of Health, Education, and Welfare, Indian Health Service, “Program Report and Plan for Indian Health: Fiscal Years 1971–1975,” 31 July 1969 (held by National Library of Medicine, Bethesda) 1–3. (Hereafter referred to as the IHS Strategic Plan. Emphasis in the original.)

14. Executive Summary of The First 50 Years of the Indian Health Service: Caring & Curing (IHS “Gold Book”) available from https://www.ihs.gov/newsroom/factsheets/ (accessed 20 December 2018), 9. This publication was produced to mark the 50th anniversary in 2005, but it lacks a formal date or author. The original “Gold Book” was an IHS report to Congress in 1957.

15. IHS Strategic Plan, 3 and 5. See also Rashid Bashshur, Technology Serves the People: The Story of a Co-operative Telemedicine Project by NASA, the Indian Health Service, and the Papago People (Tucson: Indian Health Service Office of Research and Development, 1980, GPO Report No. 017-028-00009-0). For additional background about the challenges the federal government faced in providing Native American health care, see 32–39.

16. Rife and Dellapenna’s Caring and Curing provides an overview of IHS history. David H. DeJong wrote two volumes on IHS history: If You Knew the Conditions: A Chronicle of the Indian Medical Service and American Indian Health Care, 1908–1955 (Lanham and Lexington, 2010), and Plagues, Politics, and Policy: A Chronicle of the Indian Health Service, 1955–2008 (Lanham, 2011).

17. IHS Strategic Plan, 24–26.

18. Wilkinson, Charles, Blood Struggle: The Rise of Modern Indian Nations (New York, 2005), 129–48Google Scholar, provides a summary and analysis of these AIM developments. Thanks to historian David Kleit for suggesting this excellent source. Also see Laura Waterman Wittstock and Elaine J. Salinas, “A Brief History of the American Indian Movement,” https://www.aimovement.org/ggc/history.html (accessed 6 February 2017.

19. “NASA’s Multiple Interagency Interfaces Blend Know-How Toward Complex Programs,” Aerospace Management (General Electric Co.) 5. no. 1 (1970), copy in General Jacob Smart Bio File, file 2111, NASA Historical Reference Collection. (Hereafter NASA HRC, NASA Headquarters, Washington, DC (NASA HRC).

20. Johnson, Stephen B., The Secret of Apollo: Systems Management in American and European Space Programs (Baltimore, 2002)Google Scholar; Launius, Roger D., “Managing the Unmanageable: Apollo, Space Management, and American Social Problems” Space Policy 24 (2008): 158–65CrossRefGoogle Scholar; and Needell, Allan A., “James E. Webb, Technology, and the New Deal Roots of ‘Space Age Management,’” Technology and Culture (July 2017): 790–814CrossRefGoogle Scholar.

21. Space Science Technology Panel of the President’s Science Advisory Committee, “The Next Decade in Space” (Washington, DC, March 1970), 1. See also Logsdon, After Apollo?, esp. chap. 5.

22. J. W. Humphreys, “Memorandum for the Record, RE: Health Services Preview Office of Science and Technology,” 10 May 1971, in Federal Council for Science and Technology, file 12476, NASA HRC, 1.

23. The executive summary of the 1969 Space Task Group report is available at https://history.nasa.gov/taskgrp.html; information about President Nixon’s Shuttle decision is at https://history.nasa.gov/stsnixon.htm; and dates of service for and biographical information about NASA Administrators and Deputy Administrators are available from https://history.nasa.gov/prsnnl.htm (all accessed 11 January 2019).

24. Bashshur, Rashid L. and Shannon, Gary W., History of Telemedicine: Evolution, Context, and Transformation (New Rochelle, NY, 2009), 156–97Google Scholar.

25. Space Science Technology Panel of the President’s Science Advisory Committee, “The Next Decade in Space” (Washington, DC, March 1970), 1. See also Logsdon, After Apollo?, esp. chap. 5.

26. Doarn, C. R., Nicogossian, A. E., and Merrell, R. C., “Application of Telemedicine in the United States Space Program,” Telemedicine Journal 4, no. 1 (1998): 19-30CrossRefGoogle ScholarPubMed.

27. Bashshur and Shannon, History of Telemedicine, 203–4.

28. The Health Education Experiments have received some attention from historians. See Tess Lanzarotta and Jeremy Greene, “Communications Technologies as Community Technologies: Alaska Native Villages and the NASA Satellite Health Trials of the 1970s,” https://www.technologystories.org/communications-technologies-as-community-technologies-alaska-native-villages-and-the-nasa-satellite-health-trials-of-the-1970s/ (accessed 11 January 2019, and Bashshur and Shannon, 204–6).

29. NASA Johnson Space Center Press Release number 74-264 “NASA-JSC Tests Apollo-Soyuz Satellite Communications Relay,” 22 October 1974, in ATS-6 File, NASA HRC. For more on the relationship to the National Library of Medicine, The National Library of Medicine, “Programs and Services Fiscal Year 1974” at National Library of Medicine, Bethesda, 33–34.

30. Congressional Record, 21 March 1975 (Humphrey); 2 May 1974 (Moss); 31 July 1974 (Mondale); 30 May 1974, and 5 June 1974 (Teague), in ATS-6 File, file #5652, NASA HRC. This is not an exhaustive listing in the Congressional Record.

31. See, for example, Lyndon Johnson, “Memorandum on the Need for ‘Creative Federalism’ Through Cooperation with State and Local Officials, 11 November 1966, available from https://www.presidency.ucsb.edu/documents/memorandum-the-need-for-creative-Federalism-through-cooperation-with-state-and-local (accessed 11 January 2019). Johnson’s successor, Richard Nixon, embraced a different vision of federalism known as “new Federalism.” See Richard Nixon, “Address to the Nation on Domestic Programs,” 8 August 1969, available at https://www.presidency.ucsb.edu/documents/address-the-nation-domestic-programs (accessed 11 January 2019). A fuller discussion of Nixon’s understanding of Federalism can be found in Bruce Katz, “Nixon’s New Federalism 45 Years Later,” The Avenue (Washington, DC: Brookings Institution), available from https://www.brookings.edu/blog/the-avenue/2014/08/11/nixons-new-Federalism-45-years-later/.

32. Cowie, Jefferson, Stayin’ Alive: The 1970s and the Last Days of the Working Class (New York, 2012)Google Scholar, and Stein, Judith, Pivotal Decade: How the United States Traded Factories for Finance in the Seventies (New Haven, 2011) as two examples of the growing 1970s literatureGoogle Scholar.

33. Bashshur, Technology Serves the People, 85; Pitts, The Human Factor, 118 and 166; Pool, Samuel L. and Belasco, Norman, “An Integrated Medical System for Long-Duration Space Missions,” Journal of Spacecraft and Rockets 9, no. 8 (1972): 613–14CrossRefGoogle Scholar.

34. For examples of internal NASA correspondence discussing the movement to phases C and D of the IMBLMS project, see Robert Gilruth to James W. Humphreys, 24 August 1967, in Skylab-856-IMBLMS Correspondence 1967; assorted memoranda related to procurement in Skylab-856-IMBLMS Correspondence 196; Request for Procurement Plan Approval IMBLMS, 10 August 1971 Skylab-856-IMBLMS Correspondence 1971, all in Records of Johnson Space Center, University of Houston Clear Lake.

35. Bashshur, Technology Serves the People, 85, and Logsdon, After Apollo, 200–201.

36. NASA, “Integrated Medical and Behavioral Laboratory Measurement System,” Phase C Procurement Plan, 20 August 1971, 3. Skylab-856-IMBLMS Correspondence 1971, Records of Johnson Space Center, University of Houston Clear Lake.

37. Site Selection Data Sheet 1972. This was sent as an appendix in a reply letter sent to the Galveston, Texas Health Department in April of 1972 by Richard Johnston. The previous month, W. W. Kemmerer Jr., director of the Health Department, sent Chris Kraft at the Manned Spaceflight Center a letter asking if it might be possible to locate the project in Galveston. Craft referred the letter to Johnston, who replied with the list of site-selection criteria and a suggestion that Kemmerer contact Norman Belasco for more details about how Galveston might be considered. See W. W. Kemmerer Jr. to Chris Craft, 27 March 1972, and Richard Johnston to W. W. Kemmerer Jr., 21 April 1972. Both letters are in Skylab-856-IMBLMS Correspondence 1972, Records of Johnson Space Center, University of Houston Clear Lake.

38. Memorandum from George Low to Edgar Cortright, “Broadened Role for NASA,” folder 57, George M. Low Papers, Folsom Library, Rensselaer Polytechnic Institute, Troy, cited in After Apollo?, 183.

39. George Low, “Personal Notes No. 50,” 4 July 1971, and “Personal Notes No. 51,” 18 July 1971, George M. Low Papers, Folsom Library, Rensselaer Polytechnic Institute, Troy, cited in After Apollo?, 200.

40. Edgar Cortright to George Low cover memo, “Applying NASA Capabilities to National Goals” report, 8 July 1971; Cover memo from James Fletcher to Donald Rice, 21 July 1971; and undated, handwritten cover note from Donald Rice to John Ehrlichman, cited in After Apollo, 200. The “Applying NASA Capabilities to National Goals,” memo and related documents come from box 26, White House Central Files, Richard Nixon Presidential Library and Museum.

41. Richard Johnston to NASA Headquarters, RE: IMBLMS Site Selection, 6 June 1972, in Skylab-856-IMBLMS Correspondence 1972, Records of Johnson Space Center, University of Houston Clear Lake.

42. NASA Headquarters News Release, “Remote Health Care Test Site to Be Selected,” 5 November 1972, Release No: 72-210 Skylab-856-IMBLMS Correspondence 1972, Records of Johnson Space Center, University of Houston Clear Lake.

43. Johnson Memo, Skylab-856-IMBLMS Correspondence 1972, Records of Johnson Space Center, University of Houston Clear Lake.

44. Bashshur, Technology Serves the People, 23–27.

45. NASA Press Release No. 72-210, “Remote Health Care Test Site to Be Selected,” 5 November in Skylab-856-IMBLMS Correspondence 1972, Records of Johnson Space Center, University of Houston Clear Lake.

46. Boeing Company, Candidate Site Analyses: IMBLMS Phase C, vol. 1, 2 October 1972, in Bioinstrumentation Box LS163, John P. McGovern Historical Center, HAM-TMC Library, Houston. General Site Selection Criteria. A summary of the site-selection process can also be found in Bashshur, Technology Serves the People, chap. 5.

47. By comparison, Delaware compromises approximately 2,500 square miles of land. See STARPAHC Record of Transfer from NASA JSC to HEW/HIS/ORD document, 30 April 1977, 1 and, for example, http://state.1keydata.com/states-by-size.php (accessed 3 March 2017). Re the Papago population, see, for example, Pool and Johnston presentation to Royal Society of Medicine, Leyden, Netherlands, 11 October 1974, 9.

48. Bashshur, Technology Serves the People, 69, notes that only a quarter of Papago families owned motor vehicles.

49. Mutting, Paul A. and Connor, Eileen M., Community Oriented Primary Care: A Practical Assessment, Volume II: Case Studies (Washington, DC: Division of Health Care Service, Institute of Medicine, National Academies Press, April 1984), 138Google Scholar, and Office of Inspector General, “Revitalizing the Community Health Representative Program” (Department of Health and Human Services, April 1993), 1.

50. Rife and Dellapenna, Caring and Curing, 49.

51. Bashshur, Technology Serves the People, 63, 65, 69.

52. Ibid., 66. Quotes on 66 and 67.

53. Richard S. Johnston to Jacob Escalente, 15 May 1975. STARPAHC archive: records from the Space Technology Applied to Rural Papago Advanced Health Care project, 1970–79, 1991 (bulk 1972–78) (AHSL HT 0001). Special Collections, University of Arizona Health Sciences Library, Tucson, Box 11, Folder 3.34.

54. See Bashshur, Technology Serves the People, 70–71, 77, and Lanzarotta and Greene.

55. Bashshur, Technology Serves the People, 70–71, 77, 73.

56. Boeing Site Selection Report Appendix A to 5-2720-Hou-2-161. John P. McGovern Historical Center, HAM-TMC Library, Houston.

57. Boeing Site Selection Report, 5-2720-Hou-2-161. 31 May 1972. John P. McGovern Historical Center, HAM-TMC Library, Houston.

58. Bashshur, Technology Serves the People, 46–47.

59. Chronology of Events Leading to IMBLMS Site Selection, attachment to 4 April 1973 memo from Charles Berry to George Low, box 4 of STARPAHC/Papago Indians, 1971–75, National Library of Medicine, Bethesda. In this same file, there is a 6 April 1973 letter from David Sencer, Assistant Surgeon General, to Stuart Rabeau, Director of IHS ORD, informing him of this decision.

60. Rife and Dellapenna, Caring and Curing, 77.

61. Memo of 4 April from Chuck Berry to George Low in document 3.54 STARPAHC Record of Transfer.

62. Bashshur, Technology Serves the People, 88–90, 98, 3–8, and Rife and Dellapenna, Caring and Curing, 77–78.

63. STARPAHC Record of Transfer, document 3.54 from University of Arizona STARPAHC files, 30 April 1977, 3, 8 and 38 (Appendix C).

64. Bashshur Technology Serves the People, 90–91, 99.

65. Final Report: Integrated Medical and Behavioral Laboratory Measurement System, vol. 2, System Considerations (NASA-CR-115648, 14 December 1970); Allan R. Coming, “The Era of Telemedicine: Interactive Audio/Video Telediagnosis Is Proven Viable in both Government- and Privately-Funded Experiments,” IEEE Spectrum 13, no. 12 (1976): 31–36; and Samuel L. Pool and Norman Belasco, “An Integrated Medical System for Long-Duration Space Missions,” Journal of Spacecraft and Rockets 9, no. 8 (1972): 613–14.

66. Important Dates Listing following chap. 7, draft history of the STARPAHC project by Rashid Bashshur, box 4 of STARPAHC/Papago Indians, 1971–75, National Library of Medicine, Bethesda; and Paul A. Mutting and Eileen M. Connor, Community Oriented Primary Care: A Practical Assessment, Volume II: Case Studies (Washington, DC: Division of Health Care Service, Institute of Medicine, National Academies Press, April 1984), 137–39.The data from this publication are from about a decade after the STARPAHC project.

67. Bashshur, Technology Serves the People, 10.

68. Pool and Johnston presentation to Royal Society of Medicine, Leyden, Netherlands, 11 October 1974, 9.

69. Bashshur, Technology Serves the People, 44.

70. Ibid., 10.

71. Ibid., 12.

72. Higgins, C., Dunn, E., and Conrath, D., “Telemedicine: An Historical Perspective,” Telecommunications Policy 8, no. 4 (1984): 307–13CrossRefGoogle Scholar.

73. Michael Fuchs, “Provider Attitudes Toward Telemedicine: Preliminary Findings” paper presented to the second telemedicine workshop, Tucson, 5 December 1975, 9.

74. Michael Rios to Richard Johnston, 18 April 1975. STARPAHC archive: records from the Space Technology Applied to Rural Papago Advanced Health Care project, 1970–79, 1991 (bulk 1972–78) (AHSL HT 0001), Special Collections, University of Arizona Health Sciences Library, Tucson. Box 11, Folder 3.34

75. Johnston to Escalante, 15 May 1975. STARPAHC archive: records from the Space Technology Applied to Rural Papago Advanced Health Care project, 1970–79, 1991 (bulk 1972–78) (AHSL HT 0001). Special Collections, University of Arizona Health Sciences Library, Tucson, Box 11, Folder 3.34

76. See Dillingham, Brint, “Indian Health Service and the Health lnformation System,” American Indian Journal 3, no. 4 (1977): 16–18Google Scholar; Brown, Virginia B., Mason, William B., and Kaczmarski, Michael, “A Computerized Health Information Service,” Nursing Outlook 19, no. 3 (March 1971): 158–60Google ScholarPubMed; and Indian Health Service Office of Research and Development and A Summary of the Initial System Designs (Health Program Systems Center, Indian Health Service, 1969), all cited in deJong, Plagues, Politics, and Policy, 129–30 and 143.

77. DeJong, Plagues, Politics, and Policy, 134, 144–45. DeJong cites “Cronyism Within IHS Alleged”: Arizona Daily Star (Tucson), 18 October 1976, A-1; “Empire Building Charged in Moving ORD Here,” Arizona Daily Star, 17 October 1976, A-4; and “Critics Assail Indian Health Research Efforts,” Arizona Daily Star, 17 October 1976, A-1.

78. UPI, “STARPAHC Brings Medical Care to Reservation,” Hutchinson Daily News, 25 February 1976, 14.

79. Bashshur, Technology Serves the People, 73–76, quotation on 76.

80. See, for examples, Kay, W. D., Defining NASA: The Historical Debate over the Agency’s Mission (Albany, NY, 2005)Google Scholar, and Glen Asner and Stephen Garber, Origins of Twenty-first Century Space Travel: A History of NASA’s Decadal Planning Team and the Vision for Space Exploration, 1999–2004 (NASA, 2019). NASA and its contractors are currently building the Space Launch System and Orion spacecraft to send astronauts into space from U.S. soil.

81. Rife and Dellapenna, Caring and Curing, 79.

82. For information on the policy window concept, see Kingdon, John W., Agendas, Alternatives, and Public Policies (New York, 1995)Google Scholar, cited in Thor Hogan, Mars Wars: The Rise and Fall of the Space Exploration Initiative (NASA SP-2007-4410), 3. Thanks to Audrey Schaffer for mentioning this useful policy window concept in a different context.

83. See, for examples, Frutkin, Arnold, International Cooperation in Space (Englewood Cliffs, 1965)Google Scholar, and Krige, John, Callahan, Angelina Long, and Maharaj, Ashok, NASA in the World: Fifty Years of International Collaboration in Space (New York, 2013)CrossRefGoogle Scholar. One major section of the latter book addresses NASA cooperation with the former Soviet Union and Russia.

84. Lambright, W. Henry, Powering Apollo: James E. Webb of NASA (Baltimore, 1995), 215Google Scholar.

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Fig. 1. IMBLMS mission logo (Source: NASA).

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Fig. 2. Papago Indian Reservation, Southern Arizona (Source: Google Maps).

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Fig. 3. STARPAHC Mobile Unit (Source: NASA).