What do Arizona, Armenia, and space exploration have in common? All three played an important role in the development of NASA’s telemedicine capabilities. And for nearly 50 years, NASA’s work in telemetry, remote communications, and the life sciences has led to unprecedented advances in the fields of both space and rural medicine.
On Earth and in the Heavens
The roots of telemedicine at NASA are entwined with the agency’s earliest days and the modern history of human spaceflight. The dominant medical question prior to Yuri Gagarin’s successful spaceflight in April 1961 was whether the human body could function in space. In particular, physicians were concerned that the removal of gravity would impede circulation and respiration. To determine if this would indeed be a problem, both the U.S. and the Soviets performed a number of test flights using animals attached to medical monitoring systems, which sent the animal’s biometric data to scientists on Earth via a telemetric link. Even after it was determined that spaceflight posed little risk to circulatory and respiratory health (at least as far as non-human animals were concerned), NASA still sought to understand if spaceflight would have any other physiological or psychological effects on the human body. The focus on possible limitations of the human body forced the agency to take a technologically focused approach to telemedicine. As Dr. Sherman Vinograd, then Chief of Medical Research in the Directorate of Space Medicine, noted “the concern of the medical scientists centered mostly on assuring man’s support in space and his safe return to Earth—while predetermined engineering goals were achieved.” This, continued Vinograd, meant that medical research outside of monitoring was “secondary to the engineering objectives of the mission.”
The culmination of this engineering-focused approach came with the introduction of the Integrated Medical and Behavioral Laboratories and Measurement Systems (IMBLMS) program in 1964. IMBLMS was an expansion of the measurement systems debuted on the Mercury and Gemini flights. IMBLMS, however, was designed from the outset to do more than simply revamp existing technology from ongoing human spaceflight programs—rather NASA viewed the program, and the new and upgraded technology created as part of it, as critical for supporting its post-Apollo goal of conducting longer duration human spaceflights, especially supporting the eventual construction and occupation of an orbiting space station. In situations where a quick return to Earth was not possible, the ability to not only monitor biometric data, but also to engage at least rudimentary guided medical treatment by non-physicians was critical: if a medical emergency arose, astronauts would have only their crewmates to accurately diagnose them. But rising inflation and the subsequent funding cuts for human spaceflight programs as the Apollo program wound down, pushed NASA’s ambitious plans for the IMBLMS program to margins of the agency’s funding priorities during the late 1960’s and early 1970’s
The New Telemedicine at NASA: STARPAHC and Beyond
IMBLMS might have stayed a partially realized dream if not for a letter from the newly created White House Domestic Policy Council in July 1971. This new initiative explored ways to inexpensively stimulate a flagging economy by using government programs already in development. Administrators at NASA saw the Domestic Policy Council’s request as an opportunity—if NASA couldn’t test IMBLMS in space why not build a terrestrial analog? The result was a new program, Space Technology Applied to Rural Papago Health Care, or STARPAHC.
While building terrestrial analogs was a fairly common practice at NASA, STARPAHC represented an important new direction for the agency, largely because the technology generated was designed from the outset to serve a broader group than just astronauts. The search for this expanded clientele was driven both by political considerations from the White House, and the need to spread the development costs across multiple parties—this forced NASA to seek a diverse range of partners including new groups like the Indian Health Service and the Papago (now Tohono O'odham) people of Southern Arizona. NASA also sought to engage long-time collaborators like the Lockheed Missiles and Space Company, which was the primary contractor for IMBLMS, as a way to ensure that existing technical knowledge involving microwave relays and other communications technologies could quickly be leveraged. 
The remote location of the Tohono O’odham reservation, and the fact that the state was one of only a handful to allow the delivery of care by paraprofessionals such as physician’s assistants, ensured that the terrestrial analog would more closely resemble the situation aloft. NASA’s participation in STARPAHC was operational from 1973 until 1977, with NASA taking an active early role in the program to design and the test the technology that linked rural patients in mobile support units with physicians in Indian Health Service hospitals in Sells and Phoenix, Arizona. After NASA’s role was diminished, the project did continue into the 1980s. The focus on interagency and interpersonal cooperation that underpinned STARPAHC imploded the technocratic focus characterizing prior NASA telemedicine efforts. As a 1974 NASA report noted, “this approach [cooperative telemedicine] has ‘spin-off’ potential, in that space technology employed in the basic design of a flight system may be extremely beneficial to improving the quality of health care delivery here on [E]arth.” Moreover, the report continued STARPAHC was “a necessary step” for improving health care delivery for both astronauts and ordinary Americans.
By setting this new expectation—that NASA telemedical technology would have both direct application in a terrestrial and a space setting, the agency placed a visible priority on a part of its mission outside of exploration—transferring space technology to better humankind. This dual commitment was tested less than a decade later during several earthquakes, first in Mexico City in 1985, and later in Soviet Armenia in 1988. There was also, especially in the case of the Armenian earthquake, the sheer scale of the disaster—estimated causalities were over 50,000 people and an additional 500,000 people were left homeless.
NASA’s efforts in Armenia were particularly important because they began a period in the agency’s history where telemedicine became a wedge for increased international cooperation. Unlike many other technology transfer solutions, many of which had a more direct military application, remote medical communications had a clear humanitarian purpose that transcended strategic considerations and the still pervasive opposition to communism that characterized the waning Cold War period. The Armenian program, which operated between May and July of 1989, became known as the “Space Bridge to Armenia” and is perhaps the most cited example of how shifting social and technical goals altered the agency’s telemedicine program by the 1980’s.
The U.S. and Soviets had cautiously began a dialog on health and medicine during the Apollo-Soyuz test project in 1975; however, as the decade progressed biomedical communication channels became more institutionalized through the Joint Working Group on Space Biology and Medicine. By the time of the Armenian earthquake in 1988, there was an established track record of international medical cooperation and a basic understanding of each side’s telemedical capabilities. Commitment at both the top level, and at the agency level, ensured that building a “space bridge” would be a political and technical priority.
In addition to its social and diplomatic aims, the “Space Bridge to Armenia” was, like STARPAHC before it, an important way to test technological innovations in anticipation of the construction of a new space station. Consequently, the program generated important lessons that NASA would apply to later telemedicine efforts, including meeting technical challenges like establishing a multi-site video connection across multiple time zones; identifying personnel in both countries with appropriate technical skills; and finding the best forms of media to securely transmit complex patient information. The “space bridge” also addressed such concerns as understanding the effect of trauma on individual health, and engaging in a frank discussion of medical ethics and informed consent across different medical traditions. Subsequent efforts were made to establish a “Space Bridge to Moscow” during the early 1990’s and a “Space Bridge to Russia” in 1996 that further refined the technology used to transmit and analyze medical information and strengthened interpersonal relationships between physicians and medical technologists in both countries., This project was at the forefront in the integration of medicine with the Internet and the World Wide Web.
Dr. Arnauld Nicogossian, the former Associate Administrator for Life Sciences and Microgravity Sciences, and others at NASA including Charles Doarn, the former Program Executive for Aerospace Medicine and Telemedicine, saw the value of commercializing telemedicine technology as a way to encourage more rapid technical development, to promote a wider diffusion of the technology to a non-governmental audience, and finally to defray development costs for NASA. Nicogossian and Doarn’s push for the commercialization of telemedical technology was in line with an agency-wide mandate to spin off the benefits of human spaceflight and other scientific and technical endeavors—a mandate that has guided NASA since the early 1960’s. In order to better facilitate this, in 1997, the agency sponsored the creation of a Commercial Space Center named Medical Informatics and Technology Applications Consortium (MITAC) at Yale University (it later moved to Virginia Commonwealth University). Until its closure in 2007, MITAC not only pursued a range of telemedical projects and but most importantly created a variety of different terrestrial test beds for new technology in remote locations in Ecuador, Russia, and the Artic.
Telemedicine at NASA Today
With NASA’s sustained presence in space through programs like the International Space Station, as well as potential travel to an asteroid or other body in our solar system, telemedicine remains an important priority for NASA. The focus of current agency efforts have expanded beyond the original mandate of telemetry and remote communication to encompass new “smart medical systems” that are designed not simply to communicate and diagnose ill astronauts—but also to provide physicians on the ground with the ability to remotely provide limited treatment options. The integration of treatment and communication capabilities represents an important new direction for the future of human space flight and emergency care for remote patients on Earth.
For this next phase of efforts to improve space medicine, NASA has built strong relationships with its partners in the academic and private sectors. One such partner, the National Space Biomedical Research Institute (NSBRI), which is a consortium of twelve of public and private universities, has taken the lead in the efforts to create smart medical systems for human spaceflight. NSBRI, which is led by Baylor College of Medicine, provides funding and academic support for researchers at a range of institutions across the United States; this diversity helps to assure that NASA can draw from a deep pool of talent, regardless of proximity to existing field centers, to support the biomedical research efforts.
One of the most exciting contributions of NSBRI to the development of smart medical systems is the effort to create new ultrasound technologies. For example, a project completed in 2012 under the direction of Dr. Lawrence Crum at the University of Washington worked to develop a lightweight portable ultrasound device that can generate clearer pictures inside the human body than current ultrasound machines. These pictures can then be used by crewmembers and ground-based physicians to more accurately diagnose illnesses during spaceflight. Better quality images are only part of what Crum and his team developed—what makes this technology “smart” is that this new machine can direct High Intensity Focused Ultrasound waves to stop internal bleeding without having to resort to invasive procedures. This ability to identify and stop internal bleeding quickly is essential if an astronaut were injured during a spacewalk, or for situations on Earth where surgical access is limited and patients might otherwise die from traumatic injuries involving damage to internal organs or tissues.
Another important advance in smart ultrasound technology that NASA and NBSRI are researching is occurring under the direction of Dr. Yi-Xian Qin at SUNY Stonybrook. Qin’s research involves searching for ways to use an ultrasound device to help astronauts and ground-based physicians to more accurately assess the rate of bone loss (an important problem in space) and then use Low Intensity pulses either help heal bone fractures, or to proactively slow the rate of bone loss in healthy patients.
Since NASA’s founding in 1958, the agency has been a leader in efforts to find solutions to the biomedical issues that limit the boundaries of human spaceflight. From the early development of remote monitoring systems for biomedical functions that started with Project Mercury, to the improved communications tools like microwave relays and more functional internet interfaces for sharing audio, video, and still images over long distances, that were created to support the Apollo, Space Shuttle, and International Space Station programs, developing the technologies that meet the medical needs of astronauts has resulted in a tremendous flurry of innovations that have helped to reduce the risk, and extend the possible duration, of future human spaceflights. At the same time, as the STARPAHC and the Space Bridge projects have shown, the benefits of NASA’s telemedical efforts go beyond the technical and also have important social and humanitarian benefits.
 For more on space medicine during the Mercury, Gemini and Apollo programs see Mae Mills Link, Space Medicine in Project Mercury (Washington, DC: National Aeronautics and Space Administration Special Publication-4003, 1965) and John Pitts, The Human Factor: Biomedicine in the Manned Space Program to 1980 (Washington, DC: National Aeronautics and Space Administration Special Publication Special Publication-4213 1985).
 To learn more about the psychology of human space flight see Douglas A. Vakoch, ed. Psychology of Space Exploration (Washington, DC: National Aeronautics and Space Administration Special Publication 2011-4411, 2011).
 “Aim of Medical Experiments Program: To Better Know Earth-Man in Space” Aerospace Management vol. 5 no.1, 1970. 63-71. Quotation on 63.
 Lockheed Missiles and Space Company, “STARPAHC Systems Report vol. 1” 30 October 1977, copy in “Telemedicine STARPAHC” file, NASA Historical Reference Collection, History Division, NASA Headquarters, Washington, DC. 2-1.
 Rashid Bashshur, “Technology Serves the People” Report prepared for STARPAHC Office of Research and Development 1979 “Telemedicine STARPAHC” file, NASA Historical Reference Collection, History Division, NASA Headquarters, Washington, DC.
 Ibid. 24.
 “Space Technology in Rural Health Care” August 1974 “Telemedicine STARPAHC” file, NASA Historical Reference Collection, History Division, NASA Headquarters, Washington, DC. 2.
 “Space Technology in Rural Health Care” 2. See also Gary Freiburger, Mary Holcomb, and David Piper, “The STARPAHC collection: part of an archive of the history of telemedicine” J Telemed and Telecare, 2007; 13. 221-223.
 There was also, especially in the case of the Armenian earthquake, the sheer scale of the disaster—estimated causalities were over 50,000 people and an additional 500,000 people were left homeless. See Arnauld E. Nicogossian and Charles R. Doarn, “Armenia 1988 Earthquake and Telemedicine: Lessons Learned and Forgotten” TelemediJ E Health, 2011;17(9)19:741-745.
 Nicogossian and Doarn, “Armenia 1988 Earthquake” and Charles R. Doarn and Ronald C. Merrell, “Spacebridge to Armenia: A Look Back at Its Impact on Disaster Response” TelemediJ E Health 2011; 17(7):546-552.
 Charles R. Doarn, Arnauld E. Nicogossian, Anatoly I. Grigoriev, Galina Tverskaya, Oleg I. Orlov, Eugene A. Ilyin, and Kenneth A. Souza, “A summary of activities of the US/Soviet-Russian joint working group on space biology and medicine” Acta Astronautica 2010; 67(7-8):649-658.
 To learn more including about the development of the Telemedicine Instrumentation Pack (TIP) see Arnauld E. Nicogossian, Debra F. Pober, and Stephanie A. Roy, “Evolution of Telemedicine in the Space Program and Earth Applications” TelemediJ E Health 2001; 7(1):1-15
 Ibid and Nicogossian and Doarn.
 See Nicogossian et al. to learn more about other international telemedicine projects conducted during the 1990’s. In an interview conducted with the author in June 2013 at NASA headquarters, Charles Doarn also noted the involvement of prominent Houston surgeon Michael E. DeBakey as a leader in helping to build durable interpersonal relations through telemedicine between the United States and Russia.
 Doarn CR, Nicogossian AE, Merrell RC. Application of telemedicine in the United States Space Program. Telemed J 1998; 4(1):19-30.
Andrew T. Simpson, Summer 2013 Intern