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GUJHS. 2003 Oct; Vol. 1, No. 2
Dominick V. Bufalino, NHS 05
The human space program has existed in the collective unconscious of humanity since the dawn of awareness.
Frank White, The Overview Effect
The prospect of space flight has been the dream of man since its inception. With the foundation of NASA, humans have been able to fulfill this dream in more ways then they could have even imagined. As our race continues into the new century, the idea of long-duration space flight and interplanetary travel has become more than a dream, but rather an imminent reality. For more than thirty years NASA has been preparing to launch the first long-duration space flight to begin exploration-class missions to Mars. This will be the next generation’s Apollo missions. While the concept of this has been entertained for some time, the ramifications to the humans that would man these flights has just begun to be investigated.
Reason and Importance of the Study
In a letter dated January 5, 1999, the Administrator of the National Aeronautics and Space Administration (NASA), Daniel S. Goldin, stated to the President of the Institute of Medicine (IOM) Kenneth I. Shine that,
Space is arguably the most extreme environment that humans have ever entered. Prolonged presence in microgravity results in a number of adaptations that may not be completely reversible. Your assistance is requested in evaluating out current medical-care system and recommending the type of infrastructure we will need to develop to support long-duration missions, including interplanetary travel in which timely evacuation of crew members will not be an option (Ball and Evans, 2001).
It was this letter, as well as other meetings with NASA officials and IOM staff, that spurred the eventual IOM report, Safe Passage – Astronaut Care for Exploration Missions published in 2001.
Space travel is an innately uncertain endeavor. The environments that exist in the orbits outside Earth’s atmosphere are some of the most intense surroundings that man has ever encountered. Space is a distinctive environment for many reasons:
(1) it has unknown risks, (2) there are no validated effective responses to most of the known risks that humans will encounter there, and (3) it isolates humans, in that humans in deep space will not have the capability for either real-time communication with Earth or a timely return (Ball and Evans, 2001).
The constraints that space travel puts on humans are unlike anything they would encounter on Earth. While the field of health care and delivery is an ever expanding entity, the reality is that the current knowledge on the structure of health care delivery in deep space is severely lacking. It was for this reason that Goldin felt it was imperative that a full analysis be done of the methods in which the National Aeronautics and Space Administration (NASA) creates and executes health care in outer space.
The focus of this report was to come to a more thorough level of comprehension of these risks and the solutions to them. The charge to the committee was to create a plan of what medicine during long duration space flight would look like. In order to fulfill the undertaking that was given, the committee on Creating a Vision for Space Medicine During Travel Beyond Earth Orbit needed to remember that aside from the International Space Station (ISS), the prospects of long duration space travel is quite far in the future. For this reason, it was important that the committee focused on the development of a basic philosophy that would serve as guidelines for future evaluation of the issue. The committee feels that due to the fact that long term space flight is so innately different from the other types of aeronautics that NASA was engaged in, it would be important to reevaluate the way in which it designs space flight, from “an emphasis on the machinery of space flight to an increased emphasis on the biology of space flight” (Ball and Evans, 2001). A vision needed to be created in which NASA would better anticipate and prepare for human risks in space flight.
Along with developing the general “vision” for space medicine, NASA also designated some specific areas in which it wished the IOM committee’s attention be focused. NASA wanted the committee to look at the wide range of health problems that could possibly confront humans while traveling in deep space. They desired to better understand the knowledge available on the risks that exist to health during this specific type of space travel and what opportunities there were to pursue clinical research on these topics. The idea of space health care and what methods there are to continue the development of approaches to this health care were also other areas that were requested to be studied. NASA also felt that while it was important to continue to understand all that was available to care for the physical person in deep space, it was also of great emphasis that the committee focus on the behavioral, cultural and social issues and methods in which to gather data on safe space travel (Ball and Evans, 2001).
From these specific tasks and requests, the committee felt that there were two major arguments that were present through out the report. First, they believed that there is simply not enough amassed knowledge on the risks that exist to humans that are engaged in deep space travel, and how to go about alleviating those hazards. For this reason all should be done in order to ensure that a suitable level of understanding is reached before any deep space missions are conducted (Ball and Evans, 2001).
Methods of Study
In order to properly gain an understanding of the dynamic present at NASA, the IOM committee began with five “information-gathering” meetings spanning a 15 month period from October 1999 through December 2000. This series of meetings was closed with a final gathering in January 2001 in order to present the committee’s conclusions and recommendations. The content of the meetings included presentations by officials from NASA, onsite visits to the Johnson Space Center in Houston, Texas which included briefings from some 30 NASA clinicians and researchers in space medicine, as well as workshops that were open to the public pertaining to the data that was present on ways of maintaining the mental and physical health of the astronauts that would be voyaging on these deep space missions (Ball and Evans, 2001).
In addition to the various visits and interviews, the IOM committee also reviewed prior reports and recommendations of National Research Council findings that centered around basic biomedical issues that had been previously been prepared for NASA, as well as other NASA generated reports pertaining to medical events during previous space missions. While these reports served as a basic introduction to previous research, they were quite different from the committee’s report in that IOM focused much more on the clinical constraints that the astronauts would have to endure in long duration space flight. The IOM 2001 report also concentrates on the development of principles that can be used now and in the future to formulate a health care system that would serve to guarantee the heath and well being of the humans participating in long-duration space flights beyond Earth orbit, whereas the prior research only goes into some detail about future biomedical research.
Recommendations and Conclusions
After careful evaluation and research, the committee felt that there were seven areas that needed to be altered: risk, health care, research, behavioral health, data collection and access, engineering and biology, and organization. The following is a synopsis of what they found.
In order to establish what would be defined as risk, the committee used data from prior space missions, as well as other missions carried out in extreme environments such as underwater and Antarctic expeditions, in order to create an evidence base from which they would establish some of their conclusions and recommendations. After thorough analysis of this data the Committee came up with what they felt were the three most critical health issues facing a human on a long-duration space mission.
There is significant data on the radiation environment that is present in low Earth orbit, but little is understood about the type and magnitude of the radiation that is present in deep space. The effects of the nonionizing radiation that the astronauts would be exposed to are for the most part unknown (Ball and Evans, 2001). There is much concern about the radiation emitted from the Sun in solar particle events (SPEs) and the committee feels that there needs to be some method of measuring these levels of solar and cosmic radiation (Ball and Evans, 2001). Until there is a larger knowledge base on this topic and a method to ensure the humans manning these space flights would not be putting themselves at undo risk, the committee feels that deep space travel should be postponed (Ball and Evans, 2001).
In previous missions the loss of bone mineral density was not a major concern due to the relatively short duration of the flight, but when dealing with the length of missions involving interplanetary travel the effects of this loss must be brought into consideration. While in microgravity the loss of bone mineral density is at the average rate of 1% per month. The average time that it would take to reach Mars, set up an expedition and return safely home is approximately three years, so in theory, if gone unchecked the astronaut could lose up to50% of their bone mineral density by the time they returned to Earth (Ball and Evans, 2001). The committee found that the countermeasures currently in place to deal with this phenomenon were inadequate.
The final health hazard that the committee deems of significant concern is the risks of psychological and social stresses due to the isolation and captivity of living on a space vessel for an extended period of time. The crisis aboard the Mir is a paragon of the effects of high stress in isolated environments. Jerry Linenger, the fourth American to serve on the Mir, showed signs of mental breakdown when he cut off voice communication with NASA headquarters and refused to help out with repairing the damaged Mir. (Burrough, 1999) Some of the Russian cosmonauts where even worse off; Aleksandr Lazutkin vented his frustration while on board,
We were tired. We were like little hamsters that had to be doing everything. We were tired psychologically. We were exhausted. We couldn’t find the leak. And the fact that we couldn’t find the leaks put constant psychological pressure on us. That’s why Vasily was so irritated all the time. (Burrough, 1999)
These examples are quite normal on a long duration space flight, and the committee feels that NASA needs to address these concerns before launching flights into deep space.
Despite the NASA established counter measures, continued exposure to microgravity affects the body in many ways. There are minor problems such as facial edema from fluid shifts, and there are more serious consequences such as the continued loss of bone mineral density while in flight. The committee suggests that there be established countermeasures that would be used in flight to mend some of the physiological adaptation dilemmas in space. Part of this process involves taking better advantage of clinical research opportunities that would allow NASA to better understand and measure the different effects that microgravity and long-duration space flight would have on the human involved (Ball and Evans, 2001)
In order to maintain pre, during, and post-flight health at an optimum level, it is essential that NASA creates a comprehensive health care system for the dual purpose of maintaining astronaut health as well as collecting and
analyzing data for future use in long-duration and other space travel. The system would include care for all astronauts, those still in training as well as former astronauts and their families. It would also call for the application of new and innovative techniques for dealing with emergencies as well as the involvement of prominent experts in the field of clinical medicine.
The foundation of NASA’s commitment to the health care of its people is research; the constant pursuit of methods that will allow them to send and maintain humans safely in space (Ball and Evans, 2001). The idea of research is central throughout all parts of the NASA health care system, and is what will allow the possibility of long-duration space flight in the future. By its very nature, space medicine allows for a myriad of research and health care opportunities, whether they be in the development of better methods of measurement, more efficient in space medical procedures, or simply more comprehensive health coverage in deep space.
It is the committee’s belief that, “the principle underlying a health care research strategy is that it have a steadfast, prospective, and methodologically sound approach to the collection of data,” (Ball and Evans, 2001). NASA has already in place both intramural and extramural research programs that the committee interjects should be at the forefront of tackling the two main issues that currently face NASA: “The relative paucity of relevant clinical data and the heretofore relatively closed clinical research environment that has characterized NASA,” (Ball and Evans, 2001). While in the past NASA has done an excellent job of conducting meaningful research on the various topics that face the space administration, in the future there needs to be a system that allows NASA to open its doors to other research groups and allow them to contribute to this growing wealth of knowledge.
Regardless of the system that NASA chooses, it is imperative that the end product result in a schema that would allow for a method to test theories concerning the risks to humans in low Earth orbit as well as the treatment and countermeasure in place to diminish the risks during deep space travel (Ball and Evans, 2001).
With the knowledge gained from the incidents reported to have taken place on the Mir, the committee feels that the notion of behavioral health is not one to be taken lightly. The logistics of a long-duration interplanetary mission call for the crew manning that flight to be in cramped quarters, relative isolation, no real time communication with Earth, and relatively hostile conditions for up to three years. The compilation of these environmental factors plus the added stress of the mission is known to cause altered mental ability such as the incident on the Mir when by mistake a cosmonaut unplugged a cable that guided the solar panel to point in the right direction (Burrows, 1998). It is vital that the members that of crew remain not only physically healthy but mentally as well. “Maintaining a healthy behavioral condition, that is, behavioral health, in such an extreme, isolated microenvironment is, in the committee’s view, critical to the success of the mission and to the return to Earth of normally functioning human beings” (Ball and Evans, 2001). The IOM committee deems it necessary to gain a better understanding of group interactions in extreme environments as well as identifying potentially disorderly behaviors and a means to better monitor and mediate them.
While NASA has documented the presence of behavioral abnormalities during long flights in space, there is still a need for additional research in the form of engineering and technological interactions, biomedical and behavioral exchanges, group relations, as well as interactions in the general living environment (Ball and Evans, 2001). The committee also considers that NASA should reevaluate their methods of screening, selection, and training of astronauts to avoid future catastrophes in space.
Data Collection and Access
The barriers to the data collection and access to information on the astronaut’s previous medical history are somewhat different than what a normal clinician would come in contact with during a routine day to day medical examination. The reality is that certain medical predispositions or conditions are all taken into account when NASA is selecting a group to enter space, and the astronauts realize that the disclosure of this information may put them in jeopardy of receiving this mission. It is for this reason that often times it is difficult to obtain accurate medical histories from the astronauts concerning their experiences in space.
While the idea of confidentiality of clinical data is an important one, the committee believes that the astronaut’s health is of a much larger importance than that of someone in the normal workforce. Therefore it is their feeling that there should be a reevaluation of the Privacy Act in order to obtain better data on these men and women which would allow for a better grasp of the issues facing humans in space flight. Instead, an occupational health model should be developed for NASA which would allow for the timely and proper collection and analysis of astronaut health data (Ball and Evans, 2001).
Engineering and Biology
Historically the problems that NASA has faced have pertained primarily to engineering design and machinery and much less to the human. Since the nature of the human machine is much different from that of a space craft, the committee feels that there needs to be a more expansive approach, “one that develops a deeper understanding of the nature and causes of risks and the diversity of the responses” (Ball and Evans, 2001). This recommendation means that NASA would need to make a concerted effort to unite both its agencies of health and engineering in order to ensure that they are unified in the push for long-duration space endeavors. A suggestion of this magnitude means that the entire culture of NASA needs to be shifted from the primarily engineering based methodology of today to a symbiotic relationship between man and machine.
There is a lot that can go wrong in space and the dilemmas that the astronauts face is that they are far from any means of medical attention aside from that which is on board with them. The committee suggests that NASA come up with a “resource based medical triage system” that would allow for a comprehensive method to deal with individual and group casualties. The emphasis on training and developing techniques should center around the following areas: anesthesia and pain management, surgery and trauma, rehabilitation on long-duration missions, catastrophic illness, death, and personel and other health care resources.
The world of medicine, officials at NASA, and the general public would believe that the presence of a physician on board a long-duration interplanetary mission would be essential. The reality of an on board physician would mean a variety of things such as cross training for the crew and method that would have to be created that would allow the physician to perform skill maintenance exercises such as retraining the psychomotor skills that would be affected in microgravity. The committee also suggests that a space medical catalog be formed that would contain all the necessary information a medical personnel would need on a long duration space flight (Ball and Evans, 2001).
The committee has made a wide variety of recommendations and suggestions to NASA as to what they can better do to ensure the health of their personnel on long-duration space flights as well as the overall health of all the astronauts. While these recommendations are valid, without the proper organization and leadership, this will never come to fruition. The committee recommends that NASA should develop a system comprised of, “an organizational component headed by an official who has the authority over and accountability for all aspects of astronaut health, including appropriate policy-making, operational and budgetary authority” (Ball and Evans, 2001).
It is not the charge of the committee to pass judgment on present leadership, howver, it interjects that the current organizational structure has not been developed enough to certify astronaut health and safety during long-duration space flight. The committee wants to ensure that whatever system is put in place involves coordination with other areas of NASA,integration of the health of the personnel and the mission, and authority to decide what is in the wellbeing of the astronauts (Ball and Evans, 2001).
In years past the monolithic institution that was NASA was cloaked in secrecy. The tests and outcomes of missions that were preformed behind closed doors were very much kept clandestine from the public. In fact when there was a malfunction or something went awry, NASA not only did not explain it, they denied the occurrence. However, NASA has crossed into the next century and realized the importance of its relations with the public as well as other governmental bodies. It was apparent with the recent Columbia tragedy, NASA was on the forefront with press conferences and methods to give the information to the public as it was discovered. This new openness by NASA is the administration’s attempt to open its doors to other bodies. Many of the recommendations that were made by the committee involved the opening of groups that had been previously NASA specific, and these proposals have been met with much success.
The influence of this study on NASA has been quite broad; in fact six of the seven recommendations have been in some way implemented. Since the publication of the study NASA has begun to open discussion on research to other groups such as discussing ethics in space at various conferences. There have been discussions with the astronauts attempting to explain to them the risks of their missions and the newly emphasized importance of proper and honest reporting on health issues in order to not jeopardize the missions, as well as what data should be kept private and what could be publicized. There has been a huge influx in the amount of information made available to the public, such as the most recent study led by Dr. Francis A. Cucinotta of the Radiation Health Office at the Johnson Space Center showing that astronauts who have been exposed to prolonged time in space are more prone to develop cataracts (NASA, 2001). They have also put forth data that documents the effects of prolonged space flight and psychological effects. These studies are examples of how NASA has began to utilize outside groups for various types of research in order to gain a vast majority of opinions on the methods in with the administration is run.
Of all of the recommendations made by the committee, the one that NASA has had the most difficulty incorporating has been the idea of engineering and biology. In the past, the problem solving techniques and methods of assessing risk at NASA has been geared toward dealing with machines and not biological beings. As humans gain the technology to engage in long-duration space flight, the methods in which NASA assesses risk and creates countermeasures must change in order to incorporate the biological model of the human that will man these flights. The reality is that this recommendation is asking two entire cultures to change; cultures that historically have been quite set in their ways. NASA has been open to this type of change, but the time when the integration between health and engineering is some years away.
The prospect of interplanetary and long-duration space flight is a fascinating and exciting new enterprise. The technology and engineering that has made these flights possible is truly astounding and a tribute to the ingenuity and genuius of man. However, while reveling in the vast achievements humans have made in the worlds of aeronautics and space flight, it is imperative not to forget to care for the being that made this all feasible. The possibilities of long-duration space flight are endless, but there needs to be a new focus on the health and wellbeing of the men and woman that would serve as the crew on these missions. There many problems that could arise in space and their needs to be to methods both up there and down on Earth to deal with those situation as they come to pass. The IOM report,Safe Passage – Astronauts Care for Exploration Missions, puts forth a comprehensive plan to establish the necessary agencies to care for the men and women of the space program as we emerge in this new century. The committee has been involved in extensive research and interviews in order to properly assess the needs in order to realistically endorse long-duration space flight. The resulting report covers all aspects of health and the mechanisms in which to promote it, and serves as the quintessence of health policy design.