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Safe Passage: Astronaut Care for Exploration Missions
SAFE PASSAGE
Astronaut Care for Exploration Missions
John R. Ball and Charles H. Evans, Jr., Editors
Committee on Creating a Vision for Space Medicine During Travel Beyond Earth Orbit
Board on Health Sciences Policy
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, DC
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Safe Passage: Astronaut Care for Exploration Missions
NATIONAL ACADEMY PRESS
2101 Constitution Avenue, N.W. Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
Support for this project was provided by the National Aeronautics and Space Administration. The views presented in this report are those of the Institute of Medicine Committee on Creating a Vision for Space Medicine During Travel Beyond Earth Orbit and are not necessarily those of the funding agency.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine (U.S.). Committee on Creating a Vision for Space Medicine during Travel Beyond Earth Orbit.
Safe passage: astronaut care for exploration missions/John R.Ball and Charles H.Evans, Jr., editors; Committee on Creating a Vision for Space Medicine during Travel Beyond Earth Orbit, Board on Health Sciences Policy, Institute of Medicine.
p.; cm.
Includes bibliographical references.
ISBN 0-309-07585-8 (pbk.)
1. Astronauts—Health and hygiene. 2. Space medicine.
[DNLM: 1. Aerospace Medicine—standards. 2. Health Services Needs and Demand. 3. Astronauts. 4. Radiation Effects. 5. Space Flight. 6. Weightlessness—adverse effects. WD 751 I59s 2001] I. Ball, John, 1944- II. Evans, Charles H. (Charles Hawes), 1940- III. Title.
RC1135 .I576 2001
616.9’80214–dc21
2001005443
Additional copies of this report are available for sale from the
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Copyright© 2001 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
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“Knowing is not enough; we must apply. Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE
Shaping the Future for Health
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THE NATIONAL ACADEMIES
National Academy of Sciences
National Academy of Engineering
Institute of Medicine
National Research Council
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M.Alberts is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm.A.Wulf is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I.Shine is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. Wm.A.Wulf are chairman and vice chairman, respectively, of the National Research Council.
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COMMITTEE ON CREATING A VISION FOR SPACE MEDICINE DURING TRAVEL BEYOND EARTH ORBIT
JOHN R.BALL (Chair), Executive Vice President Emeritus,
American College of Physicians, Havre de Grace, MD
JOSEPH V.BRADY, Director,
Behavioral Biology Research Center, The Johns Hopkins University, Baltimore, MD
BRUCE M.COULL, Head,
Department of Neurology, University of Arizona College of Medicine, Tucson, AZ
N.LYNN GERBER, Chief,
Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD
BERNARD A.HARRIS, President,
The Harris Foundation, Houston, TX
CHRISTOPH R.KAUFMANN, Colonel MC (USA),
Division of Surgery for Trauma, Uniformed Services University of the Health Sciences, Bethesda, MD
JAY M.McDONALD, Professor and Chair,
Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
RONALD D.MILLER, Professor and Chair of Anesthesia and Perioperative Care,
University of California at San Francisco, San Francisco, CA
ELIZABETH G.NABEL, Scientific Director,
National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
TOM S.NEUMAN, Professor of Medicine and Surgery and Associate Director,
Department of Emergency Medicine, University of California at San Diego, San Diego, CA
DOUGLAS H.POWELL, Senior Partner,
Powell and Wagner Associates, Cambridge, MA, and
Clinical Instructor in Psychology,
Harvard Medical School, Boston, MA
WALTER M.ROBINSON, Assistant Professor of Pediatrics and Medical Ethics,
Harvard Medical School, Boston, MA
CAROL SCOTT-CONNER, Professor and Head,
Department of Surgery, University of Iowa College of Medicine, Iowa City, IA
JUDITH E.TINTINALLI, Professor and Chair,
Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
Committee Liaisons:
Institute of Medicine Board on Health Sciences Policy
GLORIA E.SARTO, Professor of Obstetrics and Gynecology,
National Center of Excellence in Women’s Health, University of Wisconsin, Madison, WI
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Institute of Medicine Board on Neuroscience and Behavioral Health
STEVEN M.MIRIN, Medical Director,
American Psychiatric Association, Washington, DC
National Research Council Space Studies Board
MARY JANE OSBORN, Professor and Head,
Department of Microbiology, University of Connecticut, Farmington, CT
Institute of Medicine Staff
CHARLES H.EVANS, JR., Study Director and Institute Senior Adviser for Biomedical and Clinical Research
MELVIN H.WORTH, JR., Scholar-in-Residence
JUDITH RENSBERGER, Senior Program Officer
VERONICA SCHREIBER, Research Assistant
SETH M.KELLY, Project Assistant to August 2000
TANYA M.LEE, Project Assistant from August 2000
GREG T.SHERR, National Research Council Intern (Summer 2000)
Institute of Medicine Board on Health Sciences Policy Staff
ANDREW POPE, Director
CARLOS GABRIEL, Financial Associate
ALDEN CHANG, Administrative Assistant
Institute of Medicine Auxiliary Staff
MICHAEL EDINGTON, Managing Editor to March 2001
PAIGE BALDWIN, Managing Editor from March 2001
SUSAN FOURT, Librarian to December 2000
WILLIAM McCLOUD, Librarian from December 2000
Copy Editor
MICHAEL K.HAYES
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Reviewers
The report was reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the report review process:
JAMES P.BAGIAN, Director, National Center for Patient Safety, Veterans Administration, Arlington, VA
SAMUEL BRODER, Executive Vice President, Celera Genomics, Rockville, MD
EDNA FIEDLER, Manager, Federal Aviation Administration, Civil Aeromedical Institute, Federal Aviation Administration, Oklahoma City, OK
JOHN C.FLETCHER, Professor Emeritus of Biomedical Ethics, University of Virginia School of Medicine, Keswick, VA
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LAZAR J.GREENFIELD, Frederick A.Coller Distinguished Professor and Chair, Department of Surgery, University of Michigan, Ann Arbor, MI
JOHN P.KAMPINE, Professor and Chairman, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
NICK KANAS, Professor, Psychiatry, University of California San Francisco, San Francisco, CA
STEPHEN I.KATZ, Director, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
RUSSELL B.RAYMAN, Executive Director, Aerospace Medical Association, Alexandria, VA
JAMES L.REINERTSEN, Chief Executive Officer, Care Group, Boston, MA
DANNY A.RILEY, Professor, Department of Cell Biology, Neurobiology, and Anatomy, Medical College of Wisconsin, Milwaukee, WI
RICHARD H.TRULY, Director, National Renewable Energy Laboratory, U.S. Department of Energy, Golden, CO
DEBORAH J.WEAR-FINKLE, Forensic Psychiatrist/Flight Surgeon, United States Navy, Pensacola, FL
Although the individuals listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Robert A.Frosch, Harvard University, and Robert M.Epstein, University of Virginia, Charlottesville, VA. Appointed by the National Research Council and the Institute of Medicine they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments are carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Foreword
Many American astronauts have participated in space shuttle missions which kept them in space for periods of 1–2 weeks. A few American astronauts participated in missions on the Russian space station Mir during which they spent substantially longer periods of time in space, missions measured in months rather than weeks. Some Russian cosmonauts spent substantially longer periods of time in space. For all of these missions, there was the potential to bring an acutely ill participant back to earth in a relatively short period of time.
Exploration missions into deep space, such as a journey to Mars, raise a series of new questions about the health of human participants. Some of the physiologic effects of shorter periods in space such as loss of bone calcium are likely to continue indefinitely during longer missions. Some risks such as radiation exposure may be increased as humans proceed further into space. Psychological and mental health issues will grow increasingly important during longer missions in a confined space, often involving individuals of very different social and cultural backgrounds. For prolonged missions, it will not be feasible to return an acutely ill individual to earth in a timely manner.
The Institute of Medicine convened a committee of experts to examine the issues surrounding astronaut health and safety for long duration space missions. At the request of the National Aeronautics and Space Administration (NASA), the committee was asked to make recommendations regard-
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ing the infrastructure for a health system in space, the principles that should guide such a system to provide an appropriate standard of care for astronauts, and to identify the nature of the clinical and health services research required before and during such long-term missions for astronauts.
The committee was faced with an extraordinary spectrum of issues related to prolonged travel into deep space. It focused its efforts upon the available data with regard to astronaut health and upon the areas where the evidence base was deficient. It particularly focused on areas that were amenable to investigation and development in preparation for human exploration of deep space.
The committee was selected with the intention of including some individuals with significant direct experience with space travel, but it included other experts in health care delivery and clinical research who could bring some fresh perspectives to the subject. We are deeply indebted to this volunteer committee expertly chaired by Dr. John Ball for their dedicated commitment to this project. We believe that the ideas, conclusions, and recommendations contained in this report should be helpful to NASA, as it prepares for further space exploration, as well as being of use to others who are concerned about the care of individuals in isolated locations on earth.
Kenneth I.Shine, M.D.
President, Institute of Medicine
July 2001
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Preface
The National Academies, particularly the Space Studies Board of the National Research Council (NRC), have contributed substantial information on a full range of issues focused on basic aerospace research that has been a principal source of scientific advice to NASA. For example, the Space Studies Board recently provided guidance on a biomedical research strategy (SSB and NRC, 1998a, 2000). The present study by the Committee on Creating a Vision for Space Medicine During Travel Beyond Earth Orbit is the first time that the National Academies has addressed clinical issues through an analysis of the clinical research and health care practice evidence base for space medicine. In presenting its request to the Institute of Medicine (IOM) for the study presented in this report, NASA leadership noted that efforts to develop a more capable medical care delivery system in space have been internal to NASA itself, as documented in Chapter 1 of this report. The request used the language “create a vision” for health care for astronauts traveling on long-duration missions beyond Earth orbit. What was intended by the request was that a perspective beyond that internal to NASA and different from that provided by NRC be applied to the issues.
Those issues are reflected in the charge to the committee, which were (1) to assess what is known about the effects of space travel on health (which is the focus of Chapter 2 of this report), what is not known, and what might be done about the latter; (2) to suggest how health care during space travel
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PTH
parathyroid hormone
SMAC
spacecraft maximum allowable concentrations
SMS
space motion sickness
SPEs
solar particle events
STS
Space Transportation System
T3
tri-iodothyronine
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Contents
EXECUTIVE SUMMARY
1
Task of the Committee,
2
Risk,
3
Health Care,
6
Research,
8
Behavioral Health,
11
Data Collection and Access,
13
Engineering and Biology,
17
Organization,
19
1
ASTRONAUT HEALTH BEYOND EARTH ORBIT
23
Background,
23
Health Risks of Space Travel,
26
Charge to the Committee,
29
The Committee’s Study of Health Care for Astronauts Traveling Beyond Earth Orbit,
30
2
RISKS TO ASTRONAUT HEALTH DURING SPACE TRAVEL
37
Overview,
37
Countermeasure to Solve Physiological Adaptations to Space,
40
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Musculoskeletal System,
42
Loss of Bone Mineral Density in Microgravity,
42
Reversibility, Genetic Variability, and Mechanism of Bone Mineral Density Loss,
44
Clinical Research Opportunities in Astronaut Physiology and Health,
46
Effects of Microgravity on Skeletal Muscle,
47
Circulatory and Pulmonary Systems,
48
Orthostatic Hypotension,
48
Other Effects on the Cardiovascular System,
49
Effects of Microgravity on the Pulmonary System,
51
Alimentary System,
51
Nutrition in Space,
51
Space Motion Sickness,
51
Nervous System,
52
Neurovestibular Function,
53
Sleep and Circadian Rhythm,
53
Eye-Hand Coordination and Sustained Gross Motor Activity,
55
Peripheral Nervous System,
55
Reproductive System,
56
Effects of Radiation on Gametes,
56
Human Reproductive Physiology in Space,
57
Sex Differences,
59
Urinary System,
60
Physiological Monitoring,
61
Monitoring During Space Travel: Development of Technology,
61
A Strategy for a Space Medicine Clinical Research Program,
62
A Clinical Research Program for NASA,
69
Conclusion and Recommendation,
71
3
MANAGING RISKS TO ASTRONAUT HEALTH
75
General Principles and Issues,
76
Medical Events in Extreme Environments,
78
Health Risk Assessment,
86
Nutrition,
88
Pharmacodynamics and Pharmacokinetics,
90
Environmental and Occupational Health,
92
Health Care Practice Opportunities,
97
Cardiovascular Care,
97
Dental Care,
98
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Endocrine Function,
101
Gastrointestinal Issues,
102
Gynecological Health Issues,
103
Hematology, Immunology, and Microbiology,
105
Mental Health Issues,
106
Neurological Issues,
110
Urinary Disorders,
111
Conclusion and Recommendation,
112
4
EMERGENCY AND CONTINUING CARE
117
Anesthesia and Pain Management,
118
Airway Management in Space,
118
Anesthetics,
119
Regional Anesthesia,
120
Surgery and Trauma,
121
Physiological Response to Injury,
121
Surgical Skills and Training,
123
Surgical Equipment,
124
Technical Aspects of Surgery,
125
Prevention of Infection,
126
Management of Common Surgical Emergencies,
126
Management of Abscesses and Soft-Tissue Infections,
127
Rehabilitation for Astronauts on Long-Duration Missions,
127
Catastrophic Illness, Death, and End-of-Life Considerations,
130
Personnel and Other Health Care Resources,
131
Development of a Space Medicine Catalog and Database,
132
Conclusion and Recommendation,
133
5
BEHAVIORAL HEALTH AND PERFORMANCE
137
Astronaut Performance and General Living Conditions,
138
Background,
138
Current Practice and Knowledge Base,
138
Requirements for Additional Knowledge,
142
Use of Pairs of Transport Vehicles for Small Groups Traveling Beyond Earth Orbit,
149
Support and Recovery Systems,
149
Background,
149
Current Practice and Knowledge Base,
150
Requirements for Additional Knowledge,
152
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Screening, Selection, and Training,
158
Background,
158
Current Practice and Knowledge Base,
159
Requirements for Additional Knowledge,
161
Strategic Research Considerations,
165
Conclusion and Recommendation,
167
6
EXPLORING THE ETHICS OF SPACE MEDICINE
173
Ethical Issues in Clinical Care for Astronauts,
174
Institutional Pressure to Underreport Clinical Signs, Symptoms, and Medical Data,
174
Current Practice Regarding the Confidentiality of Individual Astronaut Medical Data,
175
Earth-Based Analogs for Balancing Medical Confidentiality with Public Health,
177
Justification for Using the Occupational Health Model to Balance Privacy and Safety,
178
Ethical Issues in the Astronaut-Flight Surgeon Relationship,
180
Opportunities for Collecting Medical Data Aboard the International Space Station,
181
Expand the Collection of Occupational Health Data,
181
Change the Process for Review of Clinical Research Protocols in Space Medicine,
182
Suggested Changes in the Approach to Review of Proposed Clinical Research or Data Collection for Astronauts,
183
Ethical Issues and the Special Circumstances of International Crews,
186
Conclusion and Recommendation,
187
7
PLANNING AN INFRASTRUCTURE FOR ASTRONAUT HEALTH CARE
189
Mission and Goals,
189
Organizational Components,
191
Leadership,
192
Critical Elements of the Organizational Framework,
193
Alternative Organizational Frameworks,
195
Organizational Structure to Ensure Astronaut Health and Safety,
197
Conclusion and Recommendation,
198
Systems Development,
199
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Policy and Legislation,
201
Funding,
202
Internal Relationships,
202
External Relationships,
203
Operational and Clinical Components,
208
Standard of Care,
210
Medical Care,
210
Medical Informatics,
212
Personnel and Training,
214
Evaluation and Performance Improvement,
216
Conclusion and Recommendation,
218
REFERENCES
221
APPENDIXES
A Background and Methodology
247
Letter from Daniel S.Goldin, Administrator, NASA
261
B Committee and Staff Biographies
263
INDEX
275
LIST OF BOXES, FIGURES, AND TABLES
EXECUTIVE SUMMARY
Box 1
Clinical Research Opportunities for Astronaut Health,
5
Box 2
Health Care Opportunities in Space Medicine,
8
Box 3
Behavioral Health and Performance Research and Development Opportunities,
14
Box 4
The Key Elements in the Committee’s Recommendations,
21
1 ASTRONAUT HEALTH BEYOND EARTH ORBIT
Figure 1–1
Trajectory of a human mission to Mars in 2014,
26
Box 1–1
Charge to the Committee,
31
Box 1–2
What Is Space Medicine in Reference to Developing a Vision and Strategy for Astronaut Health?,
34
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2 RISKS TO ASTRONAUT HEALTH DURING SPACE TRAVEL
Box 2–1
Some Major Human Physiological Changes Resulting from Extended Travel in Earth Orbit,
39
Figure 2–1
Countermeasure (CM) evolution,
41
Table 2–1
Average Bone Mineral Density Loss on Mir,
44
Box 2–2
Altered Sleep Patterns as Example of Multifactorial Problems Arising During Space Travel,
54
Box 2–3
Elements of the Critical Path Roadmap Project,
63
Table 2–2
Critical Path Roadmap Project: Critical Risks,
64
Figure 2–2
Countermeasure (CM) development and evolution,
68
Box 2–4
What Constitutes Clinical Research?,
69
Box 2–5
Clinical Research Opportunities for Astronaut Health,
72
3 MANAGING RISKS TO ASTRONAUT HEALTH
Box 3–1
Major Health and Medical Issues During Spaceflight,
77
Table 3–1
In-Flight Medical Events for U.S. Astronauts During the Space Shuttle Program,
81
Table 3–2
Medical Events Among Seven NASA Astronauts on Mir,
82
Table 3–3
Medical Events and Recurrences Among Astronauts of all Nationalities on Mir,
83
Table 3–4
Pharmacopoeia Usage During Mir Missions,
84
Table 3–5
Incidence of Health Disorders and Medical-Surgical Procedures During 136 Submarine Patrols,
84
Table 3–6
Reasons for 332 Medical Evacuations from All Submarines, U.S. Atlantic Fleet, 1993 to 1996,
85
Table 3–7
ANARE Health Register Illnesses in Antarctica from 1988 to 1997,
85
Box 3–2
Potential Methods of Risk Assessment and Screening,
86
Box 3–3
Breast Cancer as an Example of Risk Assessment in Space Medicine,
88
Box 3–4
“Normal” Findings on Physical Examination in Microgravity,
90
Box 3–5
Advances in Preventive Dentistry,
99
Box 3–6
Health Care Opportunities in Space Medicine,
113
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4 EMERGENCY AND CONTINUING CARE
Box 4–1
Health Care Opportunities in Space Medicine,
134
5 BEHAVIORAL HEATH AND PERFORMANCE
Box 5–1
Evidence of Emotional or Social Problems on Short-Duration Missions,
139
Box 5–2
Recovery and Reintegration,
153
Box 5–3
Systematic Multiple Level Observation of Groups,
156
Box 5–4
Potential Uses of Neuroimaging Methods for Astronaut Selection, Training, and Intervention,
163
Box 5–5
Distributed Interactive Simulation,
165
Box 5–6
Behavioral Health and Performance Research and Development Opportunities,
168
6 EXPLORING THE ETHICS OF SPACE MEDICINE
Box 6–1
Examples of Earth-Based Limitations on Doctor-Patient Confidentiality to Decrease Risks to Others,
176
Box 6–2
The Common Rule and Informed Consent,
182
Box 6–3
Potential Categories of Clinical Research or Data Collection Protocols for Astronauts,
184
Box 6–4
Examples of Category 2 Clinical Research or Data Collection Protocols for Astronauts,
184
7 PLANNING AN INFRASTRUCTURE FOR ASTRONAUT HEALTH CARE
Box 7–1
Infrastructure Elements for Developing a Comprehensive Health Care System for Astronauts,
199
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