Safe Passage: Astronaut Care for Exploration Missions (2001)
Chapter: Front Matter
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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
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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.
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
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
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
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.
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-
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
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
might be approached (which is the focus of Chapters 3 and 4); and (3) to suggest how a system of health care for astronauts might be organized (which is the subject of Chapter 7 and, to some extent, of Chapters 3 and 4). The committee has sought to bring to its task the fresh perspective that NASA requested. That perspective has, for example, identified at least two specific areas on which we believe NASA’s focus has been less than that which is now necessary. The first area involves a set of issues that are behavioral and cultural, including crew selection and training (Chapter 5). The second area is the collection of clinical data on astronauts, for which a new ethical approach is needed (Chapter 6).
What is the committee’s perspective, then? Although the committee members come from diverse professional backgrounds, each with specialized knowledge, the diversity is within a relatively narrow range relative to the diversity of knowledge held by the general population or even the scientific community as a whole. Only a quarter of the committee members have had any previous experience with the space program, and only one has flown in space. The committee members do, however, have similar backgrounds, in that almost all are physicians (and those who are not are involved in clinical fields) and all have had experience in academic medicine. The committee thus brings a common perspective informed by the shared individual backgrounds of its members and the shared experiences of each of the members of the committee as it reviewed the evidence relative to its task. That perspective is largely, although not absolutely, that of the academic clinician and clinical researcher.
How these clinical and academic perspectives play out in the chapters of this report is illustrated by the following examples. In Chapter 2, the committee uses a biological systems approach to examine the data on what is known about clinical information, a systems approach that is based on an understanding of fundamental processes. In addition, the committee’s approach reflects the academic perspective, one that values openness of dialogue and processes of peer review, particularly of research proposals. The committee’s perspective is thus reflected in its conclusions and recommendations in Chapter 2 that relate to NASA’s research process. In Chapter 3, the committee uses the perspective of the clinician, using the principle of continuity of care in its conclusions and recommendations.
Although Chapter 7, on planning an infrastructure for a system of astronaut health care, was prepared from the committee’s perspective of academic clinician and clinical researcher, it differs from the other chapters in one important way. Whereas for the other chapters the committee reviewed
hundreds of pages of NASA policies and procedures, cast a practiced eye on the evidence, analyzed that evidence, and reached conclusions that led to recommendations supported by the evidence in the individual chapters, for Chapter 7 the committee focused on principles drawn from the evidence examined throughout the study to support the conclusions and recommendations that the committee advances in Chapter 7. Thus, the committee suggests from its particular perspective what principles should be taken into account in the creation and evolution of a health care system for astronauts who will travel on long-duration missions beyond Earth orbit.
None of the committee members is a practicing engineer, and none is a physicist. Thus, we do not believe that our conclusions and recommendations should replace those of others. We hope, instead, that this report will add to the richness of NASA’s approach to solving some of its most vexing issues.
As with all IOM reports, this one was a collaboration of the committee and IOM staff. The committee especially thanks Charles Evans for his excellent management of the project and leadership of the staff and for the staff support of Mel Worth, Judy Rensberger, Veronica Schreiber, Tanya Lee, and Seth Kelly. NASA staff, both at NASA headquarters and at the Johnson Space Center, gave generously of their time and energy; without the information that they provided, this report would not have been possible. Chapters of the report were developed by working groups of the committee headed by Lynn Gerber, Carol Scott-Conner, Doug Powell, and Walter Robinson; their dedication to the project was substantial. Lastly, the chair wishes personally to thank the committee members for the collegial manner in which they approached the task and for their responsiveness to the demands that such a complex project requires.
John R.Ball
Chair
June 2001
Acronyms
ADA
American Dental Association
AHRQ
Agency for Healthcare Research and Quality
ANARE
Australian National Antarctic Research Expeditions
ART
atraumatic restorative treatment
CAD-CAM
computer-aided design-computer-aided manufacturing
DCS
decompression syndrome
EVA
extravehicular activity
FAA
Federal Aviation Administration
IOM
Institute of Medicine
ISS
International Space Station
JSC
Johnson Space Center
MeV
million electron volts
NASA
National Aeronautics and Space Administration
NIH
National Institutes of Health
NRC
National Research Council
NSBRI
National Space Biomedical Research Institute
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LIST OF BOXES, FIGURES, AND TABLES
EXECUTIVE SUMMARY
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Box 1 |
Clinical Research Opportunities for Astronaut Health, |
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Box 2 |
Health Care Opportunities in Space Medicine, |
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Box 3 |
Behavioral Health and Performance Research and Development Opportunities, |
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Box 4 |
The Key Elements in the Committee’s Recommendations, |
1 ASTRONAUT HEALTH BEYOND EARTH ORBIT
2 RISKS TO ASTRONAUT HEALTH DURING SPACE TRAVEL
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Box 2–1 |
Some Major Human Physiological Changes Resulting from Extended Travel in Earth Orbit, |
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Figure 2–1 |
Countermeasure (CM) evolution, |
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Table 2–1 |
Average Bone Mineral Density Loss on Mir, |
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Box 2–2 |
Altered Sleep Patterns as Example of Multifactorial Problems Arising During Space Travel, |
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Box 2–3 |
Elements of the Critical Path Roadmap Project, |
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Table 2–2 |
Critical Path Roadmap Project: Critical Risks, |
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Figure 2–2 |
Countermeasure (CM) development and evolution, |
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Box 2–4 |
What Constitutes Clinical Research?, |
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Box 2–5 |
Clinical Research Opportunities for Astronaut Health, |
3 MANAGING RISKS TO ASTRONAUT HEALTH
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Box 3–1 |
Major Health and Medical Issues During Spaceflight, |
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Table 3–1 |
In-Flight Medical Events for U.S. Astronauts During the Space Shuttle Program, |
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Table 3–2 |
Medical Events Among Seven NASA Astronauts on Mir, |
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Table 3–3 |
Medical Events and Recurrences Among Astronauts of all Nationalities on Mir, |
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Table 3–4 |
Pharmacopoeia Usage During Mir Missions, |
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Table 3–5 |
Incidence of Health Disorders and Medical-Surgical Procedures During 136 Submarine Patrols, |
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Table 3–6 |
Reasons for 332 Medical Evacuations from All Submarines, U.S. Atlantic Fleet, 1993 to 1996, |
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Table 3–7 |
ANARE Health Register Illnesses in Antarctica from 1988 to 1997, |
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Box 3–2 |
Potential Methods of Risk Assessment and Screening, |
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Box 3–3 |
Breast Cancer as an Example of Risk Assessment in Space Medicine, |
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Box 3–4 |
“Normal” Findings on Physical Examination in Microgravity, |
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Box 3–5 |
Advances in Preventive Dentistry, |
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Box 3–6 |
Health Care Opportunities in Space Medicine, |
4 EMERGENCY AND CONTINUING CARE
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Box 4–1 |
Health Care Opportunities in Space Medicine, |
5 BEHAVIORAL HEATH AND PERFORMANCE
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Box 5–1 |
Evidence of Emotional or Social Problems on Short-Duration Missions, |
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Box 5–2 |
Recovery and Reintegration, |
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Box 5–3 |
Systematic Multiple Level Observation of Groups, |
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Box 5–4 |
Potential Uses of Neuroimaging Methods for Astronaut Selection, Training, and Intervention, |
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Box 5–5 |
Distributed Interactive Simulation, |
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Box 5–6 |
Behavioral Health and Performance Research and Development Opportunities, |
6 EXPLORING THE ETHICS OF SPACE MEDICINE
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Box 6–1 |
Examples of Earth-Based Limitations on Doctor-Patient Confidentiality to Decrease Risks to Others, |
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Box 6–2 |
The Common Rule and Informed Consent, |
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Box 6–3 |
Potential Categories of Clinical Research or Data Collection Protocols for Astronauts, |
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Box 6–4 |
Examples of Category 2 Clinical Research or Data Collection Protocols for Astronauts, |
7 PLANNING AN INFRASTRUCTURE FOR ASTRONAUT HEALTH CARE
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Box 7–1 |
Infrastructure Elements for Developing a Comprehensive Health Care System for Astronauts, |
