The Man on the Moon Needs Health Care

(First published in 2019 on SpaceHealth.net)

Apollo 12 mission. Courtesy of NASA Images.

Nakuto-Hansen Industries, Kepler Crater Office

The year is 2045. Hugo Lars is one of many employees of Nakuto-Hansen Industries, a Japanese-Swedish conglomerate with headquarters in Luxembourg and on the moon’s Kepler Crater. The close affiliation with the Luxembourg Space Agency, with its industry-friendly and pro-space mining legislation, gives Nakuto-Hansen Industries unfettered access to powerful business and legal resources to pursue its mining operations on the moon and on AMOR-class asteroids, Earth-approaching asteroids with orbits located between Earth’s and Mars’ orbits. Its lunar location allows it to use local water and Helium 3 resources to power its off-Earth fleet of vehicles and mining robots.

Hugo Lars is an expert in Machine Psychology. He spends his working hours in one of the company’s subterranean labs, talking to all manner of robots and programs. While the simpler AI-powered devices are in the care and feeding of software engineers and programmers, the well-being and sanity of self-aware AIs are Hugo’s domain. Part software/hardware engineer, part psychologist and part lifestyle coach for the AIs, his job is to diagnose troubling trends in the AIs’ processing functions and persuade them to readjust their self-learning mechanisms by taking in a more varied diet of information.

It is an exciting time in humankind’s history - as well as in the evolution of Nakuto-Hansen Industries and similar space-focused business concerns. Funding for space transportation and space research (particularly for mining purposes) is now abundant. Governments have hopped back on the space exploration bandwagon brandishing notions of national prestige and national security to push forward legislative changes aimed at settling land ownership and resource extraction rights within the boundaries of the Solar System. Small territorial scuffles flare up here and there, such as when China and New Zealand both landed rover robots on the same one kilometer diameter asteroid, but so far they have been worked out by the robots themselves.

It is also an exciting time for software engineers and artificial intelligence designers. The anti-AI paranoia of the 2020s has abated as artificial intelligence has gradually crept into every corner of human existence. AI now permeates the very fabric of Earth societies, from the administration of traffic lights, to air traffic control and to political elections, unobtrusive but all-seeing.

It should be an exciting time for Hugo Lars too, considering his recent promotion to Head of the Machine Psychology Clinic. His new role puts him in charge of a team of two other psychologists responsible for the company’s entire lunar fleet of higher order AI-powered machines. Soon enough, should the company’s asteroid-mining operations expand as planned, Hugo will have a shot at becoming the company’s first Chief Machine Psychology Officer.

But Hugo has other things weighing on his mind. After months of headaches and nausea, he had finally made an appointment next-door at Nakuto-Hansen’s Human Physiology Clinic, where an irregular-shaped tumor the size of a cherry tomato was found lodged in his right temporal lobe. Apart from the normal feelings of anxiety any human being experiences when faced with a serious medical condition, this situation poses a number of very practical dilemmas for Hugo.

To begin with, the tumor may have already affected his professional abilities as a machine psychologist, leading him to wonder whether his AI patients may have detected slight aberrations in his reasoning and manipulated them to their advantage. Just as disturbingly to Hugo, his mental preoccupation over his diagnosis may have seeped over into his work and unwittingly introduced biases into the AIs’ thinking.

Secondly, while the equipment used by the Human Physiology Clinic is top-of-the-line, the best neurologists and brain surgeons practice with their feet firmly planted on Earth where normal gravity ensures that neither surgeons nor surgical utensils bounce around. But traveling to Earth for surgery would not be without peril for Hugo. Hugo has been living on the moon for more than two years now, and his circadian rhythm, blood and lymph circulation, muscle mass, bone density and heart health have adjusted to a low gravity environment – with the aid of exercise, medicine, and some genetic pre-travel treatments done by Nakuto-Hansen at no cost to Hugo.

Lastly, and speaking of costs, Nakuto-Hansen covers all medical expenses for its employees, but that assumes Hugo continues to stay in the employ of the company while his condition gets addressed. Should that not be the case, Hugo’s Outer Space Health Insurance Policy might kick in, but only if he can prove that his brain tumor was caused by working at an outer space office location. It is worth noting here that Outer Space Health Insurance Policies for Nakuto-Hansen’s employees are underwritten by NH Insurance, a subsidiary of Nakuto-Hansen Industries - and one of the first insurance players in the still unregulated space health insurance market.

All things considered, Hugo is in a precarious situation. He has to start treatment as soon as possible, knowing full well that both his brain tumor and the treatment for the tumor may impair his ability to work and render him demoted or even fired. Being out-of-work in outer space is a few orders of magnitude worse than being out-of-work on Earth, as anyone can guess, but returning to Earth would not be a good option either, as the health impacts of two years of living on the moon would count as a ‘pre-existing condition’ when seeking health insurance.

Will Hugo be able to navigate the ins and outs the circa-2045 health care system to get the help he needs, make a successful recovery and move on to leading a fulfilling life?

The Space Economy

“The vision is to figure out how there can really be dynamic entrepreneurialism in space” (Jeff Bezos, Yale Club, New York, Feb. 2019)

Propelled by demand for communication satellites, nano-satellites and re-usable launch vehicle systems, the space industry has grown considerably over the past thirty years and has morphed into a highly innovative economic sector – the aptly named “Space Economy”. Currently evaluated at around $350 billion, studies done by investment banks such as Goldman Sachs, Morgan Stanley and Bank of America Merrill Lynch predict that the global Space Economy could grow to $1 trillion or more in the 2040s[i]. That is – if the Space Economy can address its Achilles’ heel, which is the space legislation.

The Grand Duchy is the first European country to offer a legal framework on the exploration and use of space resources. Photo by Benh Lieu Song, Creative Commons Attribution License.

The history of space law started over 100 years ago, with an article published in Paris, in 1910, and took shape gradually, with important commentaries and dissertations appearing in the 1930s, 1940s and 1950s. By the time Sputnik-1 was launched on October 4, 1957, theoretical constructs had turned into practical concerns, and the need for a new body of law to regulate the activities of humankind in space became stringent. Several countries – USSR, United States, Japan, France, Canada and Argentina, to name a few – enacted national space laws devoted to the oversight of national activities in space. The United Nations’ Committee on the Peaceful Uses of Outer Space (COPUOS) issued several treaties and declarations of principles during this time, the most important one being the Outer Space Treaty (OST), signed by the United States, United Kingdom and the Soviet Union in 1967. The OST affirmed that exploration and use of outer space should be carried out for the benefit of all mankind, and that outer space could not be subject to any appropriation or claim of sovereignty.

The OST lacked in many regards, including in the setting of rules about the ownership of metals, minerals and other resources that may be found there, and in imposing policy constraints on human behavior in outer space. In the United States, under pressure from investors and space mining companies, the U.S. Congress passed a new law – the Space Act – in 2015, to grant U.S. space firms the rights to own and sell natural resources they mine from celestial bodies. Smaller players, such as the Grand Duchy of Luxembourg and Belgium, also found opportunity in the loose and sometimes contradictory nuances of past space legislation, and used it to forth their own legal frameworks for the ownership of space resources and for the authorization and supervision of space missions.

With aspects of national legislation viewed by legal experts as objectionable due to potential conflict with international law, the current patchwork of national and international space laws subsists in a delicate balance. Moreover, existing legislation is not yet robust enough in its coverage for commercial space exploration scenarios, and the social components of space travel and space habitation have only recently begun to receive serious attention.

Considering that many of the challenges related to making space exploration a reality deal with our own relationship with the outer space, and with our relationship with each other while in outer space, the social factors at play cannot be overemphasized. To operate in an environment as remote, dangerous and inhospitable as the moon, humans will have to collaborate and share knowledge and resources with an effectiveness and precision seldom experienced on Earth. Questions of ownership, property rights, needs prioritization, welfare allocation and ethical vs. unethical behavior will naturally arise as humans settle into their new habitat. But while Earth societies have the luxury of debating such questions over long periods of time, off-world settlements do not. Exposed to health hazards, constrained by limited resources and relegated to long-term physical isolation, an outer-space human settlement will be a Petri dish for survivalist human dynamics where any conflict, any disagreement, any communication breakdown arising within the boundaries of the settlement will significantly jeopardize the odds of survival of the entire community.

Therefore, a tremendous amount of thinking, planning and organization, cutting across country boundaries and national interests, will have to be done to find solutions to such vital legal and social questions as:

• How should the existing and emerging national and international space-related legislation be governed to avoid conflict and reflect all space concerns fairly?

• How should the rule of law be applied and enforced in outer space, both for governmental and commercial concerns?

• What are the rights and responsibilities of personnel working in outer space?

• What laws and codes of ethics apply to personnel working in outer space?

• How should multi-national human settlements in outer space be governed?

• What obligations do the governmental and commercial concerns have in regard to their personnel’s health and well-being, for personnel – employees and contractors - working in outer space?

• Do the governmental and commercial concerns have any liabilities in regard to their personnel’s actions and behavior while in outer space?

• What safeguards should the law provide for space investors and entrepreneurs?

• How does the concept of “public goods” apply to outer space, and how are such "public goods" to be governed and provisioned?

Workforce Challenges

Expansion into outer space is going to require a strong, permanent or semi-permanent human presence in space – a workforce orders of magnitude more numerous than the existing international contingent of astronauts, commercial crew and space tourism enthusiasts taken together. This workforce will come more or less from the same pool of engineers, designers, pilots, technicians, chemists, biologists and medical staff that all the other major industries are drawing from.

Attracting and retaining a well-trained and highly motivated space workforce is already proving to be a challenge in this era where web giants like Google, Facebook and Amazon lure tech talent away from other industries and hire top engineering graduates right out of school. In the United States, the result has been that the aerospace industry has been steadily graying, with the median age of large space program employees hovering above mid-50s – the highest in two decades[ii].

Countering this trend and attracting qualified candidates to the space industry will require agencies such as NASA, together with private space companies, to become better attuned to the preferences of the younger workforce. Most millennials and Gen-Z’ers value meaningful work, quality of life, diversity and independence, and the space industry will have to adjust to meet these generations’ priorities. Health care in particular is one of the areas where millennials and Gen-Z’ers expectations differ from those of their elders. People in this age group (roughly, those born after 1982) are heavily focused on healthy living, see work-life balance as a prerequisite for wellness, and expect fitness benefits from their employers.

This large cohort of young people carry influence, and they are pushing for greater use of technology, faster delivery of care, telemedicine options, transparency in pricing, and a shift toward consumer-oriented service. In other words, they expect an “Amazon experience” in their health care[iii]. At the same time, this generation is comfortable with the gig economy and expects to change jobs relatively frequently. Since their approach to obtaining health care services is largely cost-based and transactional, many millennials and Gen-Z’ers look for convenience and easy payment options in their health insurance.

Considering these lifestyle preferences, one might wonder what the space industry has to offer - from a health care and quality of life perspective - to appeal to this demographic, while at the same time providing transparency and full disclosure to applicants as to the health risks posed by out space travel and work.

Health and Health Care Considerations

The effects of space travel on human health are still being studied and much is yet to be discovered about the mid- and long-term impacts of space travel on health, but life on the International Space Station (ISS) has already revealed some of the considerable challenges that would be faced by space travelers and space workers.

Usually astronauts are sent to the ISS for about six months at a time, but American astronaut Scott Kelly broke the record in 2016 after completing a 340-day mission specifically targeted specifically at understanding of how weightlessness, radiation, and isolation affect the human body during long stays in space[iv].

Astronaut Karen Nyberg, assisted by astronaut Chris Cassidy, performs an Ocular Health (OH) Ultrasound 2 scan on the International Space Station. Courtesy of NASA Images.

What researchers have learned from the ISS missions is that gravity, cosmic radiation and confinement can have hazardous impacts on the astronauts’ health. The reduced gravity in space can cause bone loss and osteoporosis, an irreversible condition, and can lead to dangerous build-up of pressure of fluids in the head accompanied by high-blood pressure and temporary or persistent eye problems. The prolonged exposure to cosmic radiation can cause sickness and fatigue, and lead to cancer and damage to the nervous system. Living in isolation, in a confined environment, can trigger sleep disorders, depression and behavioral issues, and it can also weaken the immune system’s ability to fend off microbes.

In astronaut Scott Kelly’s case, comparative body testing done on him and his twin brother, Mark Kelly, revealed that 7% of Scott Kelly's genetic expression (i.e., how his genes function within cells) did not return to baseline after his return to Earth. Hypoxia (deficient tissue oxygenation), damage to mitochondria (the part of the cell that produces energy through respiration and regulates cellular metabolism), changes in collagen, blood clotting and bone formation, as well as a hyperactive immune system in response to “space stress” – are all probable causes for his genetic changes.

In the United States, NASA’s Human Research Program (HRP), aimed at investigating and mitigating the risks to astronaut health and performance, has identified 30 primary risks to human health (shown below), and developed a long-term roadmap for risk reduction that takes into consideration human health and performance factors, NASA’s Space Flight Human System Standards, as well as requirements related to the provision of enabling medical capabilities.

Human Risks of Spaceflight - NASA HRP, Evidence Reports[v]

NASA’s Human Research Program partners with external organizations to research and develop new approaches to reduce risks to humans on long-duration exploration missions. One of these partnerships is the Translational Research Institute for Space Health (#TRISH), a cooperative agreement between NASA and a consortium led by Baylor College of Medicine, which consortium includes the California Institute of Technology and Massachusetts Institute of Technology.

TRISH funds research projects that push the boundaries of bio-medicine and technology in areas related to predicting adverse cognitive and behavioral conditions in space, gene therapy to counteract the effects of space radiation, composite materials for shielding medications in space, and improving the astronauts’ cognitive performance through non-pharmacological means, such as through auditory stimulation.

NASA’s Human Research Program is testing noninvasive techniques to evaluate and measure intracranial pressure as part of the One-Year Mission research. The Chibis suit shown in the image could help shift fluids from the upper body to the lower body in crews before returning to Earth. Courtesy of NASA Images.

NASA is not alone in performing research on medical conditions related to space travel. In the private sector, the Mayo Clinic is laying the foundation for its own deep space medicine research program, which is focused on understanding how lack of gravity, cosmic radiation and prolonged space travel adversely affect organ physiology.

The Mayo Clinic’s program is spearheaded by Dr. Alejandro Rabinstein (previously with SpaceWorks), who is studying hypothermia as a way to facilitate deep space travel. Other researchers, such as Drs. David and Michelle Freeman, are working on high-resolution camera devices that use computer vision algorithms to monitor subtle changes in astronauts’ vital signs, contact-free. The technology they have developed, called photoplethysmography, can detect the blood pulsations through the skin and calculate the pulse and oxygenation levels.

The advances that are underway in deep space medicine are very promising, and many are positioned to find applicability on Earth as well. It is clear, however, that the business of providing health care services and treatment prior to, during, and after space travel is only in its incipient developmental stages, and, moreover, that it involves significant expenses.

The question posed in the first part of this article is as valid for today’s space workforce as it will be for Hugo Lars in 2045: Who should cover the health care costs for commercial crew and space travelers? The millennials and Gen-Z’ers the space industry is targeting would certainly want to know.

The Missing Link: A Robust International Health Care System

In their influential book Delivering Health Care in America[vi], authors Leiyu Shi and Douglas A. Singh make the case that the four basic components of a health care system are financing, insurance, payment, and delivery. To these, the World Health Organization adds a fifth component – governance, defined as the way leadership is exercised to ensure that health authorities take responsibility for steering the health sector and for dealing with future and current health challenges. Governance is exercised through transparent and inclusive processes, through health policies, strategy, and plans that set a clear direction for the health sector and through the institutional mechanisms aimed at monitoring key population health indicators and at making information available to communities, the civil society, health professionals and politicians[vii].

NASA astronaut Scott Kelly after returning to Earth from nearly a year on the ISS. Scott Kelly has been an advocate for giving NASA authority to provide additional medical screening and treatment to former astronauts. Credit: NASA/Bill Ingalls

Comparing and contrasting these five components of a robust health care system to the health care currently available to astronauts and commercial space crew, it becomes apparent that the current space health care system is really not a “system” yet, but rather a combination of standard health care mechanisms augmented by programs and initiatives funded by governments (primarily) for research and exploration purposes.

Financing for astronauts’ health care comes from governmental agencies such as NASA, ESA and national space agencies conducting medical research, from 3rd party insurers, as well as from the astronauts’ own pockets in the form of premiums and deductibles. Insurance is purchased mainly through employers, or through individual insurance policies, or through government-run programs such as Medicare (in the United States, available for people over 65 years of age).

Payments for health care flow from government research centers, insurers and/or the insured individuals to the health service providers. It is interesting to note that until the TREAT Astronauts Act[viii] was signed into law in 2017, NASA astronauts did not have lifelong health insurance coverage after they retired, and received no health services or financial support after their retirement for health conditions acquired during space flights. To compound the issue, private insurers would regard some of the health issues acquired during service as pre-existing conditions, and therefore as the basis for either refusing coverage or increasing premiums.

The TREAT Astronauts Act, signed as part of a larger NASA authorization bill in response to studies on astronauts’ health performed by organizations such as the Institute of Medicine (IOM) and after protracted congressional hearings, partially resolves the issue by allowing NASA to treat its former astronauts for all medical issues resulting from their flights to space. No provisions are made in any of the existing legislation in regard to commercial space crews’ health care coverage or availability of health care services after retirement.

The delivery of health care services to active astronauts and commercial crew is primarily provided on Earth – before and after outer space flights, and, at a minimal level, during the astronauts’ stay in space. So far, none of the successive International Space Station (ISS) crews, for instance, have suffered any life-threatening injuries or conditions. If they were to, in accordance with the Memorandum of Understanding on the ISS between the Russian Space Agency (RSA), NASA and the other international partners, the policy would be to stabilize any seriously sick or injured astronauts and transport them back to Earth on a Soyuz spacecraft, where they would be treated by agency medical personnel.

How commercial crew flying private sector spacecraft or working in outer space would receive and pay for health care services delivered while in space – that is still left to be seen, and it is anyone’s guess as to how responsibility and liability for the space workforce’s health and health care will be distributed between the individual, their country of origin, their employer, and their space transportation carrier.

What is almost a certainty is that future space missions will bring together personnel of various nationalities, from countries with potentially differing health care models, who nevertheless must have the same access to health care and similar ability to pay for health care services in order to perform at their best while in outer space. Health care is perhaps the one issue where international collaboration is a must, as the health and health care of the future space workforce represent issues that have no national borders.

In summary, while the existing methods and means for financing health care and providing medical care to the few heavily vetted and trained government space personnel are adequate for relatively low-risk missions in low orbit, the leap to a future where humans are able to spend extensive periods of time in outer space will require an intentional, purposeful effort to create an innovative, robust and distinct health system. Such a system could only emerge as a result of international collaboration, and will require:

• International governance and oversight mechanisms;

• A legislative and regulatory framework for providing health care services before, during and after space travel/habitation, and for safeguarding patients’ rights;

• Legislative and regulatory provisions for health care insurance and for payments processing, together with the necessary supervisory organizations and informational systems;

• The health care delivery infrastructure (personnel, facilities, instrumentations, medications, methods of care, etc.) enabling the provision of health care services specifically tailored to the needs of space travelers and to the particulars of delivering health care off-Earth;

• Emergency care infrastructure for space travelers suffering from severe injuries or diseases; and,

• A well-defined funding pipeline to support technological advances, translational research, and knowledge-sharing in deep space medicine.

Conclusion

Reaching a future where humans can travel, live and work in outer space communities, safe in the knowledge that their quality of life and health is on a par with their peers’ on Earth, will call for relentless international cooperation, revolutionary thinking and exponential solutions. Some may question the worthiness of embarking on what will undoubtedly be a protracted, expensive, sometimes painful, other times exhilarating, journey towards making healthy life in space possible. To them, I’ll quote the words penned by anthropologist Margaret Mead many years ago, in her article “Man on the Moon”, published shortly before Neil Armstrong set foot on the moon:

"Many people are shrinking from the future and from participation in the movement toward a new, expanded reality. And, like homesick travelers abroad, they are focusing their anxieties on home. The reasons are not far to seek. We are at a turning point in human history... We could turn our attention to the problems that going to the moon certainly will not solve ... But I think this would be fatal to our future... A society that no longer moves forward does not merely stagnate; it begins to die." [ix] ------------

Simona Lovin is a seasoned business and IT executive whose sector expertise includes U.S. government, healthcare, international development, investment services, higher education, and telecommunications. A life-long space enthusiast, Simona is leveraging her strategy setting and business architecture experience to envision viable futures in space development. Simona holds a Master of Business Administration from the Heriot-Watt University, the Edinburgh School of Business, and a Master of Science in Computer Science from the Polytechnic Institute of Bucharest, Romania.

------------- [i] Morgan Stanley. (2018, November 7). Space: Investing in the Final Frontier. Retrieved January 28, 2019, from https://www.morganstanley.com/ideas/investing-in-space [ii] Henry, C. (2018, May 10). America's space industry has a hiring problem, and it must battle the Silicon Valley to solve it. Retrieved January 28, 2019, from https://spacenews.com/americas-space-industry-has-a-hiring-problem-and-it-must-battle-the-silicon-valley-to-solve-it/ [iii] Minemyer, P. (2017, April 07). Use technology, wellness programs and a hands-on approach to engage millennial patients. Retrieved January 28, 2019, from https://www.fiercehealthcare.com/patient-engagement/how-providers-can-better-serve-millennial-patients [iv] BBC.com. (2018, January 10). Space travel: Here's what happens to the human body. Retrieved January 28, 2019, from https://www.bbc.com/news/world-42627341. Source: NASA [v] NASA. (n.d.). Human Research Program Evidence. Retrieved January 28, 2019, from https://humanresearchroadmap.nasa.gov/evidence/ [vi] Shi, Leiyu; Singh, Douglas A., Delivering Health Care in America, Seventh Edition, Jones & Bartlett Learning, 2017 [vii] World Health Organization. (2010, May). Key components of a well-functioning health system. Retrieved from https://www.who.int/healthsystems/publications/hss_key/en/ [viii] The “To Research, Evaluate, Assess, and Treat Astronauts Act” of 2017, also called the TREAT Astronauts Act, directs the National Aeronautics and Space Administration (NASA) to establish a program that provides for the medical monitoring, diagnosis, and treatment of crewmembers for space flight-associated medical conditions. [ix] Mead, Margaret, Man on the Moon, Redbook Magazine, July 1969. Available in: by Margaret Mead and Rhoda Metraux, A way of Seeing (New York: McCall Publishing Company, 1970)