Hallie Trial
Rice University
Houston (29.7° N, 95.3° W)

Humans were never meant to live in space. In microgravity, lack of mechanical stress on the body leads astronauts’ bones to dissolve, and smaller loads on astronauts’ muscles cause muscular atrophy. Radiation exposure outside the protective blanket of Earth’s atmosphere not only damages astronauts’ DNA, but it also suppresses their immune system, which makes ordinary illnesses more dangerous. Astronauts must not only face these extraordinary dangers but do so out of the reach of normal healthcare personnel and equipment. Space medicine is a growing field that addresses these health concerns.

Because of the enormous cost of sending people into space, astronauts cannot have a full medical team onboard to treat problems that arise. Therefore, before the mission begins, physicians called flight surgeons teach their assigned crew how to perform the basic medical procedures they might need. Flight surgeons also meticulously examine the health of each crewmember to ensure that they have no preexisting conditions that could endanger them during the mission. In this way, space medicine focuses much more heavily on prevention of illness than does ordinary medicine. As Emmanuel Urquieta Ordonez, a scientist at the Translational Research Institute for Space Health, pointed out in an interview for Longitude.site, “Aerospace medicine deals with very healthy people, and we prevent them from getting sick from the physiological changes that they experience during space flight… traditional medicine deals with sick patients, and you bring them back to health.”

Space medicine presents unique challenges in other ways, too. Unlike ordinary physicians, flight surgeons cannot directly talk to and touch their patients to come up with a diagnosis. In an interview published on Healthcare IT News, Shannan Moynihan, Deputy Chief of Space and Occupational Medicine at the Johnson Space Center, said that once the crew launches, “Our ability to communicate with and examine our patients is limited to audio and video communication via telemedicine.” During a mission, flight surgeons work in the Mission Control Center in case the astronauts need to contact them for a medical concern or emergency and hold weekly medical conference calls with the crew. Flight surgeons must also meet their space-going patients at the landing site, sometimes in far-flung locations, to help them readjust to Earth’s gravity.

In addition to flight surgeons, organizations like NASA need medically-trained administrators with an understanding of aerospace science to minimize the medical risk both astronauts and ground crews experience. J.D. Polk, NASA’s Chief Health and Medical Officer, explained that he oversees “the technical requirements that impact the astronauts’ health, such as how a vehicle will be built, whether radiation can be mitigated, how much exercise a crew can do on board, and their food and water needs during a mission,” in an interview for The DO.

Another path into space medicine is through medical research. Our understanding of how microgravity affects human physiology is still “in its infancy,” according to Shannan Moynihan at the 2019 Owls in Space Symposium. For longer space trips like the planned 2030 Mars mission to become a reality, we must advance our knowledge of how the environment of space impacts human health and develop new ways to mitigate those health risks. Emmanuel Urquieta and other scientists at the Translational Research Institute for Space Health contribute to this goal through a huge variety of projects. Some investigate which genes hardy microscopic organisms like tardigrades use to protect themselves from radiation in hopes of finding ways to make similar genes in humans work in such a way. Others are “trying to find out artificial intelligence and machine learning techniques to not just diagnose but to predict when a medical condition is going to happen,” said Urquieta. Such techniques will prove necessary for deep space explorations like the 2030 mission to Mars because traveling greater distances means greater communication delays with flight surgeons, making the crew’s ability to deal with medical emergencies using technology on hand even more vital.

Space medicine researchers can gain qualifications for their positions through PhD programs or combined MD/PhD programs. Aspiring flight surgeons must earn certification in aerospace medicine from the American Board of Preventive Medicine by completing an aerospace medicine residency and required graduate coursework. Besides certification, most successful flight surgeons have an extensive breadth of medical knowledge because they must diagnose and treat any health issue that emerges in orbit, from ordinary stomach complaints to emergencies like decompression sickness that could arise during a spacewalk.

Humans were never meant to live in space. And yet, we do. Despite the incredible technical, medical, and financial challenges in our way, we continue to reach out into the universe around us, ever driven to push back the frontier of the unknown. The limitations of our own bodies now pose some of the greatest barriers to advancement. As space medicine conquers these challenges, the deep space exploration humankind has dreamt of for generations may someday become reality.

Other suggested resources

An article about space medicine, including descriptions of individuals’ careers and information about opportunities for building a career in the field.
https://www.aamc.org/newsroom/newsreleases/469122/space_medicine_09072016.html

An interview with J.D. Polk, NASA’s Chief Health and Medical Officer, about his experiences in space medicine.
https://thedo.osteopathic.org/2016/12/nasas-top-doc-do-oversees-the-health-of-astronauts-preps-for-mars-mission/

Information about residency programs in aerospace medicine and the requirements for becoming an aerospace physician.
https://www.asma.org/about-asma/careers/aerospace-medicine/residency-programs-related-courses

An interview with Shannan Moynihan, Deputy Chief of Space and Occupational Medicine at the Johnson Space Center, about her career path and experiences in aerospace medicine.
https://www.healthcareit.com.au/article/out-world-medicine-meet-doctor-managing-astronaut-healthcare

A summary of the qualifications and duties of flight surgeons at NASA.
https://www.nasa.gov/content/flight-surgeons

David Yang
Rice University
Houston (29.7° N, 95.3° W)

featuring Dr. Emmanuel Urquieta Ordonez, scientist at the Translational Research Institute for Space Health and assistant professor of emergency and space medicine at the Baylor College of Medicine, Houston (29.7° N, 95.3° W)

Emmanuel Urquieta Ordonez is a scientist at the Translational Research Institute for Space Health and an assistant professor of emergency and space medicine at the Baylor College of Medicine. After graduating medical school, he worked as a helicopter pilot airlifting critically ill patients for an emergency medical system in Mexico City. He later completed a Master of Science in Aerospace Medicine from Wright State University and participated as a test subject for NASA’s Human Exploration Research Analog (HERA) at Johnson Space Center. He is also a private pilot and scuba diver.

Throughout our conversation, one important theme that stuck out to me was how trueDr. Urquieta is to his interests and values. He has been passionate about aviation since he was a child, and his current job combines his interests in both medicine and aviation. Likewise, since family and spending time with them is important to him, he chose to become a physician instead of pilot based on the differing lifestyles of the professions.

Talking with Dr. Urquieta made me realize that a medical doctor is not limited to clinics or hospitals. Aerospace is one example of a field that is different from traditional medicine but still has a great need for medical professionals. While Dr. Urquieta doesn’t see patients as part of his job, aerospace medicine still has its focus on the person, just like traditional medicine. Dr. Urquieta explained that “aerospace medicine deals with very healthy people,” instead of sick patients as in traditional medicine, and his goal is to “prevent them from getting sick from the physiological changes that they experience during space flight or just a normal flight inside the atmosphere.” I found his current projects interesting, such as the one to find different ways to protect astronauts from damage to their central nervous systems. Since my current area of interest is chemistry, I wonder how drug discovery would help in aerospace medicine.

As someone planning to attend medical school, I am inspired by Dr. Urquieta to explore options outside of practicing traditional medicine in a clinical setting. His experience showed me that I don’t necessarily need to follow the same pathway as my peers; if I follow my interests continually, I’ll have an enjoying and fulfilling profession to look forward to everyday.

Highlights from the Interview

What was your background and how did it get you into your current position in this field?

I’m a physician by training. After medical school, I worked for two years in a helicopter emergency medical system in Mexico City. Basically, I was in charge of airlifting critically ill patients within Mexico City. That was my first connection between medicine and aerospace. Afterwards, I moved to the United States to complete a Master of Science in aerospace medicine at Wright State University in Dayton, Ohio, where I was able to do some research in the cardiovascular changes after long duration in space flight. Specifically, my thesis was on how the shape of the heart changes from being kind of a cone to a sphere because of the microgravity changes.

Afterwards, I was able to participate as a test subject in an analog mission at NASA Johnson Space Center. It’s called Human Research Program (HRP). I was inside a tin can with three other people, and we were there for thirty days. There was no communication with the outside world besides mission control. There were no windows. Of course no internet or social media. We got to eat the same food that astronauts eat. Basically, we simulated a three-year mission to an asteroid. It was compressed into thirty days. So we basically lived the same lifestyle as astronauts live on the space station. We used a bunch of the same equipment that they use. We tested some hardware that is now flying on the space station. These analogs work really well— to test how humans interact as individuals, and as teams, in what we call an isolated and confined environment. Because when we go to Mars in the 2030s, the volume of the spacecraft that will take us to Mars is going to be very small. So the crew is going to be composed of maybe four crewmembers. The conditions are very similar to this analog that I was mentioning. Very small volume, no windows, no real time communication. The communication time delay between the distance of Earth and Mars is about twenty minutes.

Additionally, I am a private pilot and a scuba diver. I think all those areas—my previous experience on the research side and being the test subject in this analog mission—allowed me to get the position that I’m working now at the Baylor College of Medicine Translational Research Institute called TRISH. It is funded by a twelve-year cooperative agreement with NASA awarded to Baylor College of Medicine. I work for TRISH, but I’m a Baylor employee. I also have an appointment as an assistant professor of emergency and space medicine at Baylor. I’m not a practicing physician. I’m on the research, science management side.

During your education, did you first have a passion for space and aviation or did you first realize that you wanted to be a doctor?

Actually I wanted to be a pilot first. My dad is an aeronautical and aerospace engineer. And my grandpa was a pilot in Mexico City. I’m originally from there. I’m a naturalized U.S. citizen, but I’m originally from Mexico. When I was a kid, aviation was part of family conversations, and quite often my dad took me to the airport to see the airplanes and stuff like that. The gliders and hangers and stuff. And since I have that memory, I have always been interested in aviation. I originally wanted to be a pilot, and then afterwards I decided to go to medicine. Aviation has always been a part of me. When I completed medical school, I had the opportunity to work for the helicopter emergency medical systems, which combined both of my interests. And then the space part came when I did my master’s. But in all, it has always been aviation and space that I have been really interested in.

If you always wanted to be a pilot, what caused you to pursue medicine as well, instead of just going straight into being a pilot?

For me, family has always been very important. I have a wife, I have a four-year-old daughter, and my wife is due for another daughter in the next month. Having a family has been something important for me. Pilots, due to the nature of their work, are away from the family often, so I think that that’s one of the things that made me change from just doing aviation towards doing something else.

How did you choose to enter into the NASA analog experiment?

To be honest with you, I just thought it was interesting. I sent my resume and they called me. They did a lot of medical testing to make sure I was a good fit. For this type of simulation, they like to have what they call “astronaut-like” subjects. You have to be between thirty and fifty-five years old. You need to be in good health, so you go through very stringent medical assessments. And more importantly, psychological assessments: you go through two or three days of psychological assessments to make sure you aren’t going to go crazy inside a tin can. After that, they told me I was selected for the prime crew. We had two weeks of training before the mission, then thirty days of the mission, then a week after that, for what we called debriefing. So it was almost two months in total.

Can you explain what exactly is space medicine and how does it intersect with being a doctor and the specifics of the projects you work on?

Space—aerospace—medicine is very different from traditional medicine. Aerospace medicine deals with very healthy people, and we prevent them from getting sick from the physiological changes that they experience during space flight or just a normal flight inside the atmosphere. Whereas traditional medicine deals with sick patients, and you bring them back to health.

Basically, as we’re speaking, the space station is going around the earth. Every ninety minutes, it makes an orbit. And it has been there for decades now, so it’s been a really common thing to talk about ISS, and we take it for granted, and we’re really really good on ISS. Astronauts are really healthy there, and we have most things figured out. They come back healthy; we have no issues there. So the next step now is Mars, which is completely different. It’s a complete paradigm shift from what we have on ISS. The medical conditions that will happen on a mission to Mars are completely different from ISS. The first one is radiation. Astronauts, during what we call deep space missions, are going to be exposed to chronic radiation. The central nervous system, the cognition of the central nervous system, and the cardiovascular system will mainly get affected. So this is pretty much the biggest challenge that we have for these missions. At TRISH, we are tasked by NASA to find new approaches to these issues of human space flight and for new space missions. We try to come up with new approaches, really innovative ideas that could potentially be game changers. We try to bring new ideas that could potentially save years of research and have new approaches to solve these problems.

For example, in the radiation section, we have currently a few projects aiming to develop ways to increase radiation resistance from the genetic perspective, these are very early stage projects with a huge potential. So that’s one approach.

The other approach that we have is trying to figure out what genes confer radiation resistance. We’re doing research on bacteria—like E. coli, that gives you diarrhea, for example. It’s resistant to extremes. Also, the tardigrades, the water bears [microscopic animals that can survive in many extreme conditions], they’re very resistant to radiation, so we’re figuring out what genes make them resistant to radiation, and then we try to figure out which of those genes have what we like to call human homolog. That means that we have the same genes that they have, and once we’ve figured that out, we would potentially have the capability of increasing the expression of those genes in the way that will increase resistance and protection to radiation.

Another thing that happens to astronauts on space missions is what we call SANS, space flight-associated neuro-ocular syndrome. They get farsighted. So they’re not able to read things close to them. There’s still a lot of questions about this. We don’t know exactly what happens, what’s the cause of this. We know clinically what they develop, but we don’t know the cause of this. So we have a bunch of projects—I would say half a dozen projects—aiming to create a new hypothesis of this to be able to find the cause. All the projects are actually developing techniques to diagnose this, promptly, so that way you can advance the prevention phase.

We also have research on medical conditions. There’s a list of about a hundred medical conditions that are likely to happen on these missions. So we are really trying to find out artificial intelligence and machine learning techniques to not just diagnose but to predict when a medical condition is going to happen. We have some projects on those areas too, trying to predict when a medical condition will happen. And to help the astronauts diagnose themselves, because astronauts are not physicians. More likely, there’s not going to be a physician. Or, if there’s one, one of them is going to be a physician, but he or she could also get sick. The fact that you are a physician doesn’t preclude you from getting sick yourself. So the entire crew needs to have at least a basic understanding of how to make medical diagnoses without input from a flight surgeon, which is again the change from space station to deep space. Everything needs to be done on the spacecraft. So we’re trying to develop techniques and technologies that will allow them to be able come up with diagnoses in real time.

I was in a medical professionalism observership class, and we were talking about the role of artificial intelligence in medicine and how it might replace the jobs of some physicians. What impact do you think that artificial intelligence will have in your field?

There is always going to be a place for the physician. I think that all these tools are great because they reduce the risk of misdiagnosing something. I mean the physician, at the end of the day, is just a person. It is impossible for a single person to memorize the entire differential diagnosis for every single condition, even for specialists. Having all these tools is essential. It makes you a better diagnostician. It reduces the burden in the system of the patient having to go back and wait long times to come back and delaying diagnoses for other people. I think these are great tools to support the clinical physician. At the end of the day, the physician needs to make the final decision, but I think that the more information the physician means they can have a better diagnosis. We have incredible tools now that really support the physicians in that.

If you could talk to the public directly about your research and your work, what would you say? Why do you think the general public needs to care about the research and the work that you and your team are doing?

I think at TRISH we are extremely fortunate to be working for the space program for NASA and support them. I think that if you ask a person who was here when we went to the moon, they remember exactly where they were, what were they doing, when they watched Neil Armstrong coming down from the lunar lander to the moon. I think you and I will be able to live the same experience when we go to Mars, and we will be able to remember that moment forever. So, you know, being able to be part of the huge effort of hundreds of thousands of people—not just in the U.S. but all over the world, people making sure this happens—it is a huge privilege to be a part of this and making sure that our astronauts can make it to Mars safely. We always think of the person that’s going there. We try to be very thoughtful of the person that is going to go there. Not just a system or the research of the engineering or the technologies but the user, which is the astronaut. So that’s our paramount thing, the safety of the astronauts that go to Mars.

What do you think about the future of your field? As a general timeline, when do you think humans will first go to Mars?

I think there’s never been a better time to be in this business than now. I mean not just from the government perspective, from NASA, but also from private companies like SpaceX, Blue Origin, Virgin Galactic—all these companies that are also really trying to send humans both to low orbit and to the moon and to Mars. I think that it is the best time to be in this industry. People are again starting to be very interested in space flight and human space exploration. I just think that it is going to be growing and growing. From the commercial perspective, in probably twenty or thirty years, it will be possible for people to go to Mars. Actually, I was just reading that Elon Musk said that for $500,000, you would be able to go to Mars. So it’s just great to be working for this now. I think that this field, not just space medicine field but the space exploration field in general, is going to grow exponentially. It’s going to be great that we’ll become the first—that we know of—the first interplanetary species. When the Apollo 8 mission went to the moon, they were the first ones seeing the Earth from the moon. When we go to Mars, we’ll be the first to see the Earth from Mars—so I think that is going to be a historical part of humans as a species. 

How much do you think other physicians know about your field and how much do you think policymakers know about your field? Do you think your field gets enough attention to get enough funding or do you think that other people need to be aware…

I’m going to call it specifically from my perspective. We are funded by NASA, so we depend on NASA’s budget for this. I don’t want to get into politics and stuff, but just recently the space council was created—was called again. The last time that the space council was created was for the moon missions. So this is when the government administration calls the people with most of the knowledge of space, not just of space missions but space in general. They call them to make decisions and to make recommendations to the administration on how to pursue this. So just a few years ago, they called the space council again, and I think again that has a good representation from astronauts, policymakers, etc. And I think that we’re in a good position for achieving our goals.

Do you see yourself being an astronaut in the future? Do you hope that you yourself will be able to see the Earth from Mars one day?

Not myself. I mean, I absolutely respect and admire astronauts. I don’t think I could do it myself. I think my responsibility, as a big part of TRISH, is to make sure that when they go, they also come back healthy and safe, back to their families. That’s going back to the idea that we’re always very sensitive to the fact that it’s a person. It’s somebody’s friend, somebody’s father or mother, somebody’s son or daughter, and we want to make sure that everybody makes it safe both there and back.

If someone is interested in going into space medicine, what do they need to do? Should they go to medical school first and then get trained?

I just talked about my experience on the science management side, but there’s also the possibility of being a flight surgeon. Flight surgeons are the astronauts’ doctors. If they are interested in that pathway, it’s also very interesting. They will end up working for NASA or, in the future, any of the companies that I mentioned, Space X, etc. So, basically, they need to go to medical school, then they need to complete a residency program in any specialty. It could be internal medicine, general surgery, family medicine, pediatrics, etc. Then they need to complete a two-year fellowship in aerospace medicine, then after that they could be board certified as a flight surgeon, and then they can work for NASA. And they are the ones that really take care of the astronauts. One by one. They are assigned to a single astronaut on a specific mission, from the time they start training until the end of the mission when they come back. They are fully responsible for a single astronaut for the entirety of the mission. So that’s something very interesting to do. That’s another option.

Did you always know that you were going to end up in the position you are in right now?

No, not necessarily. I think that life takes you to different ways, different pathways, and at the end of the day, everything makes sense and everything connects. The dots get connected. I absolutely love my job. It’s just incredible to be part of this.

Has there been a person that’s inspired you in your field or has shaped the way that you’ve progressed through your career?

My family is my inspiration. In my current position, I think that my bosses, my leadership, have been absolutely supportive of me, and they have allowed me to grow. I think that’s a key part of it. Not just my job but any job. Have leadership be supportive of your personal and professional growth. That’s essential and key in any job— to feel fulfilled when you’re in a job.

(Interview excerpts have been lightly edited for clarity and readability and approved by the interviewee.)