"HOUSTON _ WE HAVE A PROBLEM!" This simple exclamation stimulates for all Americans a dramatic concern for the welfare of explorers on their way to the moon. For some of us it prompts recall of earlier days in Aerospace Medicine. Those days were characterized by extrapolation of research and observation to predict the risks of sending humans into a microgravity-vacuum environment. In spite of doubts expressed by some very prominent scientists in those early days, experience has validated man's remarkable adaptability.
Humans have now lived continuously in the microgravity environment of earth orbit for up to 84 days during the U. S. Space Lab Program and for more than one year in the Russian Mir Space Station. Changes have been observed in the function of several organ systems. Adjustment occurs fairly rapidly in vestibular function, blood volume and fluid distribution. Most prominent are those changes involving the musculoskeletal, endocrine, renal, hematologic and cardiovascular systems, but thus far, no related conditions have been observed that prevented a return to normal function after a period of readaptation to the earth's one-G environment.
Knowledge of Aerospace Medicine has expanded rapidly over the past forty years, but what we have learned in Aerospace Medicine is only a fraction of the contributions to our lives and our culture that has come from the space program. The lives of earth-bound humans have been enriched by many products and benefits from space. Orbiting satellites provide communications and information about weather and earth resources that have greatly accelerated a global economy. Modern medical science has become dependent upon telecommunications, automated data services, fiberoptics, micro-miniturization, and upon many of the strong, durable, lightweight, malleable, non-reactive materials which are directly related to the space program. There have been many other significant developments. As we enter the 21st Century, the aerospace industry has evolved to become a major player in the international political and economic scene, and unmanned launches are far more frequent than the more publicized "manned" space vehicles.
Much of the stimulus that propelled the United States into space and on to the moon within a decade was the threat of the Soviet Union. The race to "control" space was driven by competition between the two nuclear powers to develop weapons technology and counter-technology. No longer is there a serious threat of global nuclear holocaust. An interesting and perhaps greater competitive force — economic survival — has replaced it.
The eleventh edition of Janes' Space Directory records forty-seven (47) nations with satellite or rocket launch involvement. India became the eleventh (11th) nation to launch a satellite into earth orbit more than a decade ago. The rapid spread of the interest in space and ability to exploit satellite technology has significant public health ramifications that will be mentioned later in this paper.
Many governments subsidize major programs not only for rocketry development, but also in order to reduce the cost of commercial launches. Several commercial operations have been unsuccessful and have already dropped out of this potentially lucrative business. Space-industry revenue in 1996 is reported to have been $77 billion, and will top $121 billion for the year 2000. Greater than half of this comes from commercial activity and most of that is generated in the United States. The Kennedy Space Center alone provided a $1.038 billion boost to Florida's economy in Fiscal Year 1997. We Floridians have a vital interest in this commercial space competition. Our investment in the future involves a concern for jobs, scientific progress and technologic leadership.
How do these developments affect the health and healthcare of the workforce in the aerospace industries? Well, just as there has been maturation and transition in the space program, so has there been change in healthcare priorities.
For years concern for the health and protection of the astronauts was prominent in industry meetings and publications. The health of flight crew members is of paramount importance and a number of unique risks continue to need special attention from the medical community; however, the health of millions of workers, worldwide, who design, test, construct, launch and maintain the hardware and supporting systems is of growing concern. Realization that the health and safety of this huge workforce is critical to the efficiency, productivity and commercial success in this industry has led to recognition that specialized health care to this occupational group is important.
For several years, the Kennedy Space Center (KSC) in Florida hasbeen a recognized leader within the U. S. Government in providing comprehensive quality Occupational and Environmental health services to a large aerospace workforce. The Kennedy Space Center program was described in a special edition of the Journal of the Florida Medical Association on Space Medicine.1 There have been several significant changes since the 1992 publication.
In late 1996 The National Aeronautics and Space Agency (NASA) decided, as a part of the effort to reduce the size of the Washington, DC Headquarters, to move the management of the NASA Occupational Health Program from Washington, DC to KSC. The Kennedy Space Center was designated the "Lead Center" for the NASA Occupational Health Program. The major goals of the NASA Program were stated in the Memorandum of Understanding between NASA Headquarters and The Kennedy Space Center for Support of the NASA Occupational Health Program, dated October 3, 1996. They are:
One of the first major activities funded by the Lead Center was a comprehensive assessment of the existing Agency Occupational Health services. The objectives of this assessment were stated in the controlling documentation that authorized the effort. The objectives were to:
The assessment was completed and the final report submitted in September 1997. It confirmed the quality of the NASA Occupational Health programs. The report emphasized that the central orientation of a successful program must be to prevent illness or injury of the worker and for optimal success it is necessary to share information and have free communications among the occupational health specialists and members of many other health disciplines. Cooperation with industrial hygienists, health physicists, environmental sanitation and pollution control engineers, waste management engineers, emergency medical services personnel, medical technicians, occupational health nurses, employee assistance counselors, health education specialists, training program instructors, workers' compensation experts, employers, and community health resources is essential for a world class program.
Several elements are considered basic for any comprehensive Occupational Medicine program, whether support is for a NASA Center or some other large aerospace workforce. Details of each of these elements will vary depending on the location and the population. While the following are considered essential elements, many other services may be offered.
A physician trained and experienced in the specialty of Occupational Medicine, and familiar with the worksite should be available during clinic hours. All providers of clinical Occupational Medical services should be familiar with the workplace and have the opportunity to periodically do work place walk-through surveys. Illness and injury prevention demands that the health care providers understand the work-place processes and the inherent risks to the workers.
Treatment services for work related illnesses and injuries to the workforce (including Case Management, Workers' Compensation and OSHA reporting, and return to work) must be available. Effective case management can return sick or injured employees to work quickly. Cooperation with employers is essential to identify meaningful jobs for employees with temporary restrictions. Investigation of even the most minor of illnesses or injuries is an important part of preventing future health problems in the work place.
Reliable Emergency Medical Services (EMS) should be assured. Such services may be provided "in-house" or from external emergency systems. While Occupational Health personnel may not be directly involved in the provision or direction of the EMS, there should be a mechanism in place for the Medical Services Director to review reports from EMS responses to the worksite.
Surveillance physicals are only a small part of a comprehensive surveillance program, but are the most important way to detect unsuspected exposures or early health risks. The results of the exams should be reported to the worker and records available to the personal physician. If the exams are not performed on-site then some mechanism to have the results reviewed by the OHP Medical Director should be in place.
The extent of worker and work place surveillance will vary with the environmental and physical risks to the worker. There may be confusion regarding the nomenclature used in a surveillance program. This can best be avoided by written guidelines and procedures that define terms. A generally accepted set of definitions for monitoring programs2 is as follows:
Clinical Monitoring is a standard complete physical including review of the employee's health history and a hands-on examination.
Medical Monitoring is sometimes called health effects monitoring and includes standard blood chemistries for hepatic, renal, metabolic and other organ function, as well as electrocardiographic and pulmonary function testing. The test results are compared to population norms and to baseline results established on the individual worker.
Biologic Monitoring is sometimes called biochemical effects monitoring. It refers to the evaluation of specific environmental exposures through measurements of the agents (e.g. lead, cadmium, cholinesterase, etc.) or their metabolites in biological samples. The results are compared to reference values known as biological exposure indices (BEIs).
Environmental Monitoring is the estimation of exposure by sampling of the workplace environment for known or suspected hazardous agents. The results are compared with the published threshold limit values or TLV (ACGIH), or the permissible exposure level or PEL (OSHA).
The health education and wellness program may be very limited or quite extensive. There is increasing evidence that good programs can be cost effective. However, there is little data to indicate that programs are effective in reducing costs of illness care if they do not offer baseline health risk appraisals (HRA) to identify persons at increased risk of cardiac and/or behavioral events. Aggressive educational programs to reduce risks (concentrating on the high-risk group), and documentation of the risk reduction through follow-up testing are essential components of effective programs. Such programs require the participation of a high percentage of employees and the cooperation of their personal physicians.
The aerospace workforce is mobile. Many travel frequently on work-related assignments. Safeguarding the health of these travelers is a major preventive medicine concern. The emphasis on travel medicine and traveler health services may differ with the circumstances. Those locations with many travelers to developing countries should provide comprehensive services. Those with few travelers, or travelers predominantly to western and developed nations should adjust their programs accordingly. The goal of the traveler health service is to prevent travel-related illness or mishap and promote a successful trip. It is essential that the traveler begins the trip in good health, or that chronic health problems are stable and compatible with the itinerary. Preparation and education are the cornerstones to successful travel. A core body of knowledge plus access to current information is essential to provide quality services to international travelers. The required information is quite dynamic and includes social, political, meteorological and health conditions on a global scale.
The Employee Assistance Program (EAP) should be more than a counseling service for substance abusers. To be maximally effective, the counselors should provide recurring training to managers and supervisors about the scope and appropriate use of the program and early recognition of mental health problems, in themselves and co-workers. Restricted access and integrity of the program must be maintained or those who most need the service will not use it (this is a management responsibility).
The statutory nature and great potential fines for non-compliance sometimes elevate the priority of these programs beyond important preventive health programs in the budget cycle. Well planned, proactive programs to anticipate and avoid any non-compliance issues are the goal. Effective programs require close coordination and sharing of resources and information between the health, environmental and safety disciplines.
Effective prevention of work place illnesses and injuries begins with reporting of all mishaps. If one believes that all accidents are preventable, then minor incidents, not even of OSHA reportable severity, should be reported and investigated. The program should be a cooperative effort by many offices and organizations. Accurate data on work place injury/illness severity and lost-time occurrences are necessary to evaluate the success of the program.
There should be techniques to measure quality and continuous improvement in every Occupational Medical service provided. The quality assurance program must provide for confirmation of credentials and the assignment of responsibility based upon those credentials. There should be written permission for the staff to perform special examinations or procedures, approved by the Medical Director. Protocols for treatment of specific conditions and dispensing of medications by Physician's Assistants, Nurse Practitioners, Registered Nurses (RN), Licensed Practical Nurses (LPN), paramedics and technicians should be approved in writing by the Medical Director. Such provision of care and dispensing should comply with state and federal legislation. Retrospective audit should be done on samples of representative health records in order to assure that minimum acceptable documentation of appropriate care is legibly recorded.
The ten elements described are essential to any comprehensive Occupational Health program; however, since much of the medical support to the aerospace industry is provided through contracting by the Government or major corporate entity, obviously the procurement offices responsible for arranging these services must have major involvement to assure the quality of the care provided to their workforce.
International Public Health concerns related to the expansion of the aerospace industry was mentioned above, and deserves elaboration. There are dozens of countries involved in launching rockets. In Florida our rocket launches usually occur over water, but in some countries launches must occur near and over populated areas. Regardless of the emphasis on safety, major accidents will occur.
A number of propellant mixtures are under development, (and in use), that have less toxicity for humans, however, most of the launch systems currently use one of the hydrazine mixtures as fuel, and an oxide of nitrogen (usually Nitrogen Tetroxide) as the oxidizer.
Both of these chemical families are potentially very hazardous for humans. Physicians and Public Health officials that live near launch areas should learn what materials are used, and the related hazards.
Even those mixtures less toxic for humans still have great explosive potential. This is true also for the solid rocket engines that are being commonly used as "strap-on" engines to increase lift capacity.
Many of the heavy lift launch systems are using liquid oxygen and liquid hydrogen or liquid oxygen and one of the petroleum fuels. The orbiting payload, either manned or unmanned usually still will use a hydrazine fuel with an oxide of nitrogen oxidizer as the propellant in the orbital maneuvering and reaction control rockets. These are prepared and fueled before launch and present a sometimes-overlooked potential for significant exposure.
The greatest chance for human exposure to the hazardous rocket propellants is during storage and fueling operations. Odor is not a valid indicator of a dangerous environment. The environmental monitoring equipment must be reliable and of sufficient sensitivity to indicate the presence of toxic gas in very small concentrations. A good Occupational Medicine program, anywhere in the world, must provide medical and biologic monitoring for employees working in propellant storage and fueling operations, and work closely with Public Health Officials in planning for the protection of the inhabitants of communities near rocket launch facilities.
Florida physicians should be especially proud of the significant role that we have had in the success of the U. S. Space Program and the many health benefits that have directly resulted from the space experience and related technologic advances. It is more important that we recognize the expanding commercial and international competition in this industry, the potential public health risks involved, and the necessity for medical community participation in providing the skilled occupational health services needed by this growing specialized workforce.
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