    [House Hearing, 114 Congress]
    [From the U.S. Government Publishing Office]

                   HUMAN SPACEFLIGHT ETHICS AND OBLIGATIONS:
                      OPTIONS FOR MONITORING, DIAGNOSING,
                         AND TREATING FORMER ASTRONAUTS

    =======================================================================

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON SPACE

                  COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 June 15, 2016

                                   __________

                               Serial No. 114-83

                                   __________

     Printed for the use of the Committee on Science, Space, and Technology

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

           Available via the World Wide Web: http://science.house.gov

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                  COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY

                       HON. LAMAR S. SMITH, Texas, Chair
    FRANK D. LUCAS, Oklahoma             EDDIE BERNICE JOHNSON, Texas
    F. JAMES SENSENBRENNER, JR.,         ZOE LOFGREN, California
        Wisconsin                        DANIEL LIPINSKI, Illinois
    DANA ROHRABACHER, California         DONNA F. EDWARDS, Maryland
    RANDY NEUGEBAUER, Texas              SUZANNE BONAMICI, Oregon
    MICHAEL T. McCAUL, Texas             ERIC SWALWELL, California
    MO BROOKS, Alabama                   ALAN GRAYSON, Florida
    RANDY HULTGREN, Illinois             AMI BERA, California
    BILL POSEY, Florida                  ELIZABETH H. ESTY, Connecticut
    THOMAS MASSIE, Kentucky              MARC A. VEASEY, Texas
    JIM BRIDENSTINE, Oklahoma            KATHERINE M. CLARK, Massachusetts
    RANDY K. WEBER, Texas                DONALD S. BEYER, JR., Virginia
    JOHN R. MOOLENAAR, Michigan          ED PERLMUTTER, Colorado
    STEPHEN KNIGHT, California           PAUL TONKO, New York
    BRIAN BABIN, Texas                   MARK TAKANO, California
    BRUCE WESTERMAN, Arkansas            BILL FOSTER, Illinois
    BARBARA COMSTOCK, Virginia
    GARY PALMER, Alabama
    BARRY LOUDERMILK, Georgia
    RALPH LEE ABRAHAM, Louisiana
    DRAIN LAHOOD, Illinois
    WARREN DAVIDSON, Ohio
                                     ------

                             Subcommittee on Space

                         HON. BRIAN BABIN, Texas, Chair
    DANA ROHRABACHER, California         DONNA F. EDWARDS, Maryland
    FRANK D. LUCAS, Oklahoma             AMI BERA, California
    MICHAEL T. McCAUL, Texas             ZOE LOFGREN, California
    MO BROOKS, Alabama                   ED PERLMUTTER, Colorado
    BILL POSEY, Florida                  MARC A. VEASEY, Texas
    JIM BRIDENSTINE, Oklahoma            DONALD S. BEYER, JR., Virginia
    STEVE KNIGHT, California             EDDIE BERNICE JOHNSON, Texas
    WARREN DAVIDSON, Ohio
    LAMAR S. SMITH, Texas

                                C O N T E N T S

                                 June 15, 2016

                                                                       Page
    Witness List.....................................................     2

    Hearing Charter..................................................     3

                               Opening Statements

    Statement by Representative Brian Babin, Chairman, Subcommittee
      on Space, Committee on Science, Space, and Technology, U.S.
      House of Representatives.......................................     4
        Written Statement............................................     6

    Statement by Representative Donna F. Edwards, Ranking Minority
      Member, Subcommittee on Space, Committee on Science, Space, and
      Technology, U.S. House of Representatives......................     8
        Written Statement............................................    10

    Statement by Representative Lamar S. Smith, Chairman, Committee
      on Science, Space, and Technology, U.S. House of
      Representatives................................................    12
        Written Statement............................................    14

    Statement by Representative Eddie Bernice Johnson, Ranking
      Member, Committee on Science, Space, and Technology, U.S. House
      of Representatives.............................................    16
        Written Statement............................................    17

                                   Witnesses:

    Dr. Richard Williams, Chief Health and Medical Officer, NASA
        Oral Statement...............................................    19
        Written Statement............................................    22

    Captain Chris Cassidy, United States Navy (USN); Chief, Astronaut
      Office, NASA
        Oral Statement...............................................    28
        Written Statement............................................    30

    Captain Scott Kelly (USN, Ret.), Former Astronaut, NASA
        Oral Statement...............................................    35
        Written Statement............................................    37

    Captain Michael Lopez-Alegria (USN, Ret), President, Association
      of Space Explorers-USA; Former Astronaut, NASA
        Oral Statement...............................................    41
        Written Statement............................................    44

    Dr. Jeffrey Kahn, Professor of Bioethics and Public Policy, Johns
      Hopkins Berman Institute of Bioethics; Chairman, Committee on
      the Ethics Principles and Guidelines for Health Standards for
      Long Duration and Exploration Spaceflights, Board on Health
      Sciences Policy, National Academies of Sciences
        Oral Statement...............................................    54
        Written Statement............................................    57

    Discussion.......................................................    62

                 Appendix I: Answers to Post-Hearing Questions

    Dr. Richard Williams, Chief Health and Medical Officer, NASA.....    78

    Captain Chris Cassidy, United States Navy (USN); Chief, Astronaut
      Office, NASA...................................................   100

    Captain Scott Kelly (USN, Ret.), Former Astronaut, NASA..........   109

    Dr. Jeffrey Kahn, Professor of Bioethics and Public Policy, Johns
      Hopkins Berman Institute of Bioethics; Chairman, Committee on
      the Ethics Principles and Guidelines for Health Standards for
      Long Duration and Exploration Spaceflights, Board on Health
      Sciences Policy, National Academies of Sciences................   114

                            HUMAN SPACEFLIGHT ETHICS
                                AND OBLIGATIONS:
                      OPTIONS FOR MONITORING, DIAGNOSING,
                        AND TREATING FORMER ASTRONAUTS

                                  ----------

                            WEDNESDAY, JUNE 15, 2016

                      House of Representatives,
                                  Subcommittee on Space
                   Committee on Science, Space, and Technology,
                                                       Washington, D.C.

        The Subcommittee met, pursuant to call, at 2:43 p.m., in
    Room 2318 of the Rayburn House Office Building, Hon. Brian
    Babin [Chairman of the Subcommittee] presiding.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. The Subcommittee on Space will now come to
    order.
        Without objection, the Chair is authorized to declare
    recesses of the Subcommittee at any time.
        Good morning. Welcome to today's hearing titled ``Human
    Spaceflight Ethics and Obligations: Options for Monitoring,
    Diagnosing, and Treating Former Astronauts.''
        I recognize myself for five minutes and an opening
    statement.
        As a Nation, we have obligations to those we put in harm's
    way. As a Congress, we have a responsibility to provide for the
    treatment of conditions caused by federal service. As a
    legislator that represents the Johnson Space Center and the
    Astronaut Corps, I have a duty to care for my constituents.
        Since the 1960s, the United States of America has asked its
    bravest to travel in space in service to their country. The
    government recognizes its obligation to care for those it puts
    in harm's way in other instances. For example, we provide for
    the care of our veterans and our federal employees when their
    injuries are caused by their federal service.
        NASA currently provides treatment for active NASA
    Astronauts, and management and former astronauts are eligible
    for treatment of injuries sustained in their service through
    existing programs at the Department of Labor and the Department
    of Veterans Affairs.
        Over the last 15 years, several reports have highlighted
    the potential hazards of human spaceflight and the ethical
    obligations that we have as a Nation, and the additional steps
    that we might take and need to take to address gaps in meeting
    those obligations.
        From the dynamic launch environment to the unforgiving
    vacuum of space, to the energetic reentry to Earth, human
    spaceflight has always placed astronauts in challenging
    environments. Even training for spaceflight carries significant
    risks.
        Up until recently, however, space travel was measured in
    days. Mercury, Gemini, Apollo, and the Space Shuttle program
    placed astronauts in space for relatively short periods of
    time. Now, with the completion of the International Space
    Station, our astronauts now spend months in space. The risks
    and potential impacts on our astronauts' health are not always
    seen immediately.
        Captain Scott Kelly recently returned from the ISS after
    spending 340 days in space on one mission. This put his
    cumulative time in space at 520 days. Extended missions like
    his are teaching us a lot about the long-term effects of human
    spaceflight.
        Weightlessness leads to osteoporosis and loss in bone
    density. Long-duration space missions also seem to impact
    vision, as 60 percent of ISS astronauts reported worsening
    eyesight. Furthermore, radiation exposure increases the
    likelihood of cancer. These are just some of the conditions we
    know about. Staying in space longer and pushing farther into
    deep space will likely present additional risks.
        And while NASA attempts to mitigate these risks with
    protocols and countermeasures such as exercise, drug
    treatments, and spacecraft shielding, there will probably
    always be a cost to our astronauts that they bear for traveling
    in space.
        This raises several fundamental questions. For instance, is
    the request for additional authority simply about treating
    former astronauts, or is it also about NASA getting better data
    on human spaceflight? Are these two issues related? Are there
    classes of astronauts such as payload specialists who were not
    government employees that aren't covered by existing
    authorities? How should NASA administer treatment? Should they
    do it in-house or simply reimburse patients for this treatment?
    If NASA decided to diagnose conditions in-house, does this pose
    a potential conflict of interest when NASA is financially
    obligated to compensate former astronauts for conditions caused
    by their federal service? How would additional authority affect
    existing rights and benefits under current statutes? How would
    creating a new program at NASA impact the causation standard
    set forth by the Departments of Labor and Veterans Affairs? In
    other words, will a new authority make it easier or harder for
    astronauts to receive treatment and compensation?
        In order to address these questions, Congress included a
    provision in the 2005 NASA Authorization Act that asked for a
    plan on how to best provide for former astronaut care.
    Similarly, the most recent Authorization Act that received
    unanimous support in the House and awaits consideration by the
    Senate contained a provision asking for a cost estimate for
    expanding treatment.
        I think everyone here wants to make sure that we are doing
    right by our astronauts. They put themselves in harm's way to
    advance our knowledge of the universe and by bringing great
    pride to our Nation.
        I'm also very proud to say that I represent a great number
    of these astronauts who call Houston their home. As a health
    care professional myself and as their representative, you could
    say it's my duty emphatically to make sure these folks are
    taken care of properly.
        But this isn't simply about addressing a moral and ethical
    obligation. There is also a great benefit that we receive from
    providing this care. The long-term health information gained by
    providing treatment to former astronauts will give us a greater
    understanding of radiation exposure, vision impairment, bone
    loss, and many other ailments. This in turn will assist us to
    develop better monitoring and treatment protocols here on Earth
    for everyone, not just astronauts.
        I thank today's witnesses for joining us as we discuss
    these very, very significant and important issues, and I look
    forward to hearing your testimony and your answers to our
    questions.
        [The prepared statement of Chairman Babin follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. I now recognize the Ranking Member, the
    gentlewoman from Maryland, for an opening statement.
        Ms. Edwards. Good afternoon, and thank you, Mr. Chairman. I
    want to extend a welcome to our distinguished panel this
    afternoon, and thank you as well for your patience.
        Human space flight is inherently risky. That's why NASA
    exercises diligence and caution during all phases of a space
    mission, including training, vehicle flight testing, launch,
    mission operations, and landing.
        In addition to mission risks, astronauts bear significant
    personal risks, particularly as they relate to their health.
    Health risks during long-duration flights include both short-
    term health consequences as well as potential long-term health
    conditions that may arise months and sometimes years after an
    astronaut's service.
        This is a problem. Because of the small number of U.S.
    astronauts who have flown in space, and the corresponding small
    data set currently available on astronaut exposure during long-
    duration flights, characterizing those risks is a major
    challenge for NASA. However, if we are to go to Mars, as I have
    strongly advocated, mitigating these health risks is critical.
    But we also need to ensure that the risks NASA's astronauts
    take are recognized and addressed by the American people.
        While active astronauts receive comprehensive health care,
    former astronauts do not. This needs to change. We need to
    ensure that care is provided for all of our NASA astronauts,
    not just those who are on active status. Providing ongoing
    medical care for active and former astronauts will give NASA
    the needed insight to enable earlier detection and treatment of
    any potential medical problems that could result from human
    spaceflight. It will also provide NASA with the data that are
    necessary to help mitigate against health risks related to
    future human space exploration.
        This is also a recommendation of a 2014 National Academies
    report, which concluded that lifetime healthcare for astronauts
    is our ethical responsibility. The report's principle of
    fidelity recognizes that ``Given the risks that astronauts
    accept in participating in hazardous missions, NASA should
    respect the mutuality of obligations and ensure health care and
    protection for astronauts not only during the mission but after
    return, including provision of lifetime care for astronauts.''
        NASA responded to the National Academies report by
    proposing a legislative change that would give NASA the
    authority to provide medical monitoring, diagnosis and
    treatment for psychological and medical conditions that are
    deemed by NASA to be associated with human spaceflight.
        It's worth noting that, as the Chairman indicated, the
    bipartisan NASA Authorization Act of 2015, H.R. 810, that was
    passed by the House in February 2015, directs NASA to provide a
    formal response to the National Academies report. This
    response, as directed in the legislation, must include the
    budgetary resources required for implementation of the report's
    recommendations, as well as any options that might be
    considered as part of the response. Had that bill been enacted,
    it is likely that our discussion today would have been much
    better informed.
        That said, Mr. Chairman, it's clear to me that ensuring
    comprehensive care of our astronauts before, during, and after
    their active service is a high priority. NASA's legislative
    proposal provides one option for addressing this issue, and I
    hope that we can explore other options as well.
        However, the impact each option would have on existing
    authorities warrants careful consideration. For example, should
    Congress direct NASA to provide astronauts with lifetime
    healthcare in return for their service to the nation? Under
    this scenario, how would existing astronaut healthcare support
    systems be affected, including those provided by the Veterans
    Administration for former military astronauts? Or should
    Congress pattern astronaut care after NASA's legislative
    proposal by directing NASA to provide enhanced medical
    screening that would facilitate claims made by former
    astronauts for occupational health conditions under the FECA
    and VA processes and provide proactive diagnosis and treatment,
    if needed, while those FECA and VA processes are underway? In
    either scenario, how would such authority be implemented?
        In addition, we need to clarify on how NASA intends to
    establish the causality link between human spaceflight and any
    identified psychological and medical conditions astronauts may
    develop. The bottom line here is that we need to do the right
    thing.
        And so Mr. Chairman, if the Committee intends to address
    the issues contained in NASA's proposal, I would hope that we
    could craft legislation on a bipartisan basis, and I look
    forward to working with you.
        Thank you, and with that, I yield the balance of my time.
        [The prepared statement of Ms. Edwards follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. Thank you very much, Ms. Edwards.
        I now recognize the Chairman of our full Committee, Mr.
    Smith from Texas.
        Chairman Smith. Thank you, Mr. Chairman, and welcome to our
    all of our witnesses today including three astronauts. I often
    say publicly, and I'll say again now, that I consider
    astronauts to be our modern heroes for many, many reasons, and
    certainly appreciate their presence here today.
        Mr. Chairman, I also believe this is probably the first
    hearing we have had dedicated entirely to the subject of
    astronauts' health in space, and so it's most timely, and as
    you and the Ranking Member both mentioned, it might lead to
    legislation that can be helpful to them in the future.
        Since NASA selected the first group of astronauts in 1959,
    more than 300 of America's finest have ventured into the cosmos
    as explorers. Each one of these astronauts represented the
    compelling urge of humankind to explore and to discover and the
    lure of curiosity that leads us to try to go where no one has
    gone before. From Neil Armstrong's first step on the Moon to
    Captain Kelly's one-year voyage on the International Space
    Station, their peaceful exploration of outer space continues to
    inspire our nation and the world.
        In an age when spaceflight has come to seem almost routine,
    it is easy to overlook how dangerous it is and how little we
    know about the long-term health effects of spaceflight.
        For almost 20 years, astronauts have lived on the
    International Space Station. One of their primary missions has
    been to learn about the physiological and psychological effects
    of long-duration human spaceflight. Captain Kelly's one-year
    mission was in pursuit of a scientific understanding of how the
    human body responds to extended space flight.
        But even with our 20 years of experience on the ISS, we are
    only just beginning to understand the effects of long-duration
    missions. Our lack of knowledge becomes especially evident as
    NASA prepares for its journey to Mars.
        Only 24 individuals have journeyed beyond low-earth orbit.
    All of these astronauts flew during the Apollo era and never
    for more than a handful of days. Using our current propulsion
    technology, a successful mission to Mars will require
    astronauts to survive a roundtrip spaceflight of no less than
    several hundred days, and unlike our near-Earth environment,
    the trip to Mars will offer no natural protection from galactic
    cosmic rays and solar radiation.
        Today, through its Lifetime Surveillance of Astronaut
    Health program, NASA screens and monitors astronauts for
    occupational related injury or disease. This program
    contributes to our scientific knowledge of long-term health
    effects and assists participating astronauts in monitoring for
    spaceflight related illnesses and disease.
        But this program does not provide for diagnosis or
    treatment of those no longer serving, nor for management and
    retired astronauts because NASA is not explicitly authorized to
    provide such services. These astronauts can receive treatment
    from the Department of Labor or the Veterans Administration
    now, but this may not be the best process for the former
    astronauts or NASA's developing knowledge base.
        We as a nation have a responsibility to ensure that our
    astronauts, both active and retired, are provided with
    appropriate monitoring, diagnosis, and treatment of
    spaceflight-related injuries and disease. This is also the
    recommendation of the National Academy of Sciences in its
    review of NASA's study of astronaut health.
        For our nation, the question should not be whether we
    should provide these services to our astronauts, but rather how
    to do it in a way that best addresses the current and future
    needs of our space explorers in America's quest for discovery
    of new frontiers.
        Thank you Mr. Chairman, and I'll yield back.
        [The prepared statement of Chairman Smith follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. Thank you, Mr. Chairman. I appreciate you.
        I now recognize the Ranking Member of the full Committee
    for a statement, Ms. Johnson from Texas.
        Ms. Johnson. Thank you very much, and good afternoon. Let
    me welcome our distinguished witnesses.
        Mr. Chairman, I'd like to thank you for holding this
    hearing on ``Human Spaceflight Ethics and Obligations: Options
    for Monitoring, Diagnosing, and Treating Former Astronauts.''
        Our NASA astronauts are American heroes, and they are some
    of the most accomplished, highly trained, and courageous
    individuals who serve our nation in the pursuit of furthering
    our exploration of outer space.
        Astronauts and our human space program also inspire the
    next generation, with many of our youngest Americans dreaming
    of one day following in their footsteps and exploring outer
    space. And I might add that no child falls asleep when there's
    an astronaut speaking in high schools.
        It is no surprise that our astronauts are held in very,
    very high regard. They accept considerable risks in doing their
    jobs and serving our nation. And over the decades that we have
    been sending humans into outer space, more than a dozen NASA
    astronauts have paid the ultimate price as part of this
    service.
        That's why I'm pleased that we are examining the
    responsibility we have to care for our astronauts, even after
    they have left active status including looking at the risk of
    cancer, musculoskeletal conditions, and ocular disorders are
    just a few of the known health concerns related to human
    spaceflight. But there is still much that we are learning and
    need to learn about the potential effects of space on the human
    body and on human health.
        Congress has acted to ensure that others we have put in
    harm's way, such as those who have served in our military,
    receive lifetime healthcare. It is time we do the same for NASA
    astronauts.
        The practicalities of how we authorize the provision of
    such health care is very important, and I look forward to
    hearing from our witnesses on key questions and issues that
    Congress needs to consider before we legislate in this area.
        I thank you, Mr. Chairman, and yield back.
        [The prepared statement of Ms. Johnson follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

          Chairman Babin. Yes, ma'am. Thank you.
        Now I'd like to introduce our panel of distinguished
    witnesses.
        Our first witness today is Dr. Richard Williams, Chief
    Health and Medical Officer for NASA. In this role, Dr. Williams
    is responsible for the oversight of all health and medical
    activities at NASA including the medical aspects of all
    national and international NASA missions involving humans. He
    has extensive experience in the clinical practice of general
    surgery, aerospace medicine, and occupational medicine as well
    as in administrative medical management. During his 27-year Air
    Force career, Dr. Williams served in a wide variety of settings
    as a clinical practitioner and medical leader including service
    in the contingency deployments. Dr. Williams holds an M.D.
    degree from the Virginia Commonwealth University and completed
    residencies in general surgery at Wright State University and
    an aerospace medicine and occupational medicine at the United
    States Air Force School of Aerospace Medicine at Brooks Air
    Force Base in Texas. Thank you for being here.
        Second witness today Captain Chris Cassidy, a United States
    Navy SEAL and the 16th Chief of the Astronaut Office at NASA.
    As NASA's Chief Astronaut, he is responsible for flight
    assignments, mission preparation, and on-orbit support of U.S.
    crews as well as organizing astronaut office support for future
    launch vehicles. Captain Cassidy was selected as an astronaut
    by NASA in 2004, and he's a veteran of two space flights, STS-
    127 and Expedition 35. During STS-127, Cassidy served as a
    Mission Specialist and was the 500th person in history to fly
    into space. Captain Cassidy has been deployed twice to the
    Mediterranean and twice to Afghanistan. He is the recipient of
    the Bronze Star with a Combat V and Presidential Unit Citation
    for leading a nine-day operation at the Zawar Kili Cave on the
    Afghanistan-Pakistani border. Captain Cassidy received a
    bachelor of science in mathematics from the U.S. Naval Academy
    and a master of science in ocean engineering from Massachusetts
    Institute of Technology. Thank for being here. I'm the proud
    father of a Navy SEAL myself.
        Our third witness today is Captain Scott Kelly, a retired
    U.S. Naval Officer and former NASA Astronaut, who is fresh off
    his one-year mission in space. Welcome home, Captain Kelly.
    I've had the distinct pleasure and honor of meeting and
    visiting with Captain Kelly on several occasions before and
    after his historic mission. In 1996, Captain Kelly was selected
    by NASA. He has logged more than 520 days in space on four
    space flights and served as Space Shuttle Pilot on STS-103 in
    1999 and was the Mission Commander on STS-118 in 2007. Captain
    Kelly also served as a Flight Engineering for ISS Expedition
    25, and as the Commander of ISS Expedition 26. In March of
    2015, Captain Kelly launched for a one-year mission to the ISS
    serving as a Flight Engineer for Increments 43 and 44 and
    Commander for Increments 45 and 56. Captain Kelly returned to
    Earth on March 2nd, 2016, after his historic 340-day mission
    aboard the ISS. Captain Kelly received a bachelor of science
    degree in electrical engineering from the State University of
    New York Maritime College and a master of science degree in
    aviation systems from the University of Tennessee in Knoxville.
    Thanks for being here, Captain Kelly.
        Our fourth witness today is Captain Michael Lopez-Alegria,
    President of the Association of Space Explorers-USA, a retired
    U.S. Naval Officer, and former NASA Astronaut. Captain Lopez-
    Alegria has over 35 years of aviation and space experience with
    the U.S. Navy and NASA and a variety of roles including Naval
    Aviator, Engineering Test Pilot, and Program Manager, NASA
    Astronaut, and International Space Station Commander. He is a
    four-time astronaut, having flown on Space Shuttle Missions
    STS-73, STS-92, and STS-113, and serving as Commander of ISS
    Expedition 14, flying to and from the ISS aboard Soyuz-IMA-9.
    He holds NASA records for the most extravehicular activities,
    or spacewalks, or EVAs, 10 EVAs and cumulative EVA time of 67
    hours and 40 minutes. Captain Lopez-Alegria received a bachelor
    of science in systems engineering from the U.S. Naval Academy
    and master of science in aeronautical engineering from the U.S.
    Naval Postgraduate School. He is also a graduate of Harvard
    University's Kennedy School of Government Program for Senior
    Executives and National and International Security. Thank you
    for being here today, Captain.
        Our final witness today Dr. Jeffrey Kahn, Professor of
    Bioethics and Public Policy at Johns Hopkins Berman Institute
    of Bioethics, and Chairman of the Committee on Ethics,
    Principles and Guidelines for Health Standards for Long
    Duration and Exploration Spaceflights for the Board on Health
    Sciences Policy at the National Academies of Sciences. His
    research interests include the ethics of research, ethics in
    public health, and ethics in emerging biomedical technologies.
    Dr. Kahn speaks widely both in the United States and abroad and
    has published four books and over 125 articles in bioethics and
    medical literature. Dr. Kahn received his B.A. from the
    University of California-Los Angeles, Ph.D. from Georgetown
    University, and MPH from Johns Hopkins Bloomberg School of
    Public Health.
        The Committee also invited a representative from the
    Department of Labor to discuss how the Department of Labor
    currently provides for treatment of federal employees under the
    Federal Employee Claims Act, or FECA. The Committee sent
    Secretary Perez or anyone in the agency that he would like to
    designate an invitation to appear. Unfortunately, the
    Department of Labor could not find anyone to appear, which is
    very surprising since there are 17,000 employees at the
    Department of Labor.
        Furthermore, we only asked them to comment on what they
    already do. Executive Branch officials have a responsibility to
    Congress and to the taxpayers of the United States to provide
    testimony and inform the legislative process. I am disappointed
    that a federal agency was unable to assist Congress, failing to
    fulfill this fundamental responsibility. It is no wonder that
    NASA wants to handle these issues themselves.
        I would now like to recognize Dr. Williams for five minutes
    to present his testimony.

                   TESTIMONY OF DR. RICHARD WILLIAMS,

                 CHIEF HEALTH AND MEDICAL OFFICER, NASA

        Dr. Williams. Mr. Chairman and Members of the Committee,
    thank you for this opportunity to appear before you today to
    discuss the critical issue of astronaut healthcare. This is an
    issue that has consumed me in my role as Chief Health and
    Medical Officer for NASA, and I am very grateful that the
    Committee is using its limited time and resources to focus on
    this critical agency priority.
        Astronauts are exposed to unique hazards that no one else
    on Earth has experienced. Microgravity and space radiation are
    just two of the exposures that are only found when we venture
    into space. Some conditions such as reduced muscle mass caused
    by exposure to microgravity are somewhat foreseeable while
    others are complete surprises. Certainly, the visual problems
    and increased risk of cataracts astronauts experience was not
    expected or predicted.
        For active astronauts, NASA currently provides medical care
    and treatment. We also use data from the treatment of active
    astronauts to figure out ways to minimize negative impacts to
    astronaut health.
        Some of the things we do include monitoring for radiation
    exposure, using exercise to combat microgravity effects, and
    continued health monitoring. While these efforts can't entirely
    mitigate exposure to space, they are valuable.
        However, when it comes to former astronauts, the situation
    is different. We invite astronauts to participate in our
    voluntary Lifetime Surveillance of Astronaut Health program.
    This includes a limited health status evaluation on an annual
    basis at the Johnson Space Center Flight Medical Clinic.
        However, if there are questions or concerns from this
    evaluation, NASA can only encourage astronauts to follow up
    with their personal healthcare providers. This presents a
    number of problems. NASA cannot do all the tests it believes
    need to be done to effectively monitor former astronauts as
    some of these tests would be considered personal healthcare. If
    personal physicians do tests and evaluations, we often do not
    have access to the data unless the astronaut aggressively
    pursues getting this data to us. And healthcare providers often
    don't understand the need for some of the targeted tests that
    we require for occupational health surveillance and would not
    routinely order them.
        For example, some astronauts should probably be receiving
    yearly MRI scans of the area around their eyes. MRI scans are
    not normally used as preventive screening; they are usually
    ordered in response to illness or injury.
        I need to emphasize how small this population is. There are
    only 280 living astronauts that have flown in space--280. That
    isn't even enough to take a good consumer product survey, let
    alone try to predict what effects human spaceflight might have
    on the human body 10, 20 or 30 years down the road. An average
    doctor or nurse practitioner no matter how skilled they are has
    no exposure to or understanding of these issues.
        With only 280 people to collect data from, we need to get
    as much data as possible from every one of them. With only 60
    percent of our former astronauts participating in the current
    surveillance program, expanding our authority to provide for
    extensive testing would be a great incentive to increase this
    number. We believe 80 percent or more would participate if our
    authority to provide testing and monitoring was expanded.
        Being able to gather data on astronauts' medical conditions
    and understand the health impact of spaceflight exposures over
    time is essential to provide crew health and safety during
    long-term journeys beyond low-Earth orbit. If we're serious
    about going anywhere beyond low-Earth orbit, we'll need to
    understand these risks.
        Ethically, we will make sure all decisions astronauts make
    about their healthcare and personal information are completely
    voluntary. This brings me to an issue that may even be more
    important than our need for data, and that is our ethical
    obligation to our astronauts. When the United States government
    puts individuals in harm's way, our government has an
    obligation to care for them. Our military personnel are
    provided the care they need for the hazards and dangers they
    have faced in service to our country. The Institute of Medicine
    has in multiple studies pointed out that NASA has an ethical
    obligation to the astronauts who have dared exposures no other
    human beings in history has faced.
        To meet the health needs of our astronauts and to live up
    to our ethical obligations, I urge Congress to act to ensure we
    can safeguard the well-being of our former and future
    astronauts.
        Mr. Chairman, I would be glad to answer any question you or
    any other member might have.
        [The prepared statement of Dr. Williams follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. Thank you, Dr. Williams.
        I now recognize Captain Cassidy for five minutes to present
    his testimony.

                  TESTIMONY OF CAPTAIN CHRIS CASSIDY,

                       UNITED STATES NAVY (USN);

                     CHIEF, ASTRONAUT OFFICE, NASA

        Captain Cassidy. Mr. Chairman and Members of the Committee,
    I sincerely appreciate the chance to appear before you today.
    Thank you very much.
        As the Chief Astronaut for NASA, this issue is not only
    critically important to the agency but also of great importance
    to myself, both professionally and personally. In my role as
    the Chief, I serve in the most senior leadership position for
    active astronauts. I am the principal adviser Administrator
    Bolden through NASA leadership and the chain of command on all
    aspects of astronaut operations. This covers a wide variety of
    tasks from astronaut training, operations, and safety to
    advising on spacecraft design and even finding astronauts to
    speak in order to inspire our nation's students and the public
    and to keep those high school students from falling asleep.
        We take healthcare very, very seriously. Other than our
    crew, the most precious resource on the International Space
    Station is time. We have an international mix of six crew
    members on the Space Station, and each of them has only 16
    hours of awake time per day. Every minute of this period is
    treated as a critical resource similar to that of air, water or
    food. This time is used to accomplish the hundreds of
    scientific experiments to execute the many tasks required to
    keep the ISS functioning yet we still schedule two hours of
    exercise every single day. This is done simply because it's the
    best way we have found to counteract the effects of
    microgravity exposure. Without a doubt, there are many other
    tasks that could be accomplished with those two hours. However,
    absolutely nothing is more important than keeping our
    astronauts as healthy as we possibly can.
        Our knowledge of the kinds of health changes associated
    with the exposure to space has increased as more astronauts fly
    on the Space Station. Conditions have surfaced after long-
    duration spaceflight that were not apparent in short-term space
    exposure. For example, muscle atrophy and the associated bone
    loss have been experienced on longer-duration flights that were
    not a concern on shorter missions.
        There are other major risks to long-term exposure to space.
    There is far more radiation in space without the protection of
    Earth's magnetic field. There is also experimental evidence
    that radiation encountered in space as compared to gamma or X-
    rays commonly encountered on Earth is more effective at causing
    the type of biological damage that ultimately leads to cancer.
    This means that astronauts need to be more closely monitored
    for cancer for the rest of their lives versus someone who has
    not flown in space.
        Right now, NASA only has limited authority to provide
    medical monitoring for former astronauts. Our current program,
    the Lifetime Surveillance of Astronaut Health, does basic
    health screening but can't provide for the advanced monitoring
    and testing that is needed. Expanding the tests and conditions
    NASA can proactively monitor would greatly assist in
    establishing the evidence base that we need. It would also
    increase the numbers of astronauts who participate. With only
    about 280 living people who have flown in space, and about 60
    percent of those former astronauts participating in a limited
    health evaluation, every additional astronaut who can be part
    of this population is vital.
        The other reason for doing this extensive monitoring is to
    catch medical conditions in the early stages before they become
    more serious. Proactive monitoring gives us a much better
    chance of treating diseases in the early stages with a greater
    likelihood for a positive outcome.
        The lack of advanced monitoring worries me for another
    reason. We are involved in helping to evaluate our new
    generation of spacecraft, and the lack of data hampers us in
    our efforts to go beyond low-Earth orbit. How do we design
    vehicles to protect against the long-term effects of
    microgravity and radiation exposure if we still aren't certain
    of what those effects entirely are?
        I work with our Astronaut Corps on a daily basis. This
    isn't just an abstract issue for me. I know these men and women
    and their families. Their dedication, enthusiasm, bravery and
    diligence while they voluntarily accept the risks and dangers
    of spaceflight, that should not be an excuse to not be thorough
    with their health. We need to do everything in our power to
    understand and minimize the hazards they face in order to
    further protect future generations of Americans who will one
    day live off of our planet.
        Mr. Chairman, I would be happy answer your questions, and I
    look forward to them. Thank you.
        [The prepared statement of Captain Cassidy follows:]

       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. Thank you, Captain Cassidy. I really
    appreciate that.
        I now recognize Captain Kelly for five minutes to present
    his testimony.

                    TESTIMONY OF CAPTAIN SCOTT KELLY

                              (USN, RET.),

                         FORMER ASTRONAUT, NASA

        Captain Kelly. And Mr. Chairman, I have a short video, if
    you don't mind, an introduction video.
        [Video playback]
        Mr. Chairman and Members of the Subcommittee, thank you for
    the opportunity to appear before you today to discuss the
    importance of understanding the medical impacts of human
    spaceflight on astronauts and the proposed legislation on
    astronaut health. This issue is of critical importance to me
    and to our nation's future space exploration initiatives.
        I recently returned with my colleague, Russian Cosmonaut
    Mikhail Kornienko, from nearly a year in space aboard the Isa,
    which serves as our best asset for understanding how human
    physiology behaves in a microgravity environment. Until at
    least 2024, the Space Station will continue to provide a
    platform for research on astronaut health and many other
    scientific investigations.
        The major objective of this Year in Space mission was to
    expand the experience and knowledge base required to safely
    send humans deeper into our solar system. A Mars mission is no
    easy feat and could require astronauts to be in space for three
    years or more. During this mission, we conducted more than 400
    experiments in the fields of biology, material sciences,
    chemistry, and physics. Many of these experiments focus on how
    the human body responds to weightlessness and other effects of
    long-duration spaceflight.
        One of these experiments, which was dubbed the Twins Study,
    gave researchers the unique opportunity to study my physiology
    while I was in space compared to my twin brother, retired
    Astronauts and Navy Captain Mark Kelly, who was on Earth. Data
    acquired from this Year in Space Mission will help NASA make
    determinations that will directly affect decisions regarding
    crew safety in the years to come in areas from the design of
    future spacecraft to medical and psychological risk mitigation.
    Although I've been home for 100 days, much of the data is still
    being analyzed by researchers from around the world.
        You know, much attention is paid to the risks astronauts
    face while launching aboard rockets or returning to Earth in a
    giant fireball. Much less attention is given to the other risks
    we face, which are much more insidious but potentially just as
    fatal. The environment astronauts are exposed to while in space
    is unlike anything we experience here on Earth. Specifically,
    we're exposed to high levels of radiation and carbon dioxide,
    and a microgravity environment which causes loss of bone and
    muscle, vision impairment, and effects on our immune system, to
    name just a few. These are very real issues that need to be
    solved before the human race is able to reach destinations
    beyond the Earth and the Moon.
        When I returned after 340 days, I was surprised how
    differently I felt compared to my long-duration mission of 159
    days. My muscles more quickly stiffened, and because my skin
    hadn't touched anything for nearly a year, it was extremely
    sensitive and became inflamed. I developed a hive-like rash on
    every surface of my skin that came in contact with ordinary
    surfaces on Earth during normal activities like sitting or
    lying in bed. My legs were swollen due to the fluid shift
    imposed upon my body by gravity. I even had flu-like symptoms
    that appeared to have been a result from my extended time in
    space.
        Exposure to the space environment has permanent effects we
    simply do not fully understand. The Lifetime Surveillance of
    Astronaut Health program NASA has in place to study astronaut
    long-term health is too limited to provide the data needed to
    ensure the safety of our space explorers. If we are to go
    beyond low-Earth orbit, NASA needs the ability to proactively
    and aggressively monitor, diagnose and treat astronauts who
    serve our country in the name of science and exploration.
    Expanding healthcare coverage for our U.S. Astronaut Corps will
    enable NASA to more effectively and efficiently support it and
    collect the data necessary to push out further into our solar
    system.
        Furthermore, continued investigation of space-related
    ailments and mitigation steps will help in treating similar
    ailments on Earth such as osteoporosis, muscle wasting
    diseases, high blood pressure, glaucoma, and certain brain
    disease, to name just a few. There are already FDA-approved
    treatment modalities which are a result of space-based
    research.
        Although Mars and other long-term NASA objectives seem to
    be many years ahead of us, laying a secure foundation for
    astronaut health is imperative to the continuance of our
    nation's ability to explore. Healthcare for our astronauts is
    critically important. Our astronauts are exposed to numerous
    health risk factors while in space, and while we are aware of
    some of the impacts, we just need more data from astronauts in
    space and on the ground to better understand these negative
    effects of this harsh environment.
        The proposed legislation on astronauts health will not only
    help us learn more about the impacts of human spaceflight but
    also will serve to protect the health of those who push the
    boundaries in the name of exploration on behalf of our nation.
    We are on the cusp of a new Space Age, one in which greater
    numbers of Americans will travel to space and go further than
    ever before.
        I was honored to play a small role in paving the way for
    those future pioneers but want to make it clear, this Year in
    Space mission was not my achievement; it was the achievement of
    thousands of dedicated professionals that believe, like I do,
    that the benefit of human spaceflight is vital to the continued
    success and development of our nation and our species.
        Mr. Chairman, I'd be happy to respond to any questions you
    or other members of the Subcommittee may have. Thank you.
        [The prepared statement of Captain Kelly follows:]

       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. Thank you, Captain Kelly. We really
    appreciate your testimony.
        And now I recognize Captain Lopez-Alegria for five minutes.

         TESTIMONY OF CAPTAIN MICHAEL LOPEZ-ALEGRIA (USN, RET),

             PRESIDENT, ASSOCIATION OF SPACE EXPLORERS-USA;

                         FORMER ASTRONAUT, NASA

        Captain Lopez-Alegria. That's all right. Thanks, Chairman
    Babin, Ranking Member Edwards, and Chairman Smith, and Ranking
    Member Johnson and all the Members of the Subcommittee. Thanks
    for organizing this hearing and for asking me to give you some
    comments on the proposed legislative language as the President
    of the USA Chapter of the Association of Space Explorers.
        ASE is an international nonprofit professional and
    educational organization that has only one prerequisite for
    membership: having made at least one orbit of the Earth in
    space. Our vision is a world where living, working and
    exploring in space will be as familiar to humanity as life on
    our home planet.
        We count among our members over 400 current and former
    astronauts and cosmonauts from 37 nations and are organized
    into four regional chapters: Russia, Europe, Asia, and ASE-USA,
    by far the largest with 214 living members.
        There's a standing joke at the NASA Johnson Space Center in
    Houston that if you ask five astronauts for their opinion on an
    issue, you'll get at least six answers. Nonetheless, the
    response I received from the membership of ASE-USA was absolute
    unanimity in support of the change that would allow NASA to
    provide enhanced monitoring, diagnosis, and treatment of the
    effects of health hazards that are associated with having flown
    in space.
        I heard from former astronauts who left the agency from
    several months to several decades ago, and many of the stories
    were strikingly similar. My written statement mentions some of
    the known health hazards that are unique to the spaceflight
    environment, and members of the ASE-USA convincingly confirmed
    that that list is real with many personal accounts of
    musculoskeletal, vision, bone density, and most grimly, cancer-
    related medical issues.
        In some case, their maladies were flagged during annual
    exams that are offered by NASA as part of the Lifetime
    Surveillance of Astronaut Health but in all cases, further
    diagnosis and any treatment is at the expense of the astronaut.
    There is ample precedent for targeted surveillance and
    treatment for occupationally related medical conditions both
    within the government, for instance, healthcare for veterans as
    well as screening for DOE and DOD nuclear workers as well as by
    non-government employers for their workers in mines, foundries,
    and in civilian nuclear power industry.
        But as compelling as some of my former colleagues' medical
    situations are, the most persuasive argument for this type of
    legislation is that understanding the human physiological
    response to spaceflight is imperative to inform future policies
    and procedures for managing health risks in space.
        In the absence of methodical medical surveillance and care
    for those exposed to these health risks, we are irretrievably
    losing an invaluable source of data and severely hampering our
    plans to extend human exploration beyond low-Earth orbit.
        The current and former astronaut cadre is the only study
    population that can facilitate our understanding of past and
    future space-related health risks. It is unforgivable to not
    monitor their health and collect and analyze the relevant
    associated data.
        I'm a participant in a previously mentioned LSAH. Each year
    I travel to Houston and receive a medical check that includes
    collecting my vital signs, blood and urine samples, exams of my
    vision, hearing, and lung function, an EKG, and a brief
    physical exam by a flight surgeon. Every few years, it is
    recommended that I undergo a colonoscopy to look for polyps or
    tumors that may have appeared as a result of my exposure to
    ionizing radiation while on orbit. The procedure is completely
    voluntary, and if I do choose to have it done, the results are
    not a priori shared with NASA. This is just one example of the
    lack of monitoring that negatively affects our understanding of
    the epidemiology of spaceflight.
        Another valuable test that might be performed is high-
    powered MRI of my eyes to look for anatomical changes. Like
    about 60 percent of long-duration astronauts, I suffer from
    microgravity ocular syndrome, sometimes called vision
    impairment and intracranial pressure. VIIP is emerging as one
    of the most significant and least understood health risks for
    human exploration beyond low-Earth orbit. It seems absurd that
    we do not actively study those who have suffered from it.
        During my seven months aboard the ISS, my bone mineral
    density decreased by over ten percent. While the density itself
    recovered after a couple of years, we don't fully understand if
    the structure of the bone and therefore its resistance to
    fracture has returned. A test like QCT, quantitative computed
    tomography, cannot only measure bone mineral density but also
    assess the geometry of the bone and the stress-strain index, a
    much better measure of fracture resistance. This test is also
    not performed as part of LSAH.
        What I found perhaps most startling in responses from the
    ASE-USA membership was how many reported that they have dropped
    out of the LSAH program. A relatively routine physical that
    lacks targeted surveillance of known space-related health
    hazards, let alone any kind of in-depth diagnosis or provision
    of treatment, is simply not compelling enough for many former
    astronauts who might live far from Houston to take time from
    work and family to make the trip. This means that not only is
    NASA deprived of any data related to spaceflight-specific
    health risks, even the routine surveillance that is part of
    today's LSAH is often being done by local medical providers and
    the associated information is lost to NASA.
        There is a moral and ethical obligation on the part of any
    employer to exercise due diligence to study all occupational
    hazards that its employees encounter in the workplace to
    understand the short- and long-term health effects of those
    dangers to use all reasonable methods to prevent these risks
    from negatively impacting the well-being of its current and
    future workers and to provide care for former employees who
    suffer health issues as a result of their service.
        There are a number of significant human health risks
    associated with flying in space. Many of these perils are
    unique to the spaceflight environment and most evade our full
    understanding. It's clear that we must do our utmost to
    mitigate these risks for the cadre of current and future
    American astronauts by assiduously monitoring the health and,
    where applicable, treatment of their predecessors. This
    information is absolutely imperative for the design of
    missions, vehicles, and countermeasures for the human
    exploration of space beyond low-Earth orbit.
        Thank you again for this opportunity, and I look forward to
    answering questions from the Subcommittee.
        [The prepared statement of Captain Lopez-Alegria follows:]

      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. Thank you, Dr. Lopez-Alegria.
        And now I recognize Dr. Kahn for five minutes.

                     TESTIMONY OF DR. JEFFREY KAHN,

               PROFESSOR OF BIOETHICS AND PUBLIC POLICY,

              JOHNS HOPKINS BERMAN INSTITUTE OF BIOETHICS;

                       CHAIRMAN, COMMITTEE ON THE

                    ETHICS PRINCIPLES AND GUIDELINES

                 FOR HEALTH STANDARDS FOR LONG DURATION

                     AND EXPLORATION SPACEFLIGHTS,

                    BOARD ON HEALTH SCIENCES POLICY,

                     NATIONAL ACADEMIES OF SCIENCES

        Mr. Kahn. Thank you. Chairman Babin, Ranking Member
    Edwards, Committee Chairman Smith, and Ranking Member Johnson,
    thank you for the opportunity to present testimony on this
    timely and vitally important subject today. I am a Professor of
    Bioethics and Public Policy at the Johns Hopkins University
    Berman Institute of Bioethics in Baltimore, and I should say
    after the introduction of my fellow witnesses, a rank
    underachiever.
        I appear before you today in my capacity as Chair of the
    Institute of Medicine--now the National Academy of Medicine--
    Committee on Ethics Principles and Guidelines for Health
    Standards for Long Duration and Exploration Spaceflights, which
    issued its report in April 2014, as Representative Edwards has
    already noted.
        In addition, I should note that I'm currently Chair of the
    Board on Health Sciences Policy for the Health and Medicine
    Division of the National Academies, and a member of the
    Division's standing Committee on Aerospace Medicine and
    Medicine of Extreme Environments.
        In those contexts, I will describe recommendations
    contained in the report of the committee I mentioned related to
    protecting and sustaining astronaut health.
        First, I want to say that my committee's report in 2014 was
    not the first to identify the ethical obligations to protect
    astronaut health, as has been noted by others. As outlined in
    the 2001 IOM report titled Safe Passage, and as noted in the my
    committee's report as well, the new challenges that will be
    faced in long-duration and exploration spaceflight necessitate
    a new look at the ethics principles for these missions, and I
    quote now from Safe Passage: ``Current ethical standards for
    clinical research and practice with astronauts were developed
    in an era of short space missions when repeat missions were the
    norm and a return to Earth within days was possible. In future
    missions beyond Earth orbit, however, a diverse group of
    astronauts will travel to unexplored destinations for prolonged
    periods of time. Contact with Earth will be delayed, and a
    rapid return will be impossible. Long-duration missions beyond
    Earth orbit, space colony habitation, or interplanetary travel
    will create special circumstances for which ethical standards
    developed for terrestrial medical care and research may be
    inadequate for astronauts. These ethical standards may require
    reevaluation.'' That again is from 2001.
        My committee in 2014 noted that NASA, as an employer, a
    federal agency responsible for innovation and exploration, a
    research sponsor, and an international partner, has moral
    obligations to formally recognize and act on responsibilities
    that logically flow from the ethics principles outlined in our
    report if long-duration and exploration spaceflights are to be
    ethically acceptable. Among the six principles we identified,
    two are particularly relevant for discussion in the context of
    health care for former astronauts. Those principles are (1)
    fairness, and (2) as already noted by Representative Edwards,
    fidelity. Let me quote from the report. ``Fairness is the
    principle that requires that equals be treated equally, that
    burdens and benefits be distributed fairly, and that fair
    processes be created and followed. NASA's decision making
    surrounding missions should explicitly address fairness,
    including the distribution of the risks and benefits of the
    mission, crew selection, and protections for astronauts after
    missions.''
        An important ethical challenge of exposing humans to the
    risks of long-duration and exploration spaceflight is that the
    burden of the health risks associated with these missions falls
    to a limited number of astronauts and their families as well
    while the benefits of the proposed missions accrue primarily to
    future astronauts and to society more broadly.
        In addition to being a concern of appropriate risk-benefit
    balance about going at all, the appropriate risk-benefit
    distribution must also be considered. Asking individuals to
    accept great risk, either in likelihood or magnitude of the
    harm to be caused, can be partially balanced by making a
    commitment to provide long-term health care and health
    monitoring.
        The second principle we identified is fidelity, and again I
    quote from the report. ``Fidelity is the principle that
    recognizes that individual sacrifices made for the benefit of
    society may give rise to societal duties in return. Given the
    risks that astronauts accept in participating in hazardous
    missions, NASA should respect the mutuality of obligations and
    ensure health care and protection for astronauts not only
    during the mission but after they return, including provision
    of lifetime health care for astronauts.''
        Those who consent to incur long-term health risks for
    society's benefit are entitled to fidelity, reflected in
    society's commitment to minimize any harms that emerge,
    whenever they emerge. The committee noted that this concept of
    fidelity or reciprocity resonates with the basic, widely shared
    understanding that it is unjust to allow some people alone to
    bear burdens which, in all fairness and justice, should be
    borne by the public as a whole. As a practical matter, the
    public cannot physically share the risks that astronauts will
    bear. It can, however, share the costs and burdens of ongoing
    risk mitigation efforts.
        An astronaut's consent becomes binding and irrevocable at
    the moment the mission launches. Astronauts are free to
    withdraw their agreement to participate prior to launch of
    course, but from the launch moment forward, it becomes nearly
    impossible to turn back, and astronauts likely will encounter
    uncertain and unquantifiable risk exposures and endure
    potential harms to health that will persist after the mission.
    The irrevocability of participation in spaceflight creates an
    ethical imperative to define long-term duties owed to the
    participating astronaut.
        In this context, the principles identified by our committee
    report support the minimization of risk of harm, the treatment
    of injuries or health conditions during the flight, and the
    ongoing monitoring and provision of health care after the
    flight. This binding duty to provide ongoing surveillance,
    monitoring, and health care during the lifetime of the
    astronaut is part of the continuum of risk management that
    begins with engineering and design efforts to minimize risk and
    continues through the flight and post flight. Our committee
    concluded that the ethics responsibilities that result from
    sanctioning high-risk activities include continuous learning
    and engagement in health-related activities that protect
    astronaut health, support ongoing evaluation of health
    standards, improve mission safety, and reduce risks for current
    and future astronauts.
        Employers that knowingly expose employees to risks have an
    ethical responsibility to provide protection to the extent
    possible and to address the harms that occur when protections
    fail or turns out to be inadequate. Robust research and health
    monitoring or surveillance programs that fully inform all who
    are involved, including astronauts and their families, are
    required.
        Furthermore, the committee maintained that the nation,
    through NASA, has the ethical duties to protect and sustain
    astronaut health based on the ethics principles of fairness and
    fidelity. Providing lifetime health care to astronauts respects
    the commitment that our astronauts have made and the risks they
    have taken on society's behalf.
        Thank you.
        [The prepared statement of Mr. Kahn follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Babin. Thank you, Dr. Kahn. All fascinating
    testimony. I thank every one of you witnesses for your
    testimony, and now I recognize myself for five minutes for
    questions.
        The first one I'd like to direct to Dr. Williams. How would
    additional authority affect existing rights and benefits under
    current statutes? And would creating a new program at NASA
    impact the standards that are set forth by the Departments of
    Labor and Veterans Affairs for compensation and treatment? In
    other words, will a new authority make it easier or harder for
    astronauts to receive the treatment and compensation that they
    are due?
        Dr. Williams. Thank you for the question, sir. I don't
    think that there'll be a major impact to existing
    infrastructure. As a matter of fact, we envision using an
    existing claims infrastructure working very closely with our
    partners in the Department of Labor, and we're developing the
    same relationships with the Department of Veterans Affairs to
    approach this as a facilitated claims process, providing the
    expertise and space medicine and disease-specific experts as
    well as the evidence base that we've accrued so far to help
    determine the likelihood of association with occupational
    exposure as disease develops in our former and retired
    astronauts.
        With regard to your question about whether I think this
    will make it easier to advance the plausibility of association,
    I think it likely will, sir. I think endorsement by the
    Congress in recognition that these unusual exposures can cause
    disease in our astronauts, I think that will send a powerful
    message and will enable us to be more successful in taking care
    of them.
        Chairman Babin. Absolutely. Thank you very much, Doctor.
        The next question I'd like to direct to our three
    distinguished astronauts. If NASA is given authority to provide
    additional treatment for astronauts beyond existing programs at
    the Department of Labor and Department of Veterans Affairs,
    should NASA provide that treatment in-house at NASA or
    reimburse patients for private-sector treatment? Captain
    Cassidy, how about you first?
        Captain Cassidy. Mr. Chairman, that's an excellent
    question. I think that there's some degree of care that can be
    handled in-house at the Johnson Space Center but I also think
    that there should be some flexibility in order to take care of
    the former astronauts who potentially in their older age have a
    hard time getting back to Johnson Space Center, or because of
    their condition can't make that trip.
        Chairman Babin. Right. Okay.
        Captain Kelly?
        Captain Kelly. Sir, I don't really have anything to add
    other than what Chris said, but I think, you know, the emphasis
    on some of these guys, as we age and traveling back and forth
    to Houston could be problematic.
        Chairman Babin. Sure. Thank you.
        And Captain Lopez-Alegria?
        Captain Lopez-Alegria. Yes, Mr. Chairman, pretty similar. I
    think clearly there are some things that the clinic at Johnson
    Space Center could not do from a medical perspective. We
    couldn't, you know, treat somebody with chemotherapy, for
    instance, at JSC, but I think to the extent possible, we should
    try to keep it in-house just to facilitate the transfer of the
    data, which are very important to the discussion, but agree
    with my colleagues about that being impractical in some cases.
    I think that we should endeavor to make it happen when possible
    but realize that that won't always be the case.
        Chairman Babin. Sure, and then just to follow up, if NASA
    does decide to diagnose and treat conditions in-house, does
    this pose a potential conflict of interest when NASA is
    financially obligated to compensate former astronauts for
    conditions caused by their federal service? If one of you three
    would like to take a stab at that?
        Captain Cassidy. Well, let me start by saying--and Scott
    will back me up on this--as military aviators, we have an
    adversarial relationship with our flight surgeons generally. I
    was expecting that to be the case at NASA and could not have
    been more wrong about that. The relationship that we enjoy is
    very unique, and there's no doubt in my mind that our best
    interests are at heart when they give us treatment. So I would
    have a great level of confidence that the people with whom we
    all have personal relationships would be very disposed to help
    us to the extent possible, and I don't see there being a
    conflict of interest. I think that it if you're saying the
    conflict of interest would mean they would be reluctant, I
    don't see that as a likelihood.
        Chairman Babin. Right. Anybody else? Pretty much in
    agreement?
        It's an interesting comment you make, because I was an Air
    Force dentist, and occasionally we had to put DNIF on
    somebody's records, and they were not happy: duty not to
    include flying.
        Let's see. I think I'm out of time so I will yield back,
    and we will call on the next one, the Ranking Member from
    Maryland, Ms. Edwards.
        Ms. Edwards. Thank you, Mr. Chairman, and thank you again
    to the witnesses. Your testimony was really--was very thorough.
        One of the questions that I had as we came up, and
    particularly for Captain Lopez-Alegria, if you could tell me
    whether the care is provided in-house or out-of-house in terms
    of the surveillance data that are gathered, and Dr. Williams,
    please contribute as well, it seems to me that you all are
    already close to or you already have a tool that could--a
    screening tool that could easily be used more broadly, whether
    that's at Johnson or at some private care facility, and the
    question is whether we can authorize both the mechanism for
    surveillance but also separately the provision of health care,
    in which case you would be able to capture more than the 60
    percent, I think, of the Astronaut Corps, retired and active,
    who are currently participating. Would that be right?
        Captain Lopez-Alegria. Well, I think your last point would
    absolutely be right, that you would have far more participation
    than we have. I don't know enough about what the current limits
    of the authority on the screening that are in place right now,
    but I do know that some of the tests that I mentioned in my
    oral testimony, which could be done, which hare very
    specifically targeted to hazards that are known to be caused by
    flying in space, are not being done, and I think that if that
    authority does not exist, which I assume it doesn't, who would
    be doing them, then they should be.
        Ms. Edwards. Dr. Williams?
        Dr. Williams. Yes, ma'am. We--our current authority to
    provide that ongoing health monitoring to former and retired
    astronauts is limited. Our ability to spend appropriated funds
    in providing that diagnosis and much more so in providing
    treatment in that group, we don't feel like we have the
    authority to do that. So although we have the basic framework
    in place, which is the Lifetime Surveillance of Astronaut
    Health, we believe that that framework can be greatly enhanced
    and greatly expanded and become much more comprehensive with
    specific authority to provide diagnosis and treatment.
        Similarly, we think that our ability to engage and treat
    serious illness that arises in the Astronaut Corps will be
    greatly facilitated by the--for the lack of a better word, I'd
    say the facilitated claims process we envision with our
    partnerships with the Department of Veteran Affairs and the
    Department of Labor.
        Ms. Edwards. So, I mean, I want to get to this, because I
    think there's a separate question. If we give the authority
    that then allows for the provision of health care, we could do
    that either through those who are covered by VA, those who are
    covered under the FECA, or other kinds of private health care.
    The question then becomes, can we develop a tool that
    encompasses all of the kind of surveillance that you would need
    both to provide current health care but also to look down the
    line in terms of providing prevention or looking forward to the
    future Astronaut Corps, and you're saying that we would need--
    you would require a separate legislative authority in order to
    be able to do that?
        Dr. Williams. Yes, ma'am. I think based on the very small
    number of cadre of the astronauts and the very unique exposures
    and the need for targeted surveillance and broad preventive
    surveillance in this group targeted toward those exposures that
    we know more about than anyone else on the planet, I think that
    NASA having that care--we do have within our agency a
    comprehensive healthcare delivery system that is aimed at the
    active Astronaut Corps, and leveraging our abilities along
    those lines on behalf of the retired and former astronauts
    including helping coordinate their care wherever they live I
    think would go a great way toward making sure that we take care
    of them and recovering as much data as possible to establish
    our evidence base.
        Ms. Edwards. And Captain Cassidy, I take it that you
    believe that we--that Congress has to provide a broader
    legislative authority to provide those services?
        Captain Cassidy. Yes, ma'am. I think that it's--my
    experience base is with the active astronauts, and like my two
    colleagues here, I don't have a whole lot of experience with
    what it's like as a former astronaut to go through that. I've
    talked to both of them, but where I think we can do--I know we
    can do a better job at pulling this data together, and the
    execution of how we do that, where it happens, what tests are
    done, and the mechanism for payment I think are things that can
    be further honed and discussed as we move forward and actually
    get this going, but those are things that I think we could
    collectively get a better story on.
        Ms. Edwards. And Dr. Kahn, can you tell me, is there any
    other sector that you can think of where there's an employer
    who has an employee who engages in risk for the purposes of
    completing their employment where there isn't a comparative
    ethical obligation for care?
        Mr. Kahn. Thank you, Representative Edwards. It's a really
    interesting question. In fact, part of the work of the
    committee that I had the privilege to chair, we tried to find
    parallel occupational examples, and in fact, it's quite unique
    is the short answer. And so when people leave occupational
    environment, they tend to have either a new job or they become
    retired and then they're covered by other means. So astronauts
    are really frankly in a unique category that way.
        Chairman Babin. Thank you, Ms. Edwards.
        I now call on the gentleman from Alabama, Mr. Brooks.
        Mr. Brooks. Thank you, Mr. Chairman.
        Captain Kelly, thank you, sir, for being here today and for
    your service to America's space program. As many are aware, you
    and your twin brother, Mark Kelly, are providing scientists
    with a wealth of information on the effect that human
    spaceflight has on the body. NASA is set to share the results
    of the study next year. Are you in a position where you can
    give us any previews of what they're finding so far by sharing
    with us the most surprising or interesting things that you have
    noticed so far?
        Captain Kelly. Well, I mentioned in my testimony the
    difference between my initial 159-day flight and 340, my
    symptoms immediately upon return. I have gotten some data back,
    my bone mass, muscle mass data, some of the data on my vision,
    that for me I was kind of surprised that it was relatively flat
    in comparison to the 159 days. In other words, being in space
    for twice as long didn't mean that I lost twice as much bone
    mass. It was pretty similar. So I think some of these we do
    have, a good understanding to how to mitigate the risks to bone
    and muscle loss so we can stay in space longer.
        The data with regards to my brother and the comparison with
    me, a lot of those samples just came back on SpaceX, my
    biological samples, so, you know, like most research, you
    collect the data, you analyze the data, you write the reports,
    have it peer-reviewed. I think that type of genetic data, the
    effects of the radiation environment, the effects on my immune
    system, things like that as it compares to my brother are just
    going to take much longer.
        But I was actually, you know, pleasantly surprised that my
    bone and muscle data was pretty much flat between the two
    flights, although, you know, how I felt when I got back was
    much different.
        Mr. Brooks. And this is a question for each of you, though
    I'd like to start with the astronauts, Captain Cassidy first
    and working our way around, and then on the two ends of the
    table, and whoever wants to follow them, feel free.
        With current technology, can NASA safely send an astronaut
    on a Mars mission without resulting significant adverse health
    risk, and if not, what should be done to safely protect
    astronauts on a Mars mission?
        Captain Cassidy. Sir, that's a fantastic question because
    that's where I think our nation should go, to Mars, and that's
    where our vision is, and so how do we do that effectively and
    safely is a fantastic thing to consider, and clearly, radiation
    monitoring and protection is critically important there. Do I
    think that we could do that mission safely right now? We could
    do it as safely as we think we can, and there are certain risks
    that we don't know, and that's where collecting this data
    between now and going to Mars will keep my future colleagues
    safer.
        Mr. Brooks. Captain Kelly?
        Captain Kelly. Yes, sir. You know, my time on the Space
    Station, I was really inspired that building and operating this
    vehicle was the most difficult thing we have ever done, and I
    think it's proven that if we decide to do something and we set
    our mind to it and put the resources behind it, we can be
    successful, whether that's going to Mars or curing cancer if we
    decide that that's what we're going to do, and we devote the
    appropriate resources to do it, we can do it.
        Now, there are challenges with going to Mars. Chris
    mentioned radiation, which I completely agree with. I think the
    physical challenges, that would be the number one concern I
    would have is protecting the crew members on that long trip
    away from the protection of Earth. I think there are also, you
    know, challenges in the systems that keep us alive onboard the
    Space Station. You know, these are designed to work for long
    periods of time in low-Earth orbit but having them that can,
    you know, operate consistently, reliably, get us to Mars and
    back, is a challenge, but I think it's clearly a challenge that
    if we decide that's what we want to do, then we can accomplish
    it.
        Mr. Brooks. Well, with respect to the number one concern
    that both of you have mentioned, radiation, do we have the
    technology now to protect our astronauts from the radiation of
    a long-term flight to Mars and back or do we need to develop
    new technology?
        Captain Kelly. You know, I think there's two ways to
    approach that. One is, you get there really fast so you're not
    exposed to the radiation environment for as long, and the other
    one is some means of, you know, insulating the crew members
    from it, and you know, I'm not an expert on this, but my
    understanding is, if you have a propulsion system that
    potentially has a magnetic field as part of it, that can act
    like the magnetic field of the Earth to protect us from certain
    types of radiation, but again, I'm not an expert in this area.
        Mr. Brooks. Captain Lopez-Alegria?
        Captain Lopez-Alegria. Thank you, Representative Brooks.
    You know, I think could we do it technically, technologically?
    Perhaps. It would be incredibly expensive the things that you
    mentioned and my colleagues have mentioned about radiation. You
    could shield. That takes mass. That makes the vehicle heavier.
    That makes the vehicle more expensive. The current propulsion
    technology, we've heard how long it would take the mission.
    We'd have to bring our food with us. There are so many things
    that it's possible to do. I think a breakthrough in technology
    would make a lot of those problems go away or at least become
    much more easy to solve.
        One thing that I do think is going to happen in almost any
    case, it's going to be very difficult to have any kind of a
    reasonable abort possibility once you're on your way, and so
    this country's going to have to have a different risk
    acceptance posture, not just for radiation exposure, which is
    right now three percent above the normal population is what we
    admit for a risk of exposure-induced death, that would probably
    have to change. But also just the notion that somebody could
    have an unforeseen medical problem on the way which today we
    could have the crew member on the ground in a matter of hours,
    it would take potentially months to get them back.
        So we could do it. I think we have to go through some
    evolutionary processes in the way we think both at NASA and as
    a country for it to happen.
        Mr. Brooks. Well, my time is expired, but if the Chair
    would permit for Dr. Kahn and Dr. Williams to answer, that'd be
    great, but if not----
        Chairman Babin. No, certainly, go ahead, if you have
    something to add to that.
        Mr. Brooks. Dr. Kahn or Dr. Williams, would either of you
    like to add anything to a Mars mission safety, technological
    advances we might need to ensure health safety.
        Dr. Williams. I think my colleagues covered it quite well.
    Physiologically, we believe that we could send people on a
    Mars-duration mission out and back, you know, all the other
    safety concerns notwithstanding. We believe we could do that.
    Physiologically, I think it's safe to say that those astronauts
    would be forever changed. In all likelihood, they'd have a
    greater risk of developing a fatal cancer during their lifetime
    and the associated changes in bone and muscle. I mean, they may
    have a greater fracture risk and the cataracts and all the
    things we've talked about.
        One of the great challenges are the unknowns, and there are
    unknowns and unknown unknowns with regard to the increased
    duration of spaceflight. So that's what makes it so imperative
    for us to continue our studies and to continue gathering as
    much data as we possibly can in support of an eventual Mars
    mission.
        Mr. Brooks. Dr. Kahn, do you have anything to add?
        Mr. Kahn. I would just add to what Dr. Williams just had to
    say, that the committee that I chaired actually understood that
    there were such great unknowns and unquantifiable risks, and
    rather than try to answer the question that you posed about
    what technological breakthroughs would be necessary, whether we
    could do it today, we gave them a framework to think about the
    ethics of exceeding existing standards and how to think about
    that since, as Captain Lopez-Alegria said, there are existing
    health standards and we have to evaluate those standards in
    light of the mission that is being proposed, and that's what
    the committee that I chaired had to say.
        Mr. Brooks. Mr. Chairman, thank you for your indulgence.
        Chairman Babin. Yes, sir. Thank you.
        I'd like to now call on the gentleman from Virginia, Mr.
    Beyer.
        Mr. Beyer. Thank you, Mr. Chairman. I thank all of you very
    much for being here.
        Dr. Kahn, given the difficulty of establishing causality
    for medical conditions that may have resulted from human
    spaceflight one of the options would be to have NASA take care
    of all the medical problems that astronauts would have in the
    years to come. What are the pros and cons of such an approach?
        Mr. Kahn. Thank you, Representative Beyer, for that
    question. I think that's actually a really important question,
    and I'll speak to it from the ethics perspective because that's
    what I know, and in fact, the committee that I chaired
    discussed that, and we came to the conclusion that the
    causality question is impossible to answer, and that we as a
    country and a society owe astronauts protection and provision
    of care throughout their lifetimes without asking the question
    about whether--what they might suffer from in terms of injury
    or health needs was a result of their time in space or not.
        Mr. Beyer. Thank you, Dr. Kahn.
        I met earlier today with the Fire Chief for the County of
    Arlington in Virginia and talked specifically about this issue
    with the presumption of heart-lung disease, the presumption
    that if they got heart disease or lung disease later, that it
    was presumed to be from rushing into burning buildings, and he
    said it actually expanded in Virginia over the law to things to
    do with the GI tract also. So this just extends it to all those
    who go into space for us.
        Mr. Kahn. And as you heard from others, there's new
    information coming out all the time, and so what we don't know
    today may be something we learn about in the future, and so the
    committee that I chaired really did not find the causation
    question a compelling one as a matter of limitation of
    provision of the--of lifetime healthcare benefits.
        Mr. Beyer. I am struck today by the two big reasons we have
    at this hearing. On the one hand is the ethical considerations,
    the responsibility to take care of people who are sacrificing
    for all humankind. On the other hand, there's the simple
    practical data reason that we want to learn as much as we can
    to be able to move forward.
        Dr. Williams, what about when Captain Kelly retires and
    goes to work for a private space person, you know, SpaceX or
    Orbital, how does that influence the government's
    responsibility to take care of him and his space things, the
    space-related conditions for years to come?
        Dr. Williams. Yes, sir, another great question. I think
    there's plenty of precedent in the U.S. government that we
    would consider that to have no impact at all on our ethical
    obligation to take care of Captain Kelly and on our desire to
    gather as much data as we can to inform our database and to
    help us protect crews in the future, so I think there's no
    accrual, no effect at all, sir.
        Mr. Beyer. I was very impressed, fascinated by reading,
    Captain Kelly, all the impacts of your 340 days in space,
    everything from the rash to the flu-like symptoms and all the
    things we don't know yet, the unknown unknowns.
        So Dr. Kahn, from an ethical standpoint, especially after
    the recent death of Muhammad Ali, I mean, my mother never
    wanted me to box, right? The concussion and what the NFL is
    trying to deal with, concussions right now we see, those are
    voluntary sports. At what point do the ethical considerations
    become so great that we become reluctant to send men and women
    into space for the long voyages?
        Mr. Kahn. At what point would they? Is that the--is that
    your question?
        Mr. Beyer. You know, we send young men and women to go
    fight for us overseas because they're defending the country and
    we know we're going to lose some. We don't ever want to lose
    anybody despite Elon Musk saying the other day, ``We're going
    to go to Mars and some people are going to die.'' Do we go into
    this knowing with certainty that some of these health effects,
    the long-term health effects, are going to be inevitable?
        Mr. Kahn. I think what we want to be sure of, as sure as we
    can be, that we can protect the men and women who go into long-
    duration spaceflight to the greatest extent possible, and that
    we learn along the way, so among the things that hasn't come
    out yet today is this notion of long duration, so we're talking
    hundreds of days in transit until there's some new propulsion
    system, and so we can learn along the way. So data will come
    back to Earth from the experience of astronauts as they fly,
    and we should use that and learn and use that to decide about
    whether people should spend more time in protective cocoons in
    the--on the way or whether there should be some other means by
    which we should modify exposure along the way. So I think it's
    a notion of learning as we go but we don't go until we're
    sufficiently confident that it's safe enough, and then it's up
    to NASA to decide when and if it's safe enough.
        Mr. Beyer. Thank you very much.
        Mr. Chairman, I yield back.
        Chairman Babin. Yes, sir, thank you, and I'd like to
    recognize the gentleman from Colorado, Mr. Perlmutter.
        Mr. Perlmutter. Thank you, Mr. Chairman, and thank you for
    having this hearing. It's fascinating and it's important.
    Gentlemen, thank you for your service.
        Dr. Kahn, I want to start with you because I thought your
    two sort of pillars of fidelity and fairness really kind of lay
    out the thinking on this for me.
        You know, if somebody--these three gentlemen next to you
    are explorers and they put themselves at risk to explore in the
    name of the United States, in the name of science, in the name
    of adventure, in the name of I don't know what, lots of things,
    and they now have put themselves at risk. So it's my opinion,
    based on your two principles of fidelity and fairness, that we
    have a responsibility to provide both the medical care that
    they may need on into the future and the research that they
    provide us as to their health.
        So did your committee agree with you on this fidelity and
    fairness? It certainly resonates with me.
        Mr. Kahn. Yes. Sorry if I wasn't clear, Representative
    Perlmutter. The--my testimony represents the conclusions of the
    committee that I chaired, and everything I said actually is a
    summary of what's in our report, which was issued in 2014, and
    so that was the consensus of those 16 people who have a variety
    of expertise, some like mine but actually two former astronauts
    were members of this committee, along with scientists and
    physicians and occupational health specialists.
        Mr. Perlmutter. The reason I'm sort of thinking about this,
    and Dr. Williams, you can chime in if you choose, you know, in
    my district we have Rocky Flats, where we built the nuclear
    triggers for our bombs, and we had a lot of workers out there.
    They've developed a number of maladies as a result, some I
    guess anticipated some not anticipated, and we came up with a--
    we the Congress--came up with the Energy Employees Occupational
    Illness Compensation Program, which has worked in some regards
    and hasn't worked very well in other regards because, you know,
    whether it's bone mass or some issue of radiation or something
    like cataracts, completely unexpected, we've seen maladies that
    were never expected. So in your analysis, Dr. Williams or Dr.
    Kahn, how do we be inclusive? Do we just--see, right now, the
    burden is on the worker to say that the illness came from
    working at Rocky Flats. I'd just like to say hey, if you worked
    at Rocky Flats and you're sick, we're going to take care of
    you. If you're an astronaut and you got up there, we're going
    to take care of you. But it gets expensive. We've got to be
    prepared for potential costs if we build our astronaut base. I
    mean, what was your committee considering? And Dr. Williams,
    have we estimated what costs we might see in the future?
        Mr. Kahn. So the committee that I chaired did not--was not
    asked and did not try to estimate the cost, so we identified
    what we thought were, as you articulated, the pillars--we
    called them principles of ethics that would support
    recommendations which included a recommendation for lifetime
    provision of health care for astronauts but we did not go past
    that into the practical question of how much it would cost for
    how many people or for how many years we're discussing.
        Mr. Perlmutter. Dr. Williams?
        Dr. Williams. Yes, sir. I think when you articulated the
    sentiment that if we send you in harm's way as astronauts, we
    want to take care of you, I think that's what NASA absolutely
    wants to do.
        The practicalities of doing that with this legislation, we
    can--we have to be aware of the problems, hopefully at the
    earliest stage possible in order to remediate them, and that's
    the monitoring portion of our--the health monitoring portion of
    our proposal, which is quite detailed and quite targeted and
    broadly preventive in nature. And then I think with this
    authority, work very closely--under the envision model, work
    very closely with folks in existing claims structures--the DOL
    and the VA, whoever we need to--to lean very forward and be
    very proactive in--with regard to working--providing evidence
    and best expert opinion to try to receive favorable
    consideration of claims and acceptance of diseases as they
    arise.
        Mr. Perlmutter. Well, for all of us on this Committee, you
    know, I think I showed you, Captain Kelly, when you were up on
    Space Station, you know, 2033 we can do this. I mean, we really
    want--I don't know, you know, exactly what the timing is going
    to be. That'll be for the technicians and the engineers and you
    astronauts and the scientists to figure it out, but we want to
    get there, but we want you not to put your lives at stake. I
    mean, there will be some level of risk. I know I as a Member of
    Congress on behalf of the 750,000 people that I represent want
    to make sure that when you do put your lives at risk that--and
    your health for who knows how long down the road, we as the
    United States of America help you with your health care.
    Hopefully there's no problems, but if there are, we help you.
        And so I just thank you for your service, gentlemen. Docs,
    thank you for looking at this. This is important stuff. Thank
    you.
        Chairman Babin. Thank you. Thank you very much. Thank you,
    Mr. Perlmutter.
        I think there's a little time left if we could go back
    through for another round of questioning if the witnesses are
    agreeable and the members. Why don't we this? Instead of 5
    minutes, we'll have a 2-minute question period, okay? And Mr.
    Perlmutter, we're going to keep you at 30 seconds.
        Okay. I'm going to start out with Dr. Williams. Similar to
    the question that Mr. Perlmutter asked, NASA has indicated that
    extending existing monitoring of former astronauts would
    increase the cost to NASA from approximately $400,000 a year to
    around $800,000 a year. A recent University of Nebraska Medical
    Center report indicated that providing medical care for all 367
    astronauts and their families would cost between $2.4 and $6.5
    million a year. How much money would NASA's current proposal
    cost per year? Do you know that?
        Dr. Williams. We think the direct portion, health
    monitoring portion, would be in the neighborhood of doubling
    our current cost to $800,000 a year. Right now, we spend 400 a
    year for that portion. We believe if we--including remediating
    providers in the community for testing and imaging and so on
    and so forth, we think that would drive that cost up, and
    anticipating increased participation rates, we think it would
    drive it to $800,000.
        With regard to the remediation of illness and injury, the
    astronauts do display a very strong, healthy worker effect.
    They pursue very healthy lifestyles. They're committed during
    their careers and after their careers to maintaining good
    fitness and making good lifestyle choices. So when you compare
    chronic diseases and malignancies and so on and so forth to
    almost any comparison groups at this point, the astronauts
    compare very favorably. After latent period of exposure passes
    in the next 10 to 20 years, that's an unknown quantity at that
    point.
        But right now, we would anticipate based on historical
    precedent no more than one case, maybe two cases every one or
    two years of significant illness that would be expensive, and
    by ``expensive,'' I mean that would be in the, you know,
    $500,000 range for a catastrophic case of cancer or something,
    and that's what we believe we would be dealing with in the
    short term, sir.
        Chairman Babin. And one quick question here for you, Dr.
    Williams, and Captain Cassidy. The Department of Labor and
    Department of Veterans Affairs both provide treatment for
    conditions derived from federal service. Are there classes of
    astronaut such as payload specialists who are not government
    employees and therefore would not be covered by existing
    authorities? Do you all know the answer to that?
        Captain Cassidy. Sir, currently at NASA we have active
    astronauts and management astronauts. Management astronauts are
    folks that still work at NASA but are no longer in the line for
    a space mission, and we used to have in the past payload
    specialists. We no longer have that designation. However, from
    our perspective, anybody that goes on a space mission on a NASA
    mission should be covered.
        Chairman Babin. Right. Dr. Williams?
        Dr. Williams. And sir, for classes of astronauts like
    payload specialists, we believe that no matter what method that
    they use to enter the agency as a detailee or what method of
    employment they have, that there would be a pathway forward
    under existing structure to treat them just like we would any
    astronaut in clearly military or civilian service and pursue
    helping them.
        Chairman Babin. Thank you. Thank you very much.
        And I now call on the gentlewoman from Maryland, Ms.
    Edwards.
        Ms. Edwards. Thank you very much, Mr. Chairman, and thanks
    for the second round.
        Dr. Williams, I want to go back to the VA system because I
    understand that about 60 percent of the astronauts that have
    flown in space are military or retired military--we have two
    here on this panel--and as such, any occupational injuries or
    conditions are currently handled by the VA. Have you actually
    directly addressed with the VA how occupational-related health
    conditions for former military astronauts as a result of
    spaceflight will be handled if this legislative proposal is
    enacted?
        Dr. Williams. We have reached out to our contacts in the
    Veterans Administration and we are initiating discussions with
    them similar to those that we have initiated with the
    Department of Labor, and we would envision in implementation of
    this legislation partnerships going forward on both fronts to
    build this facilitated claims process with NASA playing a key
    role in determining accepting the diseases.
        Ms. Edwards. I mean, it is a little bit problematic, you
    know, 60 percent of the astronauts are retired military, and we
    have--you haven't engaged the VA in this discussion before
    presenting legislative proposal, but I hope that that happens
    really soon and that you're able to share that information with
    us.
        Captain Kelly and Captain Lopez-Alegria, you both are
    retired military. Have you used the existing VA system?
        Captain Kelly. I think it's important--I think it's
    important to point out that there are--astronauts come from all
    different backgrounds. Some of us are retired military. I'm
    personally, as is Mike, covered under Tricare for life as a
    retired military member. If you were a member of the military
    and you didn't retire, I believe the VA would still cover you.
    There are members of the Astronaut Corps that are civil
    servants. Some of those civil servants retire from federal
    service, in which case they do have retired civil service
    health care, but then there are other people that may fly for
    one flight or more and then leave federal service without any
    kind of long-term health care benefits until they were
    potentially eligible for Medicare. So there are different
    categories, and I think this system, this legislation, if
    enacted, would benefit them and people in different ways
    considering the fact that, you know, we already have health
    care coverage that is pretty good.
        Ms. Edwards. And in effect, at least bring the payment
    within one house, if not the care within one house?
        Captain Kelly. Certainly, and I think that the important--
    the other important factor, as previously mentioned, was the
    fact that we can collect all this data whereas if I'm, you
    know, living in another state and I'm being treated under the
    Tricare system, NASA doesn't directly benefit from any of that
    information, and also the fact that, you know, those health
    care providers may not even know what they should be looking
    for in these types of, you know, cancer or radiation-based
    illnesses.
        You know, it's interesting, Mike and I--I was going to
    point this out, and I don't think he would mind mentioning it,
    but we're going to meet with one of our colleagues tonight who
    lives in the area that has recently been diagnosed with stage
    IV pancreatic cancer, and he's, you know, flown in space on a
    number of occasions, and you know, we never know whether that's
    actually directly related to his spaceflight but it's possible
    that it is.
        Ms. Edwards. Thank you very much. I mean, a reminder, it
    took us 30 years after Vietnam to finally recognize the long-
    term impacts of Agent Orange.
        Chairman Babin. Yeah, absolutely.
        The next one, Mr. Beyer, the gentleman from Virginia.
        Mr. Beyer. Yes. Thank you, Mr. Chairman.
        And Dr. Williams, I know you're not a statistician but I
    understand from reading lots of science magazines that
    essentially we need to get to 10,000 DNA complete
    disarticulations into the database before we're really going to
    be able to figure out what some of these DNA connections are.
        You know, we have 250 retired astronauts. Sixty percent are
    in--so 150 are in the LSAH program right now. If we move to 80
    percent, that gets us 200. What are the--what's the
    implications for us of the limited sample size, the limited
    size of the database?
        Dr. Williams. It's something we've always struggled with,
    sir, whether we're actually doing space-based research with a
    small population and trying to, you know, reach conclusions or
    whether we're trying to do epidemiology on this very small,
    very uniquely exposed group of folks. The only thing--the thing
    I think that is most important to note is that given the group
    is so small, the data from every single one of them is precious
    and the data from every single one of them is important, and
    anything we can do to maximize participation in our program,
    both for the surveillance and recovery of healthcare data in
    the event of injury and illness, is critical.
        Mr. Beyer. A question for any of the three captains but
    perhaps especially for Captain Kelly. We had a Mars hearing
    here a couple weeks ago, and with, you know, the big companies
    that are developing all the places to get there, and Andy Weir
    came, who wrote The Martian, and at the end he threw out the
    proposal that we should be thinking about using rotational
    energy to create artificial gravity on the way up. So how much
    of the consequences that you all have felt have been radiation
    related versus gravity-free-related, and I say that because I
    think for Ed and for me, the highlight of this Committee so far
    has been when you and Dr. Lindgren did your flips at the end of
    the flight.
        Captain Kelly. Well, you know, I believe all the symptoms
    that we have, the stuff that we can feel when we get back, is a
    result of the microgravity environment versus radiation. I
    think the radiation effects are, you know, more long term and
    unknown, you know, of someone that does develop a cancer,
    whether or not that was due to the radiation, I don't think we
    can ever say for sure because it may have--you know, we get
    radiation here on Earth as well. It just increases our risk of
    those type of cancers.
        So as far as, you know, having an artificial gravity to
    mitigate those risks, I think, you know, based on how I felt
    after being in space for a year, if I was going to travel to
    Europa, for instance, and it's going to take, you know, many,
    many years to get there, I think--and then you have to perform
    after being in space for multiple years and you had to perform
    away from Earth, I think that type of artificial gravity would
    be crucial. If we're going to fly around the Moon or fly around
    Mars, for instance, and it's going to take, you know, three
    years and you'd be in space for three years or if you're going
    to land and be on the surface for a few weeks, being in space
    for an extended period of time is going to have a negative
    effect but fortunately you're coming back to Earth where, you
    know, there's a big, you know, system to support you. So
    artificial gravity in that type of mission I think is less
    critical.
        Mr. Beyer. Great. Thank you very much.
        Mr. Chair, I yield back.
        Chairman Babin. Yes, sir. Thank you, Mr. Beyer.
        And now for the gentleman from Colorado, Mr. Perlmutter.
        Mr. Perlmutter. For my 30 seconds.
        Chairman Babin. No, we'll give you two.
        Mr. Perlmutter. So this is to all of you. So as things have
    developed and we've heard from Mr. Musk and SpaceX that, you
    know, their intentions to try to get astronauts to Mars in the
    2020 time frame or sometime, and we know that there's going to
    be more commercial endeavors in space. So we have a small pool
    to do research on. Should we consider those astronauts that are
    on a private capsule? Should they be covered by something like
    this? And I'll start with the three captains and then go to the
    ethicist, I guess.
        Captain Lopez-Alegria. Well, I've been in this room a lot
    wearing my hat as president of a commercial spaceflight
    federation, so your comments about democratization of access to
    space are near and dear to my heart. I think that we would love
    to have the data from those folks that are going to be going,
    you know, first on suborbital but at some point on orbital
    flights. I do not think it is the responsibility ethically but
    I will leave that to the ethicist, but it seems to me that it
    would have to be a voluntary program for them, but what is
    clear is that the data that we are gathering in LSAH and
    hopefully with this expanded authority, our flights and our
    careers have been paid for by taxpayer dollars and we owe those
    taxpayers those data to help them make informed decisions about
    spaceflight.
        Captain Kelly. I don't really have anything to add other
    than what Mike said. I think that makes a lot of sense.
        Captain Cassidy. And sir, I concur as well.
        Mr. Perlmutter. Okay. So to the doctors, do you want to
    have a bigger pool? Do you want them in there, or should we
    cover them? What do you think?
        Mr. Kahn. Well, so I'll start. I think in terms of coverage
    that if it's commercial spaceflight, then those companies ought
    to take on that obligation, so I do think there's an obligation
    but not on the part of the government to protect those people
    but on the part of Elon Musk or whomever.
        In terms of the data, that to me is something that ought to
    be encouraged but I think it's hard to obligate on the part of
    individuals. So, you know, I think as our astronaut colleagues
    here will say, there's very few of them, and every bit of the
    data that is precious, and with the proper protections, there
    should be, I think, a lot of willingness to participate, but I
    don't think you can force people to do that.
        Dr. Williams. And sir, I think our database and our
    experience base would form the risk assessment database that
    the commercial companies are going to have to use. That's going
    to inform their risk decisions when it comes to a health
    standpoint and undertaking some of these longer missions.
        I agree with my colleagues. From a practical perspective,
    our health care infrastructure, and I'm sure our research
    community too would pursue helping them as much as we could by
    sharing our experience and our data as much as we can, and also
    we would seek to facilitate their gathering of data. We have a
    lot of experience in doing that. And if there were
    opportunities to leverage their data on behalf of future human
    spaceflight, we would welcome the opportunity to do so.
        Mr. Perlmutter. Thank you very much.
        Thanks, Mr. Chairman. I yield back.
        Chairman Babin. Yes, sir. Thank you, Mr. Perlmutter.
        I want to thank the witnesses. It's been an extremely
    edifying hearing, and to be honored with the three astronauts
    and the two doctors, thank you all for your many years of
    service to your country, and really I want to thank you from
    the bottom of my heart.
        The record will remain open for two weeks for additional
    written comments and written questions from the Members.
        So without any further ado, this hearing is adjourned.
        [Whereupon, at 4:27 p.m., the Subcommittee was adjourned.]

                                   Appendix I

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                       Answers to Post-Hearing Questions

    Responses by Dr. Richard Williams

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    Responses by Captain Chris Cassidy

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    Responses by Captain Scott Kelly

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    Responses by Captain Michael Lopez-Alegria

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    Responses by Dr. Jeffrey Kahn

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