Health Beyond - Report of the Advisory Council on Deep-Space Healthcare

Global Space Exploration Plans

There is a growing and shared desire among spacefaring nations to venture beyond low-Earth orbit in the coming years. Accordingly, a group of 26 international space agencies, led by NASA and including the Canadian Space Agency, has collaborated over the last decade to develop a notional plan to explore deeper into the solar system. Known as the International Space Exploration Coordination Group, it has published a plan—the Global Exploration Roadmap and a Roadmap Supplement—describing how a sequence of human and robotic deep-space missions could unfold in the coming years. An overview of this roadmap is provided in Appendix A – Human Exploration Plans for Deep Space.

The term deep space is used by the group to describe possible missions in the inner solar system, with intriguing destinations such as lunar orbit, the surface of the Moon, a near-Earth asteroid and Mars. A human mission to the surface of Mars, projected to launch in the mid-2030s, is its primary goal and ultimate objective. A voyage to the red planet will help answer some fundamental questions:

• What can the geology of Mars teach us about Earth's past, present and future?
• Was Mars ever home to life?
• What can Mars teach us about the start of life on Earth?
• Could Mars one day be a safe second home for humans?

Operational and Technical Challenges of Deep-Space Missions

The next few years of human spaceflight will focus on construction of the Lunar Gateway, a mini space station in lunar orbit, and on utilizing a research base at the south pole of the Moon. Planning for human exploration missions to the red planet will then ensue. This will be an ambitious undertaking, with many challenges. It will require a decade-long commitment and a concerted effort by several nations to land an astronaut crew on Mars and return them safely.

Some challenges of this new class of deep-space missions will be operational. A flight to Mars, for instance, will feature:

• Long distances (200 million kilometres) and duration (two-and-a-half years)
• Limited crew size
• Limited volume, mass and power allowances of onboard equipment and systems
• Minimal or no cargo resupply
• Communication latencies (six to 20 minutes one-way) resulting in reduced ability of Mission Control to assist the astronaut crew with urgent and inevitable mission contingencies that arise.

Other challenges are technical. A 2014 report by the U.S. National Research Council identifies 10 essential technologies that must mature before a crewed Mars landing mission is feasible. All vehicle systems will need to be more reliable and robust than those of spacecraft that do not venture as far from Earth. All must function autonomously, with limited monitoring and control by flight-controllers on the ground. Life-support systems will need to be closed loop design.

Crew Health, Well-Being and Performance Issues of Deep-Space Missions

Delivery of healthcare to future astronauts may be the most significant challenge of deep-space exploration. Venturing beyond Earth's orbit will expose astronauts to harsh environmental conditions and novel risks. These, if unmitigated, would jeopardize the health, well-being and performance of the crew.

In past missions, the concept of medical operations has been Earth-centric. The health of astronauts aboard the International Space Station (ISS) and other spacecraft in low-Earth orbit has been managed by a medical team on the ground. This concept of medical operations was made possible by the availability of real-time data and voice communication with the crew, and with a medical-evacuation option if necessary.

This will become impractical once astronauts venture to deep space. Ground-based oversight in urgent situations will not be possible. Medical evacuation of a seriously ill or injured crew member to Earth will no longer be an option. The onboard medical facility, limited in size, will need to support complete and autonomous care for health and cover all medical and surgical eventualities.

Venturing to deep space means we must rethink the operational approaches, crew training and critical technologies relied upon to manage astronaut health. The delivery of healthcare must become independent of Earth. Autonomous and semi-autonomous concepts must be developed and validated. Before the first crew launches, medical care must become more patient-centric, point-of-care and virtual.

Detailed operational considerations for the delivery of healthcare to deep-space astronaut crews are provided in Appendix B – Clinical, Biomedical and Performance Needs of Deep-Space Missions.

Canadian Space Exploration Plans

The daunting nature of these future space missions appeals to Canada's heritage of exploration and the national spirit of innovation—an opportunity to measure the best of energies and skills.

A focus on deep-space exploration underpins Canada's 2019 strategic plan Exploration, Imagination, Innovation: A New Space Strategy for Canada. It includes a commitment to participate in NASA's Lunar Gateway program, leveraging existing strengths like robotics while advancing others such as healthcare innovation.

The strategy specifically mentions a role in the health management of deep-space astronauts:

"By leveraging Canada's health and medical research expertise, and emerging technologies such as artificial intelligence, Canada will advance autonomous medical systems to support astronaut health in space and health outcomes at home. Through the Lunar Gateway project and via new efforts on Earth, Canada will explore questions key to improving healthcare and quality of life for Canadians."

Furthermore, an objective of this strategy is to ensure investments in space exploration bring practical benefits to Canadians. The CSA will work with stakeholders to translate novel approaches developed for spaceflight to improve the lives of Canadians on the ground.

Our Task

To advance the New Space Strategy healthcare vision, the CSA established a task force—our task force—in 2019, known as the Advisory Council on Deep-Space Healthcare (the Advisory Council or Council). Our mandate was to:

"…assist the Canadian Space Agency as it endeavors to define in detail a potential deep-space healthcare program for Canada that is nationally critical, visible, scalable, affordable and socially beneficial."

In other words, the Advisory Council was to describe in practical detail how the CSA could establish a major new program addressing the crew health, well-being and performance issues of deep-space exploration. Furthermore, we were to "identify potential national partners and stakeholders with mandates and priorities aligned with those of this potential initiative," in order to form a CSA-led partnership that could position Canada internationally at the crossroads of spaceflight and healthcare innovation. The Terms of Reference for the Advisory Council are provided in Appendix C and biographies of our 15 members are provided in Appendix D.

Our Council builds upon the work of a predecessor task force, the Expert Group on the Potential Canadian Healthcare and Biomedical Roles for Deep-Space Human Spaceflight. Its 2019 report was well received by the CSA and national stakeholders. The work of this Group and its findings are summarized in Appendix E.

We endorse the spirit and recommendations of the Expert Group and agree a CSA-led partnership should pursue an audacious goal—a leadership role in deep-space astronaut healthcare. With this current report, the Advisory Council advances that Group's work by addressing implementation issues of its vision.

Engaging Spacefaring Partners

The systematic and continuous engagement of spacefaring partners will signify that Canada is taking a leadership role in deep-space healthcare and will help achieve consensus on what is required.

Engaging the Canadian Healthcare User and Delivery Communities

This includes:

• Providers (health authorities, Indigenous communities, physician practices), regulators, industry, care practitioners, provinces and territories, academia, educators, and all levels of government.
• People (patients)

Enabling Research and Development Opportunities

This includes:

• Fostering technology-development opportunities that can be translated to delivery of care in terrestrial and space settings
• Job creation, bringing Canadian economic growth
• Creating an environment for technology demonstration and clinical validation

Frontline Healthcare in Space and on Earth

Frontline healthcare practitioners and their patients are our primary focus. We will create and implement technologies that equip, train and support health teams to protect the well-being and performance of their patients in space and on Earth.

Excellence in Delivery

Operations in harsh environments are complex and risky, with little or no margin for error. We will create partnerships that relentlessly pursue excellence in healthcare delivery with dedication, preparation and vigilance.

Equity & Spirit of Collaboration

Inherent to Canadian values, supporting the provision of equitable and pervasive healthcare will be a defining feature of our work. We recognize this program will ultimately provide health services to Canadians and the international community. Perspectives and contributions from our partners are therefore paramount. We will ensure the systems we implement operate across a representative population and help address national challenges in remote healthcare accessibility and equity.

Creating Economic Value

Combining space and healthcare partners in a joint venture will provide a unique opportunity to connect, engage and inspire technological innovation. This will showcase capabilities in space and healthcare delivery to create new economic opportunities for Canadian industry. By leading in deep-space healthcare, Canadians will be emboldened to think differently.

Inspiring a Nation

The possibility and potential to create substantial change for such a grand challenge as healthcare will ignite creativity and passion to think big and be bold. It will inspire youth to pursue STEM (Science, Technology, Engineering, Mathematics) and healthcare careers, adding further value to the cultural and economic foundation of Canada.

A Yearning to Venture Beyond Low-Earth Orbit

The last Apollo astronauts departed the Moon a half-century ago. Since then, human space missions have been confined to low-Earth orbit. However, mounting international interest in exploration, embodied in the International Space Exploration Coordination Group, has now inspired concrete plans to jointly venture farther in space and to undertake more ambitious missions.

The global impetus behind space exploration is evidenced by rising investment. Annual budgets for exploration programs of international space agencies rose to $20 billion in 2019, and are expected to reach $30 billion a year in the next decade. While most of this investment comes from major players such as the U.S., China and Europe, new players like India, South Korea and the United Arab Emirates are also investing and planning bold missions. Large, collaborative international programs are particularly attractive, representing a means for national space agencies to extend their political influence, foster knowledge-creation and enable technology transfer.

The scope of future exploratory missions has expanded to include roles for private companies. The exponential growth of the commercial space economy, driven by new capabilities and disruptive innovations, has led to sustainable business models and the opportunity to collaborate with government space agencies.

Addressing Access and Medical Outcomes for Remote and Underserved Populations

One fifth of Canadians live in non-urban areas. Our relatively large remote population and sparsely populated landscape present challenges for the delivery of accessible and equitable healthcare. These challenges also present a unique opportunity.

Physical distances and the challenges that medically isolated people face have always meant that some Canadians, such as those living in remote communities and older adults, have difficulty getting timely access to medical diagnoses and treatments and are underserved compared with other Canadians.

Innovations required to enable deep-space missions could also provide healthcare delivery solutions in our remote communities. For example, robotics-enabled healthcare, portable medical devices, health-data storage and analytics could improve the timeliness, quality and continuity of care. Telehealth, virtual and sensor technologies could augment pre-transport clinical decision-making and reduce the time that patients must spend away from their northern homes to seek tertiary care in the south.

Rapidly Changing Needs of Aging Canadians

Senior citizens make up 17% of the Canadian population and comprise the fastest-growing segment of our population. This trend will continue into the 2030s as the baby-boomers age. Canada's healthcare system is not designed to address the continuum of care/rapidly changing needs of our aging population. A national seniors' strategy and a new delivery model are needed to better manage the complexities of chronic diseases and to support the growing number of seniors who desire to age at home, as well as to support their families and caregivers.

Technology solutions for space will overlap with the telehealth needs of the aged. These include tele-monitoring of health and environmental conditions (e.g., motion sensors, wearables), AI-enabled diagnostic and predictive solutions, health and social-care robotics, and digitalization and portability of health records to facilitate patient transfers.

Healthcare Gaps Exposed by the COVID-19 Pandemic

The COVID-19 crisis exposed many gaps in the Canadian healthcare system. Our vulnerable populations were most affected by the pandemic. Travel restrictions, for instance, disrupted access to medical expertise and healthcare facilities for some Indigenous communities and chronic-care patients. The crisis also exacerbated isolation and confinement, loss of employment and reduced access to recreational activities.

Synergies exist between approaches to healthcare delivery for deep-space astronauts and strategies to mitigate COVID-19-exposed shortcomings. These include environmental monitoring and communication technologies, patient monitoring and testing systems, virtual access to medical expertise and treatment capacity. We highlight three synergistic opportunities:

Synergistic Alignment with National Priorities

National pursuit of a deep-space healthcare initiative would complement several existing social needs and economic priorities. We identify four opportunities for national collaboration:

Competition for Meaningful Roles in Deep-Space Healthcare

Other spacefaring nations have already indicated their intention to pursue the near-term leadership role in deep-space healthcare. This would become a valued niche area of national competence for any space agency. No country currently has experience or capability in the field, so securing the first-mover position is strategic and will be associated with advancements in technology, economic benefits and new jobs.

NASA has developed a Medical System Concept of Operations and a Medical Data Architecture for Lunar Gateway and Artemis Phase 1 missions. The U.S. agency has invested resources to develop exploration medical capability. Similarly, the European Space Agency (ESA) has declared its intent to be a major player. ESA has shared a medical system concept for the International Habitation Module (iHAB) of the Lunar Gateway station, featuring standard interfaces and data architecture, bio-diagnostics and countermeasure devices.

The competition is further intensified by looming deadlines of the Lunar Gateway and Artemis programs. In the upcoming months, NASA is expected to allocate healthcare roles and contributions by partners. While Canada is not prepared to play a leadership role in Lunar Gateway/Artemis, it will be strategic and urgent to secure a meaningful contribution and sub-system responsibility, as a means to position our country favourably for longer-term ambitions.

A Challenging Domestic Market for Healthcare Innovation

The Advisory Panel on Healthcare Innovation in its 2015 report found that entrepreneurs across Canada have difficulty introducing, sustaining and scaling up innovations in the healthcare system, given system fragmentation, a risk-averse culture and an inadequate focus on understanding and optimizing innovation. A deep-space/remote healthcare partnership would need to identify ways to enable the transition of health innovations from idea to market, with notable attention given to raising capital and successfully navigating regulatory approvals.

Canada is Highly Regarded as a Reliable Spacefaring Partner

Canada is among a handful of countries with the specialized technical and operational experience required to support human spaceflight missions. National expertise in astronaut selection and training as well as space robotics has enhanced our reputation as a capable and trusted partner in large-scale international programs. Our inclusion in the Lunar Gateway partnership has reinforced this.

Canada is also regarded as a reliable and honest broker in other settings such as the UN, G7, G20 and UNESCO. We have repeatedly delivered and managed significant contributions to several international programs.

Specialized Expertise in Several Relevant Areas

Canada is an important player in the international health and biosciences community. We are regarded as a leader in clinical diagnostics, practitioner training and simulation, as well as in emerging technologies such as AI, digital health, remote medical robotics and minimally invasive surgery.

While large enough to have a global impact, our national health ecosystem remains agile and adaptable. It includes innovation hubs, accelerators and incubators, and it is supported by a vibrant industry, governments, research institutions, technology providers, physician associations, healthcare operators and trainers.

Leadership in Medical Education and Practitioner Training

Canada's expertise in medical education is particularly esteemed. Our faculties of medicine and nursing are continually developing learning tools, methods and technologies to better meet the needs of students and professionals. McMaster University, for instance, pioneered a novel approach to medical-student education called problem-based learning. This approach has been so successful that it has been adopted by 500 higher-education institutions. More recently, our competency-based training model for medical specialists has been internationally commended.

Canada is a world leader in the training of rural generalists in multiple skill-sets (emergency medicine, surgery, anesthesia, maternity care, family medicine, trauma, ultrasound, cardiology, oncology). The Society of Rural Physicians of Canada, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada continue to upgrade learning programs to better meet the needs of remote practitioners. In addition to the provision of enhanced surgical and anesthesia skills, these colleges also recognize that professional attributes like surgical courage and the ability to thrive in situations of uncertainty are assets for rural generalists. One ideally acquires these qualities by years of contextual experience, supported through networks of specialist coaches using remote-presence technology.

Montreal-based CAE Healthcare is a world leader in simulation-based medical education. Its commercial products include surgical and imaging simulation, curriculum, centre management and highly realistic patient simulators. Some 8,000 CAE simulators are in use worldwide by medical schools, nursing schools, hospitals, defence forces and others.

Expertise in Advanced Healthcare Delivery

Canadian healthcare delivery is domestically and internationally esteemed. Canadian expertise is recognized in areas such as remote and minimally invasive surgery, psychology and cognitive sciences, clinical medicine, geriatric care, public health and health services.

Satellite-based telemedicine was pioneered in the 1970s by Dr. Max House of Newfoundland and Labrador to address the healthcare needs of people living in rural and remote communities. The delivery of virtual care in Canada today continues to evolve and advance.

The COVID-19 crisis has highlighted Canadian strengths in emerging areas like quantum computing and AI. Facilitated by streamlined approval processes, medical technology firms and federal regulators were brought together by the pandemic to address urgent societal needs. Canada was the first country, for example, to approve the use of an AI-enabled system to augment the interpretation of chest x-rays by radiologists.

Research and Academic Excellence

The performance of Canadian medical researchers is extraordinary. Clinical medicine represents the largest share of all research publications in Canada and 4.1% of the global share. Of all research fields in Canada, clinical medicine has the highest level of performance in the top-cited 1% of world publications.

In the life sciences and medicine category, the University of Toronto is ranked 13th, McGill University 29th and University of British Columbia 31st by the QS World University Rankings 2021. Six nursing schools (Toronto, Alberta, McMaster, UBC, McGill and Calgary) are ranked in the world's top 50 nursing schools.

This combination of research excellence and expertise in advanced healthcare education elevates Canada to a distinguished position on the world stage. It is no surprise that Canadian researchers and technologists are frequently sought as collaborators in international health and biomedical undertakings.

A National Mindset Shaped by Geography, Climate and Diversity

Canada's harsh climate and expansive geography have moulded the national culture and individual character. Our sparse population distributed over rugged terrain from coast to coast to coast is reflected in a uniquely Canadian approach to the delivery of remote healthcare. Similarly, our multicultural demography imposes considerations of equity, diversity and inclusion in all national undertakings. AI-enabled healthcare solutions, for instance, are founded on a national database representative of a broad ethnicity and are therefore applicable to other diverse settings.

Limited Internal Capacity to Engage Indigenous Communities

A deep-space healthcare initiative that also addresses the healthcare needs of remote Canadians would benefit greatly from the experiences, insights and contributions of Indigenous partners. Involvement of Indigenous peoples in a national space program would be significant—a major step forward in reconciliation. However, Indigenous communities must be engaged in a respectful and thoughtful manner. Indigenous peoples must define the nature and scope of their own participation and ensure that the initiative unfolds in a way that will be transformative for their participating communities.

The CSA, however, does not have a depth of expertise and has only limited experience in this unique kind of relationship building. Adding this capacity to a CSA-led partnership would require training, the development of protocols and the strategic selection of partners.

Limited Managerial Experience with a Healthcare Niche

The Agency's traditional stakeholders came from the space sector, and its programs are typically delivered through transactional dealings with contractors and research entities. Partnering with non-space stakeholders, such as health authorities, healthcare practitioners, patient representatives and Indigenous elders, will require flexible processes and an adaptable culture.

As a government agency, the CSA is transparent and accountable in the way it conducts business. Adherence to the principles of public-sector accountability can result in slower program approvals and implementations than in the private sector. While it will remain transparent and fair, the CSA would also need to support the speed and agility needs of its healthcare and industry partners.

A Smaller Player in Space-Exploration Programs

Despite our global reputation, Canada is one of the smaller players in space exploration. Using per-capita expenditures as a measure of the priority that countries place on space, a 2018 study ranks Canada ninth, at US$9 per capita. This is well behind the U.S. (US$125), France (US$49), the United Arab Emirates (US$39) and Russia (US$29). Being a smaller player, our international space partners will question Canada's capacity and ambitions to play a leadership role in deep-space healthcare.

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Tactical Steps

Government Departments

Federal, provincial and territorial jurisdictions that oversee healthcare policy, regulations and budgets.

Health-Delivery Agencies

Provincial and territorial health authorities are the operational element of Canada's healthcare system. They deliver coordinated care across a broad range of services, from prevention and primary care to quaternary and long-term care. They oversee an impressive array of facilities, tools, systems, policies, funding and personnel.

Frontline Healthcare Practitioners

Frontline healthcare practitioners are the nurses, physicians, midwives, community-health workers and pharmacists who deliver essential health services directly to patients in their communities. They are trusted sources of information in remote and other underserved settings, and have skills in preventing, treating and managing a variety of illnesses. Aboard a deep-space vehicle, the frontline worker is the physician-astronaut designated as the crew medical officer.

In this partner sector, we also include the academic institutions (medical schools, nursing schools, hospitals) and professional associations responsible for the training and support of frontline practitioners.

Research Institutions

Research-intensive universities and research institutes, hubs and accelerators conduct research and provide training in health and biomedical disciplines. Granting councils support R&D and facilities related to health, well-being and associated technologies.

Industry

Companies develop and produce goods and services in the space, health, technology and medical fields. Industry associations enable collaboration and foster overall development of the sector.

Indigenous and Other User Communities

The user community includes residents of rural and remote communities who are disadvantaged by limited access to tertiary-care facilities and medical specialists, new Canadians who are isolated by language and culture, chronic-care patients and long-term care residents. In particular, the key user community is Indigenous peoples who experience numerous barriers to healthcare in rural/remote as well as urban settings. Aboard a deep-space vehicle, the user community is the astronaut crew.

International Partners

International partners include space agencies such as NASA and ESA that would collaborate with the CSA and Canadian participants in the delivery of deep-space healthcare.

Government Departments

• Shared solutions to shared challenges – Deep-space healthcare technologies, developed and validated on Earth, have tremendous potential to benefit Canadians from underserved communities, in particular remote Indigenous communities. An autonomous, decentralized approach to healthcare can help improve health access, equity and outcomes for underserved populations.
• Economic and social benefits At both the national and community levels there will be benefits from the creation of desirable healthcare technology, gains in employment and improvements in community resilience, autonomy and stability.

Health-Delivery Agencies

• Cost control – Healthcare delivery costs are constantly increasing. In particular, many territorial governments must provide patients with transportation to distant tertiary clinical centres for specialized services, at great expense. The need for medical transportation would be reduced by enabling monitoring, diagnosing and treatment of patients in their communities or at home.
• Human resources – Recruitment and retention of healthcare practitioners and staff is difficult, especially in remote settings, even with financial incentives. Meaningful collaboration in a deep-space initiative, combined with upgraded training and care networks, would encourage a steady, sustained source of human resources for remote settings and hard-to-reach urban populations.

Frontline Healthcare Practitioners

• Telemedicine support – Remote healthcare providers would benefit from improved telemedicine protocols linking them with colleagues in tertiary centres, given improved access to broadband and other networking technologies.
• Simulation, training and clinical decision support – Access to high-quality simulation and virtual training, as well as AI-enabled clinical decision-support tools, would broaden the spectrum of care available to remote communities by local practitioners.

Research Institutions

• Reputational Gain – Research institutions would see their global credibility and reputation enhanced by collaborations with CSA, NASA and other international agencies, as well as engagements with non-traditional partners.
• Funding Opportunities – Dedicated research funds would open opportunities for new research programs across Canada, furthering the national culture of innovation.
• Talent Recruitment – Exciting research and academic opportunities would attract top international graduate students and postdoctoral fellows. There would be enhanced training opportunities, internships and employment for students.

Industry

• Innovation – Canadian companies would develop cutting-edge technologies addressing unmet needs in both the healthcare and space markets and gain competitive edge.
• Access to Resources – Small- and medium-sized companies would have an opportunity to gain access to accelerator testbeds for evaluation of their prototypes, and benefit from financial incentives.

Indigenous and Other User Communities

• Empowerment – Local communities and practitioners would enjoy enhanced decision-making autonomy as well as access to collected data and authority over its use. Self-determination is important to Indigenous peoples; being able to co-develop solutions and partner to bring enhanced health outcomes through improved access and empowering local health professionals is paramount. Enhancing autonomous care would reduce the need for health-related travel, which is expensive and disruptive to patients' lives.
• Social Benefit – There is an opportunity to bring practical and sustainable benefit to communities in terms of healthcare and connectivity, as well to train, employ and mentor the next generation of Indigenous professionals and leaders.

International Partners

• A Trusted Team Player – The CSA has gained a solid reputation as a trusted, reliable partner within the international space community. In activities ranging from research to operations, Canada delivers, and does so in a transparent and collaborative way. Existing partnership agreements with Canada set a precedent for future agreements.
• Technological Expertise – Canada is known for excellence in clinical research, technologies and innovation. In particular, it has significant expertise in AI, with access to a large pool of talent in this field.

Priority Near-Term Tasks:

• Formalize deep-space healthcare as a strategic priority at the CSA
• Develop a Roadmap for Action to advance national capability, capacity and credibility in remote healthcare delivery
• Prepare an economic and job-creation analysis for a deep-space healthcare initiative
• Secure a substantial and meaningful healthcare role for Canada on Lunar Gateway/Artemis
• Establish a remote medical infrastructure and Northern Demonstration Site #1 to pilot novel clinical approaches (autonomy, point-of-care, patient-centric, virtual care), training and integration of new technologies and innovations
• Bolster the deep-space healthcare ecosystem
• Develop stakeholder relations and public outreach

Priority Medium-Term Tasks:

• Contribute Canadian technology, staff and training system to the Lunar Gateway/Artemis programs
• Establish Northern Demonstration Sites #2 & #3
• Establish the deep-space healthcare partnership (management, administration, scale-up)
• Effect knowledge translation to underserved communities
• Broaden the research mandate of the CSA's health and life sciences group

Priority Long-Term Tasks:

• Develop a deep-space healthcare program management team at the CSA
• Establish a world-class program for training & certification of
  • Crew
  • Support personnel
• Contribute to deep-space healthcare system integration & oversight with international partners
• Establish a continuous presence of mission operations
• Provide resources for Canadian-based technology design, development & testing
• Foster R & D opportunities across Canada

Critical

Future space missions will encounter risks, harsh environments and operational challenges not previously found in low-Earth orbit. The most daunting challenge for the global space community will be the need to deliver healthcare to onboard crews. In fact, maintenance of the health, well-being and performance of astronauts will be directly tied to mission success. Leadership in deep-space healthcare would be a critical role for Canada.

Visible

Landing astronaut crews on Mars and returning them safely back to Earth will be one of the greatest achievements of the 21st Century. A meaningful role for Canada in this venture would instill national pride and build public excitement. Our expertise in healthcare—clinical research, digital health, medical robotics—would be showcased internationally. Simulators for the training of crew and ground-support personnel, as well as national facilities for system integration and mission operations, would provide high profile.

Scalable

The Advisory Council has proposed a phased approach to the establishment and expansion of the deep-space healthcare partnership, as program milestones are attained. Starting with a core membership, it would grow in ensuing years in its goals, functions, staffing and operating budget.

Program infrastructure (testbeds, training simulators, flight-control consoles) would also be scaled up over time. Demonstration sites would eventually be established in select First Nations, Inuit and Métis communities to catalyze the adoption of novel healthcare delivery models in underserved regions.

Affordable

A Canadian deep-space healthcare initiative cannot cure all that ails the country's healthcare system. The social determinants of health (factors such as housing, income, education, employment, social support networks) have the greatest bearing on health outcomes of marginalized populations and are beyond the scope of a CSA-led healthcare initiative. Nevertheless, approaches associated with the delivery of healthcare to deep-space astronauts could lead to lower medical costs and better health outcomes on Earth. Healthcare costs in Canada exceed $265 billion annually and are rising alarmingly. Patients in remote northern communities must often travel to tertiary-care centres in the south, at a total cost of several hundreds of millions of dollars per year. Empowering local practitioners and clinics with virtual-care support, autonomous and point-of-care technologies has the potential to reduce transportation costs, while building up community-based care.

Socially Beneficial

Improvements in the delivery of healthcare in rural and remote regions and among other medically isolated populations are a national social and economic need. Senior citizens make up 17% of the Canadian population and comprise the fastest-growing segment of our society, yet our healthcare system is not designed to address their changing needs. Seven million Canadians—19% of our population—live in rural or remote regions. They are served by just 8% of Canadian physicians. While urban Canadians enjoy world-class medical care, these people do not. Morbidity and mortality rates among northern Canadians are well above the standards of OECD countries.

Shortcomings in access, equity and healthcare outcomes are particularly acute for Indigenous peoples. The 2015 report of the Truth and Reconciliation Commission of Canada identifies health inequities as a specific and critical call to action, to "identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities… [including] the availability of appropriate health services." A role in deep-space healthcare could become an adjunct to focus attention on the delivery of remote healthcare. Training methodologies developed to support crew medical officers on deep-space missions could be translated to empower physicians and nurses working in remote regions. Appendix H provides several clinical vignettes that illustrate how terrestrial applications could arise from medical technologies developed for deep space.

Similar to the era of the Apollo Moon landings, the public could be emboldened by the audacity of deep-space exploration to address other seemingly insurmountable societal challenges—climate change, food security, global mental health. The next generation of youth could be inspired to pursue STEM educational paths and seize career opportunities in healthcare and innovation.

Systems Mindset

Healthcare, in any setting, is head-spinning in its complexity. Multiple healthcare jurisdictions exist within Canada, each with its own legislative, policy, regulatory and licensing requirements. Other considerations include patient access, equity and outcomes; privacy, quality control and safety standards; and supply chains and global markets.

At the centre of all this are frontline practitioners. Their ability to manage the health, well-being and performance of their patients is enabled by curriculum, training, simulators, procedures, communication networks, facilities and tools. In addition to physicians, these practitioners also include nurses, biomedical engineers, scientists, physiotherapists, chronic-care coordinators, mental-health specialists, dieticians and pharmacists.

An undertaking in remote healthcare—whether in deep space or in underserved communities—will necessitate a systems-level management style. An initiative led by the Canadian Space Agency would not be simply a research and development program. Technology development, in fact, would be the easy part. The hard part of remote healthcare will be coordinating the spectrum of innovations, partners, jurisdictions, training, procedures and support personnel to form an integrated system around the crew medical officer in deep-space or the frontline practitioner in an isolated part of Canada.

Mobilizing the Nation

Government space agencies have traditionally contracted with domestic industry or research institutions to deliver equipment or services to global exploration programs. To enable Canada's contribution to deep-space healthcare, the Advisory Council has proposed a different approach. We suggest that an alliance of partners—not contractors—develop opportunities, share risks and deliver solutions.

This notion of an alliance resonates with candidate partners. Prior to publication of this report, the Advisory Council met individually with several candidate partner organizations. As we briefed them on the CSA vision for deep-space healthcare and the work of our Council, we sensed a buzz of excitement. All organizations were intrigued by the audacity of the vision and the nature of the partnership. They understood how participation could benefit their own organizational mandate, and agreed that a collaboration spanning space, innovation, training and healthcare sectors would be formidable.

Be aware that there will be competition from international space agencies for the leadership role in deep-space healthcare. Leadership would bring significant benefits to any nation, enhancing its reputation, economy and innovation ecosystem, and become a highly regarded niche of spaceflight competence.

However, the notion of a national partnership would differentiate a Canadian bid for leadership in deep-space healthcare from those of competing space agencies. In essence, the full might of Canada's publicly funded healthcare system—accounting for 12% of our GDP—as well as the country's deep pools of research and industrial expertise would be brought to bear. A cross-disciplinary, well-resourced, highly networked national alliance would represent a competitive edge. A multinational collaboration to explore deep space could also benefit from quintessential Canadian leadership traits: Equity, diversity and inclusion; multiculturalism; openness and fairness; diplomacy; collaboration; reliability; good government and a spirit of exploration.

Integrating the Partners

Invention, it is said, often resides at the intersection of cross-disciplinary expertise. But management of a dynamic, multi-sectoral entity may be challenging. Much like an international astronaut crew, a deep-space healthcare partnership will bring together organizations of disparate expertise, cultures, perspectives, practices and governance. During the early years, managers will therefore need to devote time and effort to communicate clearly, build relationships, adapt processes and work smoothly across the founding membership.

Large transformational initiatives of the past have often relied on the services of system integrators to bring together diverse players and contributions. These management firms facilitate collaboration among players by maximizing synergies and ensuring that overarching systems (e.g., digital information networks) function seamlessly. If the CSA is not resourced to oversee partner integration, then the services of an established integrator firm could be sought as a means to de-risk the initiative.

A Sense of Urgency

A final key to success will be to quickly build capability, credibility and experience in deep-space medical operations.

The Advisory Council does not endorse continued middling contributions by Canada to international space programs, with self-congratulatory statements that we punch above our weight. Canada has been a respected, but minor, participant in past human spaceflight partnerships. We must do better. The current low flight-rate of CSA astronauts is inadequate to sustain a vibrant spaceflight program, showcase national innovations, capture public interest and inspire the next generation of leaders.

Rather, the Advisory Council endorses significant investment by Canada in deep-space healthcare in order to enlarge its sphere of international influence, to better position our nation among spacefaring peers, to assume a role critical to human spaceflight and to play a key part in unlocking the mysteries of the solar system.

Having been one of the smaller players in space exploration, we can expect that international space partners will question Canada's capacity to assume a lead role. There will therefore be an urgent need for Canada to secure a strategic system-level contribution to the Lunar Gateway/Artemis programs and then, in the following years, to build on national capability, credibility and experience in medical operations.

Opportunities

• The Global Exploration Roadmap. NP-2018-01-2502-HQ. Washington, DC: National Aeronautics and Space Administration Headquarters, 2018.
• Global Exploration Roadmap – Supplement – Lunar Surface Exploration Scenario Update. NP-2020-07-2888-HQ. Washington, DC: National Aeronautics and Space Administration Headquarters, 2020.
• Prospects for Space Exploration: An economic and strategic assessment of the space exploration sector. 2nd edition. Paris, France. Euroconsult, 2020. Available online at: https://digital-platform.euroconsult-ec.com/wp-content/uploads/2020/07/SPX20_Brochure.pdf
• Euroconsult Releases its Government Space Programs Report – Expenditures Reach US$70.9 Billion in 2018. SpaceQ. Marc Boucher, 2019. Available online at https://spaceq.ca/euroconsult-releases-its-government-space-programs-report-expenditures-reach-us70-9-in-2018/
• Review of Family Medicine Within Rural and Remote Canada: Education, Practice, and Policy. College of Family Physicians of Canada; Mississauga, ON. Carmela Bosco and Ivy Oandasan, 2016.
• Rural Opportunity, National Prosperity: An Economic Development Strategy for Rural Canada. Cat. No. T94-13/2019E-PDF. Her Majesty the Queen in Right of Canada, 2020.
• Delivering more equitable primary health care in Northern Canada. Canadian Medical Association Journal 189(45): E1377-8. T. Kue Young and Susan Chatwood, 2017.
• Addressing provider turnover to improve health outcomes in Nunavut. Canadian Medical Association Journal;191(13): E361-4. Maria Cherba et al., 2019.
• Canada's elder care crisis: Addressing the doubling demand. A report by Deloitte and commissioned by the Canadian Medical Association, 2021.
• How Home-Based Primary Care Can Reduce Expensive Hospitalizations. Harvard Business Review. Boston, MA. Paul Di Capua et al., 2019.
• As COVID-19 exposes long-term care crisis, efforts grow to keep more seniors at home. CBC News. Toronto. Nicole Ireland and Natalie Kalata, 2021.
• Optimizing Access to Heart Failure Care in Canada During the COVID-19 Pandemic. Canadian Journal of Cardiology, 36(7), 1148-1151. Sean Virani, et al., 2020.
• Canada's Unequal Health System May Make Remote Indigenous Communities More Vulnerable To The Coronavirus. The Conversation. Ann Seymour, 2020.
• How To Build A Better Canada After COVID-19: Make Telehealth The Primary Way We Deliver Health Care. The Conversation. Ahmad Firas Khalid, 2020.
• Coronavirus: New Technologies Can Help Maintain Mental Health In Times Of Crisis. The Conversation. Stéphane Vial, 2020.
• 2021 National Survey of Canadian Physicians – use of digital health and information technology among physicians in Canada – Report. Canada Health Infoway and Canadian Medical Association. Leger, 2021.
• Canada's Superclusters: Right people. Right place. Right time. Government Canada, 2020. Available online at https://www.ic.gc.ca/eic/site/093.nsf/eng/home
• Innovation For A Better Canada. Government Canada, 2020. Available online at https://www.ic.gc.ca/eic/site/062.nsf/eng/home
• Federal Government Commits Additional $250 Million In IRAP Funding To Support High Growth Startups. Canadian Startup News. Meagan Simpson, 2020.
• Minister Of Indigenous Services Mandate Letter. Office of the Prime Minister, 2019. Available online at https://pm.gc.ca/en/mandate-letters/2019/12/13/minister-indigenous-services-mandate-letter
• How should we act on the social determinants of health? Canadian Medical Association Journal 190 (42): E1241-2. Trevor Dummer, 2019.
• United Nations Declaration on the Rights of Indigenous Peoples. UN General Assembly, 2007. Available online at https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html
• Unleashing Innovation: Excellent Healthcare for Canada. Report Of the Advisory Panel on Healthcare Innovation. Cat. No. H22-4/9-2015E-PDF Her Majesty the Queen in Right of Canada, 2015.
• Canada's universal health-care system: achieving its potential. The Lancet. 391(10131): 1718-1735. London, UK. Danielle Martin et al., 2018.
• Pan-Canadian Artificial Intelligence Strategy. CIFAR, 2017. Available online at https://www.cifar.ca/ai/pan-canadian-artificial-intelligence-strategy
• Ecological dynamics across the arctic associated with recent climate change. Science. 325(5946): 1355-8. Eric Post et al., 2009.
• Dangerous climate change and the importance of adaptation for the Arctic's Inuit population. Environ Res Lett. 4(2). James Ford, 2009.

Threats

• Development Of an Accepted Medical Condition List for Exploration Medical Capability Scoping. NASA/TM-2019-220299. Houston, TX. Rebecca Blue, Derek Nusbaum and Erik Antonsen, 2019.
• Recommendation for a Medical System Concept of Operations for Gateway Missions. Document developed by the Exploration Medical Capability Element's Systems Engineering team. HRP-48012. Houston, TX. David Rubin, 2019.
• Unleashing Innovation: Excellent Healthcare for Canada. Report Of the Advisory Panel on Healthcare Innovation. Cat. No. H22-4/9-2015E-PDF Her Majesty the Queen in Right of Canada, 2015.
• Enabling health technology innovation in Canada: Barriers and facilitators in policy and regulatory processes. Health Policy, 123(2), pp.203-214. Maggie MacNeil et al., 2019.
• Health and Biosciences: The sector today and opportunities for tomorrow. Interim Report of the Health/Bio-sciences Table of Canada's Economic Strategy Tables. Karimah Es Sabar et al., 2018.
• Digital Industries: The sector today and opportunities for tomorrow. Interim Report of the Digital Industries Table of Canada's Economic Strategy Tables. Tobias Lütke et al., 2018.
• Canada has long way to go on virtual care. Canadian Medical Association Journal 192(30): E227-8. Lauren Vogel, 2020.
• The Innovation Dilemma: Achieving Value, Health Outcomes and Contributing to the New Economy. The Future of Medical Technology in Canada. Publication produced by OPTIMUS | SBR on behalf of MEDEC, the national association representing Canada's medical technology industry, 2017.
• The Health Costs of Climate Change: How Canada Can Adapt, Prepare, and Save Lives. Canadian Institute for Climate Choices. Ottawa, ON. Dylan Clark et al., 2021.
• Changes in Canada's Regions in a National and Global Context. Chapter 8 in Canada's Changing Climate Report, pp. 424-443. Cat. No. En4-368/2019E-PDF. Her Majesty the Queen in Right of Canada, represented by the Minister of Environment and Climate Change, 2019. Stewart Cohen et al., 2019.

Strengths

• International Cooperation. NASA. Mark Garcia and Brian Dunbar, 2020. Available online at: https://www.nasa.gov/mission_pages/station/cooperation/index.html
• Canada Joins NASA's Lunar Gateway Station Project With 'Canadarm3' Robotic Arm. Space.com. Elizabeth Howell, 2019.
• Invest in Canada: Canada's Robotics Industry. Cat. No. FR5-38/25-2016E-PDF. Her Majesty the Queen in Right of Canada, 2016.
• The Global Partnership on Artificial Intelligence officially launched. Montréal International, 2020. Available online at: https://www.montrealinternational.com/en/news/the-global-partnership-on-artificial-intelligence-officially-launched/
• Canadian Healthcare in Deep Space: Advancing Our Country's Leadership in Autonomous Care in Space And on Earth. Report of the Expert Group on the Potential Canadian Healthcare and Biomedical Roles for Deep-Space Human Spaceflight. Cat. No. ST99-61/2019F-PDF. Her Majesty the Queen in Right of Canada, 2019.
• A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills. Canadian Journal of Surgery, 58(6), pp.419-422. Nadine Caron, Stuart Iglesias, et al., 2015.
• Joint position paper on rural surgery and operative delivery. Canadian Journal of Rural Medicine, 20(4), pp. 129-138. Stuart Iglesias et al., 2015.
• Fifty Years On: A Retrospective on the World's First Problem-based Learning Programme at McMaster University Medical School. Health Professions Education, 5(1), pp. 3-12. Virginie Servant-Miklos, 2018.
• The Future Of Medical Education In Canada: A Collective Vision for MD Education. The Association of Faculties of Medicine of Canada, 2010.
• The Future Of Medical Education In Canada 2020: One vision forward - Reigniting our common vision for the Future of Medical Education in Canada. The Association of Faculties of Medicine of Canada, 2020.
• There's An AI Revolution Underway and It's Happening in Canada. Forbes. Jersey City, NJ. Bijan Khosravi, 2017.
• Toronto's thriving AI ecosystem serves as a model for the world. VentureBeat. San Francisco, CA. Naheed Kurji, 2017.
• World's First All-Robotic Surgery Performed in Canada. ZDNet. Andrew Nusca, 2020.
• Competing in a Global Innovation Economy: The Current State of R&D in Canada. Report of the Expert Panel on the State of Science and Technology and Industrial Research and Development in Canada. Cat. No. T177.C2C68 2018. Council of Canadian Academies, Ottawa, 2018.
• QS World University Rankings by Subject 2021: Life Sciences & Medicine. Available online at https://www.topuniversities.com/university-rankings/university-subject-rankings/2021/life-sciences-medicine
• QS World University Rankings by Subject 2021: Nursing. Available online at https://www.topuniversities.com/university-rankings/university-subject-rankings/2021/nursing
• A Canadian Take on the International Patient Engagement Revolution. Healthcare Quarterly 21 (Special Issue). Toronto, ON. Vincent Dumez and Antoine Boivin, 2018.

Weaknesses

• Indigenous health research and reconciliation. Canadian Medical Association Journal 191 (34): E930-1. Marcia Anderson, 2019.
• Indigenous health disparities: a challenge and an opportunity. Canadian Journal of Surgery 61(5): 300-301. Alika Lafontaine, 2018.
• The mirage of universality: Canada's failure to act on social policy and health care. Canadian Medical Association Journal 192 (5): E105-6. Andrew Boozary and Andreas Laupacis, 2020.

Recommendation 1

• Canadian Healthcare in Deep Space: Advancing our country's leadership in autonomous care in space and on Earth. Report of the Expert Group on the Potential Canadian Healthcare and Biomedical Roles for Deep-Space Human Spaceflight. Cat. No. ST99-61/2019F-PDF. Her Majesty the Queen in Right of Canada, 2019.

Recommendation 2

• How NASA Uses Telemedicine to Care for Astronauts in Space. Harvard Business Review. Boston, MA. Anil Menon et al., 2017.
• Defining the specialist generalist: The imperative for adaptive expertise in family medicine. Canadian Family Physician. Mississauga, ON. Nicole Woods et al., 2021.

Recommendation 3

• Challenge Ahead: Integrating Robotics, Artificial Intelligence and 3D Printing Technologies into Canada's Healthcare Systems. Standing Senate Committee on Social Affairs, Science and Technology. Her Majesty the Queen in Right of Canada, 2017.
• Socio-Economic Benefits Study of Deep Space Health Care Solutions Used in Northern and Remote Communities. Euroconsult and Leap Biosystems, 2019.

Recommendation 4

• Simulation in education for health care professionals. BC Medical Journal 57 (10): 444-448. Elspeth McDougall, 2015.
• A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills. Canadian Journal of Surgery, 58(6): 419-22. Nadine Caron et al., 2015.
• Doctors need retraining to keep up with technological change. Canadian Medical Association Journal 190(30): E920. Lauren Vogel, 2018.
• Training the Next Generation of Doctors and Nurses. New York Times Nov. 4, page L4. Laura Pappano, 2018.
• Research: How Virtual Reality Can Help Train Surgeons. Harvard Business Review. Boston, MA. Gideon Blumstein, 2019.

Recommendation 5

• Space medicine innovation and telehealth concept implementation for medical care during exploration-class missions. Acta Astronautica. Amsterdam. Annie Martin et al., 2012.
• 3D printers: A revolutionary frontier for medicine. The Conversation. Toronto, ON. Ivar Mendez, 2017.
• Canadian national survey of point-of-care ultrasound training in family medicine residency programs. Can Fam Physician 64(Oct): e462-7. Taft Micks et al., 2018.

Recommendation 6

• Investing in Canada's Future: Strengthening the Foundations of Canadian Research. Report of the Advisory Panel for the Review of Federal Support for Fundamental Science, 2017. ISBN 9780995924.
• Building A Learning Health System for Canadians. Report of the AI for Health Task Force. CIFAR, 2020. Available online at https://www.cifar.ca/ai/pan-canadian-artificial-intelligence-strategy/building-a-learning-health-system-for-canadians

Recommendation 7

• 10 Promising AI Applications in Health Care. Harvard Business Review. Boston, MA. Brian Kalis et al., 2018.
• An emotionally intelligent AI could support astronauts on a trip to Mars. MIT Technology Review. Neel V. Patel, 2020.
• Canada has a chance to monopolize the artificial intelligence industry. The Globe and Mail, Toronto, ON. John Kelleher and Laura McGee, 2017.
• How Artificial Intelligence Could Help Hospitals Save Lives. The Walrus. Toronto, ON. Conor Lavelle, 2017.

Recommendation 8

• Equity, Diversity, and Inclusivity in Science, Technology, Engineering, and Mathematics: Forging Paths to Enhanced Innovation. Roundtable Summary Report. Ryerson University, Toronto, ON. Imogen R. Coe and Mehrdad Hariri, May 29, 2017.

1. Provide Recommendations

In consultation with the CSA and other experts, the Advisory Council will provide recommendations on how to define a multi-partner national program in astronaut healthcare and performance. More specifically, the Advisory Council will:

• Recommend priority areas to be considered for the potential deep-space healthcare program for Canada
• Identify potential national stakeholders with mandates and priorities aligned with those of the deep-space healthcare program for Canada and the Agency, and propose an organizational structure for a multi-stakeholder partnership
• Facilitate the CSA's engagement with the Canadian healthcare, biomedical, science, performance, Indigenous and governmental communities and their relevant members
• Identify and articulate ideas and concepts that could be presented to these communities to collectively define a potential Canadian role in deep-space healthcare
• Conceptually design the multi-stakeholder partnership ecosystem and its interdependencies with other national and international partners
• Identify relevant stakeholder resources and define the potential nature of their contributions (functional, financial, in-kind)
• Identify other key stakeholders external to the deep-space healthcare program

2. Provide Expert Opinion

As national leaders of healthcare, members of the Advisory Council will provide the Agency with expert opinion on the clinical, technical, scientific, programmatic and social aspects of a deep-space healthcare initiative. They will also provide their opinion on innovation and knowledge-translation plans and investment priorities.

3. Participate in the Development of National Awareness

The Advisory Council will support the CSA in developing the vision, objectives and excitement of a potential Canadian role in deep-space healthcare to be communicated by the CSA to key stakeholders, decision-makers, media and the public.

Canadian Space Agency

With a large staff of skilled scientists, engineers and project managers, the Canadian Space Agency (CSA) has considerable spaceflight expertise. The Agency manages several national facilities for flight qualification, systems integration and mission operations. It has trained many international astronauts and ground-support personnel with Agency-developed curricula, learning tools, simulators and instructors. The CSA's operational space medicine division has provided medical support to several past missions of Canadian astronauts. This division continues to advance medical countermeasures to reduce the adverse effects of the space environment on crew health. The CSA's space life sciences group supports a Canadian research community focused on understanding the biological and physiological adaptations that occur in space.

The CSA would contribute program, policy and operational leadership to a deep-space healthcare partnership. It would oversee development of the Roadmap for Action. In the longer term, the Agency would manage operations, quality-control, timelines and scheduling of program deliverables.

Indigenous Services Canada

Indigenous Services Canada (ISC) works collaboratively with partners to improve access to high-quality services for First Nations, Inuit and Métis. It supports and empowers Indigenous peoples to independently deliver services and address socio-economic conditions in their communities.

Improving health outcomes is one of ISC's five key priorities. Timely access of First Nations and Inuit to health services is critical. ISC works in partnership with First Nations organizations to identify, design and deliver health-service solutions that better meet the needs of their communities. The Clinical and Client Care sector of ISC was developed to meet the primary healthcare needs of remote or isolated First Nations communities where limited or no provincial services are available.

In its 2021 budget, the federal government targeted $18 billion over the next five years to improve the quality of life and create new opportunities for Indigenous communities, including a $2.6-billion investment in health.

CAN Health Network

The CAN Health Network is a national response to a recommendation of the 2014 Advisory Panel on Healthcare Innovation to strengthen collaboration between industry, researchers and governments. The Network works to build a competitive healthcare innovation market in Canada for homegrown solutions. To do this, it identifies business opportunities, selects the best healthcare companies to capitalize on those opportunities, gives those companies access, insights and support to ensure their product is superior, and then provides a large market to quickly scale their businesses.

The CAN Health Network is supported by the federal government through the Federal Economic Development Agency and Western Economic Diversification Canada. It has worked with Canada's most promising biomedical companies to develop, pilot, scale and commercialize new technologies. It would be a valued partner in the deep-space healthcare initiative, by cross-fertilizing terrestrial and space innovations. It could broaden the reach of the CSA's space life sciences group to relevant stakeholders.

First Nations Health Authority

In 2013, the First Nations Health Authority (FNHA) of British Columbia assumed responsibility for the programs and services formerly handled by Health Canada's First Nations Inuit Health Branch - Pacific Region. It is the first province-wide Indigenous health authority of its kind in Canada.

The FNHA today oversees the design, management, delivery and funding of First Nations health programming in British Columbia. It is led and managed by First Nations leaders. It does not replace the role or services of the BC Ministry of Health and Regional Health Authorities, but rather works to collaborate, coordinate, and integrate respective health programs and services to achieve better health outcomes. Specifically, the FNHA works to close the healthcare gaps that exist between First Nations in BC and the rest of the province's population.

The FNHA serves both the urban and rural First Nations population, which includes 203 communities throughout the province. Community-based services are largely focused on health promotion and disease prevention.

Society of Rural Physicians of Canada

The Society of Rural Physicians of Canada (SRPC) is the national voice of more than 1900 rural physician members. Its vision is excellent healthcare close to home for all rural Canadians. It champions rural generalist medical care through education, collaboration, advocacy and research. The SRPC develops and advocates health-delivery mechanisms, supports rural doctors and communities in crisis, promotes and delivers continuing rural medical education, and encourages and facilitates research into rural health issues.

The SRPC is one of the champions of the Rural Road Map for Action, a guiding framework for a coordinated, pan-Canadian approach to rural physician workforce planning and improved access to safe, high-quality rural healthcare.

With the College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada, it promotes the acquisition of enhanced surgical, anesthesia and other specialized skills for rural practitioners.

AGE-WELL

AGE-WELL is part of the federal government's Networks of Centres of Excellence program. It focuses on the development of new technologies and services benefitting older adults and their caregivers by increasing personal safety and security, supporting independent living and enhancing social participation. AGE-WELL addresses these healthy-aging issues with a pan-Canadian network of interdisciplinary researchers, industry, non-profits, government, care providers and end-users. The centre also manages training programs, partnerships, knowledge mobilization and the commercial development of technologies.

The AGE-WELL network harnesses the power of new technologies. For instance, smart homes equipped with sensors and computer vision feed a steady stream of data into AI-enabled systems that detect and manage health conditions. Virtual assistants remind those with memory impairment where they left their eyeglasses or to take their medication. Social robots guide those with dementia through everyday tasks, such as getting dressed and making a cup of tea.

MEDTEQ+

MEDTEQ+ is the Consortium for Industrial Research and Innovation in Medical Technology. It is a national pre-market industry association of healthcare innovators. Its mission is to accelerate innovation and to position Canadian products and services in the world market. MEDTEQ+ is the most financially supportive organization for health technology innovation in Canada, having funded more than 100 projects in theme areas including artificial intelligence, augmented and virtual reality, nanotechnologies, optics-photonics, biomaterials, 3-D printing and robotics.

MEDTEQ+ oversees an ecosystem of 200 member companies, health centres, universities and investors, and works to bring the complementary skills of industrial and academic partners together with those of healthcare providers. It promotes long-term collaboration as a means to achieve better outcomes, trust and opportunities. SMEs are supported through investments, de-risked innovations and strategic alliances.

With MEDTEQ+ facilitation, the CSA could gain access to Canada's growing healthcare innovation ecosystem and leverage the consortium's expertise, capacity and network of collaborators.

Health Canada

Health Canada is the federal department responsible for helping Canadians maintain and improve their health. To carry out this responsibility, it supports activities that:

• Preserve and modernize Canada's healthcare system
• Enhance and protect the health of Canadians, including monitoring the sale and use of drugs and medical devices across Canada
• Work in partnership with others, including provinces, territories and health organizations, to ensure the needs of all Canadians are met
• Communicate health promotion and disease prevention

Health Canada acts as a regulator, service provider, promoter of innovation and trusted source of information. Its functions include financing organizations to promote innovation across Canada; supporting the delivery of healthcare to First Nations and Inuit; regulating food, health and consumer products; and setting and administering national principles to ensure that quality healthcare is available to all Canadians.

The breadth and depth of Health Canada's expertise, coupled with its healthcare oversight mandate, could help accomplish later-term deep-space healthcare goals.

Provincial/Territorial Health Authorities

In Canada, comprehensive healthcare is provided to most Canadians through multiple regional health authorities. The roles and services of health authorities include:

• Delivery of diverse clinical services with expertise in various areas of care
• Credentialled, licensed staff working within systems of care where quality is monitored, education is provided and competencies are maintained
• Systems of delivery that are being continuously updated
• Established IT systems with appropriate data security and management policies
• Well-developed research functions that can be leveraged
• Close ties with universities for training and research, especially within academic health centres
• Experience in the provision of remote/rural care
• Evaluation and implementation of new innovations

Partnering with progressive-minded health authorities from key regions, especially in the early stages of the deep-space healthcare partnership, could help the CSA navigate the complex health-provider ecosystem. (Note: The Agency's current collaboration with health authorities in British Columbia to advance the Northern Demonstration Initiative is already revealing the benefits of such collaboration.)

Canadian Medical Association

The Canadian Medical Association (CMA) is the largest organization of medical doctors in Canada, with more than 75,000 members (physicians, residents and medical students.) The CMA drives meaningful change in healthcare by engaging in health advocacy, public policy, programs and partnerships. It addresses issues facing the medical profession and works to improve the health of Canadians.

The CMA supports the leadership, innovation and training needs of physicians. It provides resources for physicians to incorporate technology in their practices. CMA Joule, a CMA subsidiary, supports physician-led innovation and encourages adoption of knowledge products and innovative technologies and services by physicians. CMA Joule has considerable financial resources.

Assistance in navigating through fragmented regulatory considerations for emerging health and medical technologies would be of particular benefit to a deep-space healthcare partnership. The CMA could also help with policy and training issues and mobilize medical expertise to develop a national roadmap for deep-space healthcare.

Canadian Nurses Association

The Canadian Nurses Association (CNA) is the national voice of 139,000 nurses across all 13 provinces and territories. It provides nationally recognized RN certifications in 21 practice specialties, and delivers professional-development programs as a means to advance nursing excellence and positive health outcomes.

The CNA promotes policy and regulation in the public interest and has influence with national decision-makers. Its report 2020 Vision: Improving Long-term Care for People in Canada called for action in response to the effects of the COVID-19 crisis on our health-care system, economy and lives. In particular, it calls for a redesign of long-term care to maximize the safety, comfort, dignity and health of residents.

In 2021, the CNA and associated nursing organizations committed to action against racism with the release of a declaration against anti-Indigenous racism in nursing and healthcare. These same groups are to convene the first National Summit on Racism in Nursing and Health Care later in 2021.

Association of Faculties of Medicine of Canada

The Association of Faculties of Medicine of Canada (AFMC) is a partnership of Canada's 17 faculties of medicine and the voice of academic medicine in Canada. The member faculties graduate 2,700 MDs and undertake $3 billion of biomedical and healthcare research annually. The AFMC serves as an important resource to decision-makers in this country, ensuring research, medical education and clinical care issues are high on the federal government's agenda.

As part of its social accountability mandate, the AFMC strives to improve the health and well-being of Indigenous peoples by training more Indigenous health professionals and by developing safe working and learning environments for learners, faculty and staff. The AFMC works with medical schools on physician resource planning, striving for a physician workforce that is responsive to the health needs of Canadians.

The Future of Medical Education in Canada suite of AFMC projects focus on enhancements to physician education, healthcare delivery and, ultimately, the health of all Canadians.

Royal College of Physicians and Surgeons of Canada

The Royal College of Physicians and Surgeons of Canada (Royal College) is an association of 44,000 physicians that sets national standards for the medical education of specialists in Canada and continuing professional development. This regulatory authority ensures that the training and evaluation of medical and surgical specialists in 80 specialties maintains certain standards of quality.

In 2018, the Royal College commissioned the Task Force on Artificial Intelligence and Emerging Digital Technologies to help the medical profession in Canada prepare for the changes that AI and digital technologies will bring to residency training and the delivery of care.

The Royal College joined forces with the CMA and CFPC in 2019 to form the Virtual Care Task Force. It identified the regulatory and administrative changes needed to support virtual care in Canada, and to allow physicians to deliver care to patients across provincial/territorial boundaries.

CIFAR

Artificial Intelligence research is an undisputed core competence of Canada. Our three national AI Institutes—Amii in Edmonton, Mila in Montreal and the Vector Institute in Toronto—are internationally renowned.

In 2017, the Government of Canada appointed CIFAR (formerly the Canadian Institute for Advanced Research) to develop and lead the $125-million Pan-Canadian Artificial Intelligence Strategy. This strategy has enabled these three AI institutes, as well as universities, hospitals and organizations across the country, to attract and retain top research talent.

In 2019, CIFAR established the Task Force on Artificial Intelligence for Health. Following national consultations and deliberations, it published its findings in 2020 in its report Building a Learning Health System for Canadians.

The 2021 federal budget renewed the Pan-Canadian Artificial Intelligence Strategy with a further $444-million commitment over 10 years. One of the four pillars of its updated strategy is "AI for health".

Canada's AI research leadership and government investment are strengths upon which to develop a digital-healthcare infrastructure for deep space.

Canada Research Coordinating Committee

The Canada Research Coordinating Committee (CRCC) advances federal research priorities and coordinates policies and programs of Canada's federal research funding agencies and the Canada Foundation for Innovation (CFI). It is a senior strategic forum for initiatives that strengthen Canada's research enterprise, foster world-leading research and advance the socioeconomic well-being of Canadians.

The CRCC comprises the executive heads of the CFI, the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council of Canada and the Social Sciences and Humanities Research Council of Canada, as well as the deputy ministers of Innovation, Science and Economic Development Canada and Health Canada, the president of the National Research Council of Canada and the chief science advisor.

Of particular note to deep-space healthcare, the CRCC oversees the New Frontiers in Research Fund. It is investing $275 million over the five-year period beginning in fiscal 2018-19, and $124 million annually thereafter, to support international, interdisciplinary, fast-breaking and high-risk/high-reward research.

U15

The U15 is a collective of Canada's most research-intensive universities. They foster the development and delivery of long-term, sustainable higher education and research policy, both in Canada and around the world. 

The U15's role is to foster a research environment where universities can continue to drive ground-breaking research. Canada's U15 institutions undertake fundamental research, train tomorrow's citizens, entrepreneurs and leaders, and work with partners from the public and private sectors to mobilize and capitalize on knowledge. They influence the national policy agenda and provide critical advice about higher education, research and development.

Top-quality university research is the foundation of our innovation ecosystem, which is one of Canada's core competitive advantages. U15 universities strengthen Canada's economy and attract talented students and faculty. Member institutions undertake 80% of all competitive university research in Canada, conduct $8.5 billion of research annually and contribute more than $36 billion each year to the national economy.

Creative Destruction Lab

The Creative Destruction Lab (CDL) is a not-for-profit organization that offers mentorship by entrepreneurs and angel investors to science and technology-based start-ups. The program provides advice on technology roadmaps, business-development support and opportunities to raise capital. It operates 10 locations globally, including five sites in Canada.

The CDL has 16 streams, including one specifically for space and one for health. The space stream brings together mentors from fields related to space exploration and development. This stream is tailored toward early-stage companies that are applying AI and other advanced technologies to space-based services. Start-ups work with mentors to sharpen objectives, prioritize time and resources, raise capital, build networks and engage with experts working on the frontiers of research.

Similarly, the CDL health stream helps seed-stage teams bring human health innovations to market. This stream is focused on improving the quality, speed, cost and accessibility of healthcare delivery and improving the operational efficiency of the health system.

National Aeronautics and Space Administration

The United States has the largest and most comprehensive space program in the world. The National Aeronautics and Space Administration's (NASA) proposed budget for 2022 is $24.8 billion, an increase of almost 7% above its current funding. NASA's deep-space exploration, science missions, space technology and STEM outreach programs are the biggest beneficiaries of this proposed increase in funding.

CSA and NASA have a long history of successful partnerships that spans space activities in all areas, including space exploration, Earth observation, science, technology, education and outreach, as well as international policy development. The mutual trust in our capabilities that has been built through this relationship is evident in the integration of Canadian astronauts within the U.S. Corps of Astronauts in Houston, and the integration of the ISS robotic operations between CSA and NASA teams.

As part of the upcoming Lunar Gateway program, CSA and the Canadian space sector are working to provide NASA and partners with Canadarm3—the most sophisticated space robotics system ever developed. The first Artemis crewed mission around the Moon, scheduled for 2023, will be a milestone deep-space mission and will include a Canadian astronaut as one of its four crewmembers.