Human beings evolved to function within the stable conditions of Earth, but our planet has places that can push the limits of the human body. From the thin air of high mountains and extreme cold to isolation, closed environments and darkness, these environments challenge the body in different ways. Studying how humans react and adapt to these conditions can teach us a great deal about oxygen availability, thermoregulation, physical performance and resilience. These lessons are becoming increasingly important as humans prepare for longer missions far from Earth, where multiple environmental stressors will affect the body at the same time.

Earth's Extreme Environments: Natural Laboratories for Human Physiology
Scientists don't always have to travel beyond Earth to study the challenges of living beyond it. Around the planet, extreme environments serve as natural laboratories where researchers investigate how humans function when familiar conditions are altered.
For instance, high-altitude environments expose humans to lower atmospheric pressure and a reduced oxygen supply. The body responds through changes in breathing and circulation, while long-term exposure can influence physical performance. Consequently, these environments provide an opportunity to understand how the human body adapts to hypoxic conditions.

Cold environments present a different challenge. The body needs to regulate its core temperature while managing heat loss, variations in blood flow and increased physiological demands. Extreme cold can also influence physical performance and mobility. These responses demonstrate that the environment can influence not only internal physiology but also the ability to perform everyday physical tasks.

Perhaps one of the most interesting terrestrial examples is Antarctica. At the European Space Agency's Concordia research station, crews experience extreme cold, prolonged isolation, darkness during the Antarctic winter and hypobaric hypoxia because of the station's altitude. ESA characterises Concordia as an environment for studying the psychological and physiological impacts of these conditions and developing possible countermeasures that could be applicable to space exploration.
Concordia is not an imitation of a spacecraft, nor is Antarctica another planet. Its significance lies elsewhere: it allows scientists to examine particular challenges of human adaptation in a controlled and remote environment.

What Extreme Environments Teach us about Human Adaptation
The key point from these environments is that the human body is remarkably adaptable, but adaptation has limits.
At high altitude, reduced oxygen availability triggers physiological mechanisms that help the body sustain oxygen delivery to tissues. In cold environments, mechanisms such as changes in blood circulation and metabolic activity help maintain core temperature. These responses are examples of the body's constant effort to maintain internal stability despite changing external conditions.
Spaceflight applies this concept in an entirely different environment.

In microgravity, the body no longer experiences the mechanical stress that is a normal aspect of everyday life on Earth. NASA highlights that without the constant pull of gravity, bones and muscles experience significant changes, making exercise and other countermeasures important for astronaut health. Microgravity also causes fluid shifts and cardiovascular changes because the body is no longer distributing blood under Earth's gravitational conditions.

However, spaceflight presents more than one physiological challenge. Astronauts may encounter a combination of altered gravity, isolation, distance from Earth, radiation and the demands of living in closed environments. NASA employs a variety of analogue missions on Earth, including Antarctic stations, deserts, underwater habitats and simulated spacecraft, to investigate individual aspects of these challenges.

This is where the significance of extreme environment research becomes evident. Each terrestrial environment reveals something different about human adaptation. High altitude helps us investigate responses to hypoxia. Cold environments demonstrate how the body reacts to thermal stress. Isolated Antarctic stations provide insights into prolonged confinement, darkness and psychological adaptation. Microgravity studies reveal the effects of significantly altering one of the basic environmental factors influencing human physiology: gravity.
These environments are not interchangeable, and none perfectly mimics spaceflight. NASA acknowledges that Earth-based analogues cannot completely simulate the spaceflight environment. Their strength is more specific: they allow researchers to isolate, study and prepare for particular challenges before astronauts encounter them in space.
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From Earth's Extremes to Human Health in Space
This approach will gain significance as human exploration extends beyond brief missions in low Earth orbit.
Future crews travelling to the Moon and eventually Mars will need to stay healthy and be able to perform complex tasks while exposed to unfamiliar environmental conditions for much longer periods. The challenge will be maintaining physical function, cognitive performance, psychological resilience and the ability to respond to unexpected problems far from Earth. That requires more than one scientific discipline.

The challenge will be maintaining physical function, cognitive performance, psychological resilience and the ability to respond to unexpected problems far from Earth. That requires more than one scientific discipline.
Physiology helps us understand how the body adapts. Exercise science helps develop countermeasures. Psychology examines the effects of isolation and confinement. Medicine monitors health risks. Rehabilitation sciences contribute to maintaining and restoring function. Engineering and environmental science help design habitats that reduce unnecessary physiological stress.
The goal is therefore not to find one perfect Earth analogue for space. Instead, it is to combine knowledge from different extreme environments to build a more complete understanding of human adaptation.
NASA's analogue research reflects this approach: terrestrial sites are used to test equipment, procedures and strategies while also investigating human challenges such as prolonged isolation and performance under demanding conditions.
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Preparing Humans for a Future Beyond Earth
The journey to understand human health beyond Earth may begin much closer to home than we realise.
Extreme environments provide opportunities to study how the human body reacts when oxygen, temperature, gravity, isolation or other environmental factors are altered. Spaceflight combines numerous challenges in a setting that is completely different from the environments to which humans have adapted.
The lesson is not that Earth can perfectly replicate space. It is that Earth gives us laboratories in which we can learn how adaptable and how susceptible the human body can be.
As we explore farther from Earth, this understanding may become as important as the spacecraft that carries us there. Understanding human physiology may ultimately be essential for ensuring that life beyond our planet is not only possible, but sustainable.

There is a thought experiment that I find useful when trying to explain space surgery to colleagues who have not encountered the problem before. I ask them to picture a patient in haemorrhagic shock: falling pressure, a rapidly narrowing window for intervention. Standard trauma. Now I ask them to add the following: the operating environment is sealed, the size of a large camper van, and potentially hundreds of millions of kilometres from the nearest blood bank. There is no anaesthetist in the room. The patient is not lying on a table. And the blood, once it leaves the vessels, does not fall.
​That last detail is the one that tends to stop people. It seems almost cinematic, a detail from a science fiction film rather than a clinical problem requiring engineering solutions. But it is entirely real, and it concentrates in a single physical fact the complexity of what performing emergency surgery in microgravity actually requires. Understanding why takes us into a set of problems that are simultaneously physical, physiological, and clinical, and that the research community has been working to solve for longer than most people realize.

Fluid Dynamics and the Microgravity Surgical Field
The behaviour of blood in weightlessness was one of the first problems confronted by space surgery researchers during early parabolic-flight experiments. The foundational work of Campbell, Billica and colleagues at NASA Johnson Space Center established what has become a bedrock principle: open surgery in microgravity requires, at minimum, a reliable system to restrain both the patient and the operator, and a fluid containment strategy.
Without gravity to pool blood at dependent surfaces, bleeding behaves differently: surface tension can cause blood to form globules or domes that adhere to the wound, while droplets, particularly from arterial bleeding, may escape into the surrounding surgical field and potentially the spacecraft atmosphere. The consequences are not merely surgical; they are a crew-safety issue.
The response to this problem has shaped the entire trajectory of space surgery research. Minimally invasive approaches, which confine the surgical field to the interior of a body cavity, have attracted sustained attention precisely because they address the containment problem at its source. Laparoscopic surgery in microgravity has been demonstrated as feasible in parabolic-flight environments, with some important caveats around technique and instrument behaviour.
The 2024 deployment of the MIRA robotic surgical platform to the International Space Station marked the first deployment of a surgical robot in space. The system performed simulated surgical tasks in autonomous and remotely operated modes, providing an important proof of concept for robotic surgery in microgravity. Formal comparative performance data from the deployment are still awaited.
For open surgical approaches, the University of Louisville group led by George Pantalos has spent years developing the Surgical Fluid Management System (SFMS), designed to enclose the operative field within a sealed environment and prevent blood and other fluids from escaping. The system has undergone repeated testing aboard Zero Gravity Corporation parabolic flights and, in 2021, an automated version was tested during a suborbital flight aboard Virgin Galactic's VSS Unity SpaceShipTwo. These experiments demonstrate that the engineering problem is tractable. The distance between an experimental system demonstrated during brief periods of weightlessness and a mission-ready surgical capability that could function reliably throughout a three-year Mars mission is, however, still significant.

The Haemorrhage Problem: Physiology Before Physics
​The physical challenge of fluid containment is real and important. But the physiological challenge of managing haemorrhagic shock in a microgravity-adapted patient may be the more fundamental problem, and it is the less often discussed one.
Astronauts undergo a rapid redistribution of body fluids on entering microgravity, with fluid shifting from the lower body towards the chest and head. As the cardiovascular system adapts, plasma volume typically falls, with reductions of around 10–15 per cent commonly reported during spaceflight. This is not a dramatic physiological alteration in a healthy person performing normal mission tasks. In the context of haemorrhagic trauma, however, it may be significant: the physiological reserve available to buffer acute blood loss could already be reduced before the first drop is shed.

The pharmacological dimension compounds this. Haemostatic agents developed for Earth-based trauma care, from Combat Gauze to tranexamic acid protocols, have not been systematically validated for the space environment. Drug stability during long-duration storage in the radiation environment of deep space remains a concern, although the effects of prolonged radiation exposure are not yet fully understood. Pharmacokinetics may also change in microgravity because the volume of distribution for some drugs could be altered by the fluid shifts of weightlessness. A dosing protocol calibrated for a terrestrial patient may therefore be miscalibrated for a patient who has spent nine months in transit to Mars. Recent research has even begun exploring whether extraterrestrial regolith, the surface material of the Moon or Mars, might serve as a haemostatic agent for missions where resupply is impossible. The fact that this question is being seriously investigated tells you something about the resource constraints the field is working within.

Anaesthesia in a Closed System
​The anaesthetic challenge of space surgery deserves particular attention, partly because it sits at the intersection of almost all the other problems described here. General anaesthesia in a sealed spacecraft introduces risks with no terrestrial equivalent. Anaesthetic gases would need to be carefully contained within a closed-loop life-support system, a problem categorically different from the open atmospheric dispersion possible on Earth. The availability of monitoring technology is also constrained by mass, volume and power budgets.

A recent mini review, published in Frontiers in Physiology in early 2026, examined specifically the potential behaviour of spinal anaesthesia in microgravity, where the relationship between drug baricity, posture, spinal curvature and cerebrospinal fluid dynamics that determines block spread on Earth is fundamentally altered by the absence of gravity-dependent density gradients. The review's conclusion is not that regional anaesthesia is infeasible in space but that the terrestrial assumptions underlying current regional anaesthetic practice may fail in microgravity in ways that are not yet characterised. Adapting regional techniques to the space environment requires research that has not yet been done.
The practical implication is that the space surgeon may need to function as their own anaesthetist, or train crew members to assist with anaesthesia administration under protocols designed for non-specialists in a resource-limited environment. Neither of those scenarios has been systematically trained for. Neither has an established protocol. 

What the Evidence Base Actually Supports
​It is important not to overstate the uncertainty. The evidence base for space surgery, while incomplete, is not negligible. Surgical motor skill does not appear to be significantly degraded by microgravity per se, provided the operator is properly restrained relative to the patient. Basic procedures including suturing, haemorrhage control and laparoscopy have all been demonstrated as feasible in parabolic-flight conditions. The robotic surgical approach offers genuine promise because it addresses the containment problem structurally and may eventually support greater procedural autonomy to help overcome the communication latencies of deep space.

​What the evidence base does not yet support is a complete, validated, mission-ready surgical capability for an interplanetary crew. The gap between feasibility demonstration in short parabolic flight arcs and reliable procedural performance over the duration of a Mars mission will need to be bridged by research that is still ongoing, in some areas barely begun. The physiological unknowns around the critically ill long-duration space patient are substantial. The pharmacological uncertainties are real. The training framework for the space surgeon has not been written.
These are not reasons for pessimism. They are a research agenda. And understanding them clearly, with the specificity that the literature supports rather than the vagueness that makes the problem seem either trivial or intractable, is the prerequisite for building what still needs to be built. What that requires is the subject of the next and final post in this series.

The Interplanetary Surgeon | Part 2 of 3

Missed Part 1? Read No Medevac from Mars: Why Medical Autonomy Will Be Essential for Deep-Space Missions.
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Read Part 1: No Medevac from Mars →

Introduction
Microgravity research reveals critical medical and biological adaptations, from cerebrospinal fluid shifts, electrolyte loss, muscle atrophy, and bone demineralization to changes in cellular morphology and cancer biology, where simulated microgravity has been shown to enhance 3D cell growth and tumor-inhibitory responses, though the exact cellular mechanisms are still being investigated.
Studying these effects through orbital spaceflight is limited by scarce resources, long lead times, and high costs. Ground-based devices, rotating wall vessels, clinostats, and random positioning machines, replicate weightlessness-like conditions on Earth, but commercial hardware is proprietary and prohibitively expensive, restricting this research to well-funded institutions and shutting out resource-limited academic ecosystems in developing countries.
This raises a central question: can resource-constrained institutions bypass commercial entry barriers using open-source hardware to build functional, localized space-simulation facilities, and in doing so, democratize cellular mechanobiology and regional health-science research? This paper outlines a methodological framework for deploying low-cost, open-source simulated microgravity systems that make this research accessible worldwide. 
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The Physics of Simulated Microgravity: How to "Trick" Gravity
Orbital microgravity is entirely real: the International Space Station accelerates sideways to about 27,600 km/h at a 400-kilometer altitude, entering perpetual orbital free fall — its forward velocity is so great that the Earth’s surface curves away beneath it at the exact same rate it falls.
To replicate these weightlessness-like conditions on Earth, ground-based instruments use distinct physical mechanisms:

• Drop towers and sounding rockets provide short-term true free fall, using vacuum shells to minimize air drag and mechanical reaction forces.
• 2D clinostats rotate the sample continuously around a single axis, continually changing its orientation relative to Earth’s gravitational field. This disrupts sedimentation and averages the direction of the gravity stimulus over time, preventing cells from experiencing a persistent “down” direction and thereby simulating key aspects of microgravity.
• 3D clinostats expand this rotation across dual axes to uniformly cover spherical coordinates and eliminate directional bias.
• Random Positioning Machines (RPM) use dual-axis chaotic rotation driven by randomized algorithms so the gravity vector hits every angle stochastically, preventing biological adaptation to repeating patterns.
• Rotating Wall Vessels (RWV) use a horizontal, liquid-filled drum where the spinning wall drags the nutrient fluid in a circular current — as gravity pulls cells downward, the upward-moving current sweeps them back up, so fluid drag cancels gravitational sedimentation and cells float in a gentle, circular free-fall orbit without touching the vessel walls.

All of these rotational systems must carefully navigate the physics trap of unwanted centrifugal force (Fᶜ = mω²r), keeping rotation speeds and radial distances low to avoid introducing an artificial outward pull that ruins the simulation.

Democratising Space Biology Through Low-cost Maker Hardware
Democratising space biology depends on affordable ground-based hardware that bypasses both the cost of orbital access and the high price of commercial simulation systems. Open-source and 3D-printable clinostats demonstrate that functional space-biology apparatus can be developed for a fraction of the cost of specialist commercial equipment. Student researcher Leanne Fan, for example, built a custom dual-axis device for her award-winning 2026 Regeneron Science Talent Search project, while other published open-source designs have demonstrated that capable 3D clinostats can be constructed for less than $1,000.
Using economical components such as Arduino microcontrollers, standard stepper motors, and 3D-printed gimbals, institutions can therefore avoid commercial systems that may cost $50,000 or more. The key mechanism is mathematical vector optimization: algorithms calculate exact constant-velocity ratios for dual-axis frames (for example, an inner speed of 1.5 rpm and outer speed of 3.875 rpm) that spherically distribute Earth’s gravity vector over time, creating conditions that approximate key biological effects of microgravity without costly closed-loop feedback systems.

Reducing Mechanical Shear Stress Via Neutral Buoyancy and Diamagnetic Levitation
​Clinostats carry mechanical drawbacks, including fluid sloshing, vibration, and friction that can exert forces on cell membranes and potentially influence cellular responses and gene expression. Alternative chemical and physical approaches can help reduce these effects. By tuning the density of the culture medium with density-gradient reagents to match suspended cell spheroids, researchers can achieve neutral buoyancy. This creates a balance of forces that allows spheroids to remain suspended without sinking or floating, providing a non-rotational approach to simulating some aspects of microgravity.

Real-time Live Imaging with Open-source Microscopy
​A major limitation of ground-based simulation has historically been the difficulty of observing cellular responses in real time. Bulky conventional microscopes can require researchers to stop rotation and inspect samples only after the fact.
Integrated platforms such as EuniceScope help overcome this by combining compact clinostat mechanics with a modular brightfield microscope inside a low-cost, open-source, 3D-printed platform. Instead of traditional optical arrangements that can restrict modification, the design uses infinity-corrected optics: a primary objective lens creates parallel beams of light that travel through an unobstructed intermediate space before a tube lens focuses them to form an image.
Because the light rays travel parallel through this open optical path, researchers can incorporate modular components such as filters, fluorescence attachments or miniature cameras without substantially disrupting image formation. This allows continuous monitoring of live cellular changes while the platform is actively rotating.
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Low-budget Miniaturised Automated Payloads and Multi-stressor Testing
​Compact, automated systems designed to operate entirely inside standard cell incubators can also reduce costs by using consumer-grade microcontrollers such as ESP32 or Raspberry Pi boards rather than proprietary industrial control hardware.
Instead of relying on continuous manual intervention, these low-budget platforms can incorporate closed-loop automation, with inexpensive onboard sensors monitoring rotation speed and environmental conditions and feeding data back to motor controls in real time.
Researchers can also combine simulated-microgravity platforms with additional controlled stressors, such as carefully calibrated UV exposure or chemical oxidative agents, to investigate how multiple environmental stresses affect biological samples. These approaches cannot reproduce the full complexity of the space radiation environment, but they can provide accessible experimental models for studying selected combined effects of altered gravity and cellular stress.
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Cellular Mechanobiology and Emerging Cancer Research in Microgravity
​Through the lens of cellular mechanobiology, researchers can investigate how cells sense altered mechanical loading and respond through mechanotransduction. These studies help illuminate pathways involved in muscle loss, bone demineralisation and vascular change, processes relevant not only to spaceflight but also to aging and prolonged immobilisation on Earth.
Beyond these terrestrial healthcare parallels, microgravity research is also opening new avenues in oncology. Janus base nanomaterials (JBNs), developed by researchers at the University of Connecticut and Eascra Biotech, are synthetic, DNA-inspired structures designed to carry therapeutic agents. Previous research supported by the International Space Station National Laboratory has shown that manufacturing JBNs in microgravity can produce more uniform and homogeneous structures than comparable Earth-based processes.
These improvements could support the development of JBN-based systems capable of carrying therapeutic agents into difficult-to-treat solid tumours while limiting exposure of healthy tissues. In 2026, Eascra Biotech reported that it was advancing JBN-based chemotherapy and immunotherapy approaches using findings from its ISS National Laboratory-supported research.
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Collaborative Innovation: The Way Forward
​Pushing the boundaries of space medicine does not always require prohibitive multi-million-dollar budgets; it can thrive on cross-disciplinary teamwork, where medical and life-science students contribute biological expertise while engineering students design and construct affordable hardware.
By leveraging open-source blueprints, 3D printing and low-cost maker electronics, students and researchers in developing regions can reduce important financial barriers, turning resource-constrained environments into active hubs of innovation. Creative, affordable technologies can help address local research and healthcare challenges while also contributing to the future of human space exploration.

​It is quite possible that this article could be relevant to some of the younger readers of InnovaSpace who may themselves be visiting the Moon two decades from now. NASA's Artemis programme aims to return humans to the lunar surface and, through increasingly ambitious missions, establish an enduring human presence on and around the Moon.
Establishing a permanent lunar base will be difficult. A major logistical problem is that almost everything must either be brought from Earth or eventually produced on site. Extreme environmental hazards include the absence of an atmosphere, leaving a lunar base exposed to solar and cosmic radiation and micrometeoroid impacts. Gravity would be just one-sixth that of Earth. Radiation, dust and extreme temperature variations would all affect human health. Temperatures on the Moon can range from around 121°C to -246°C.
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The Lunar Surroundings
Long-term exposure to low gravity, radiation, isolation and confinement raises both medical and psychological concerns. Over time, these factors may affect bone and muscle health, vision, immune function and mood. Long-term isolation on the Moon could also affect cognition, sleep and interpersonal relationships. Anxiety, depression, irritability, reduced attention and burnout resulting from confinement and separation from normal social life could occur.
In practice, healthcare on the Moon would be dependent on habitat, power, food, transport and maintenance. The lunar environment may disrupt circadian rhythms because of unusual light cycles, limited natural cues and operational stress. This can worsen sleep quality and increase fatigue, reducing concentration and judgement. Over time, these effects can affect both performance and emotional resilience.
Emergency care would involve stabilising, monitoring and treating the patient. Evacuation to Earth could be significantly delayed or, depending on mission circumstances, may not always be immediately possible. In addition to first aid and initial management, care on the Moon would therefore include procedures and treatments normally carried out by a physician or surgeon on Earth. Increased medical self-care would be the rule.
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Physiological Changes Beyond Earth
​Human bones lose roughly 1 to 1.5% of mineral density every month during extended exposure to microgravity, particularly in weight-bearing bones. Muscles also atrophy without the constant loading experienced on Earth, while cardiovascular deconditioning occurs as the body adapts to an environment where it no longer has to work against Earth's gravity.
Bone loss also increases the amount of calcium excreted in the urine, which may contribute to the formation of renal stones. Preventive measures, including regular resistance exercise, adequate hydration and appropriate nutrition, will therefore be particularly important for people spending prolonged periods away from Earth.
Although these changes are well documented in microgravity, the long-term effects of living in the Moon's one-sixth gravity are not yet known. Similar effects on the musculoskeletal and cardiovascular systems are anticipated, making exercise and other countermeasures an essential part of future lunar healthcare.
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The Invisible Threat of Cosmic Radiation
​Earth's magnetic field and atmosphere provide protection from much of the radiation encountered in space, but travellers beyond low Earth orbit face increased exposure to galactic cosmic rays (GCRs) and solar particle events (SPEs). High-energy particles can pass through the human body, damaging cells and DNA and potentially increasing the long-term risk of cancer and other health effects.
Unlike crews aboard the International Space Station, future lunar inhabitants will spend prolonged periods beyond the protection provided by Earth's magnetic field. Radiation exposure will therefore be one of the major health challenges associated with living and working on the Moon. Protecting crews will require careful monitoring of radiation exposure, effective habitat shielding and procedures for responding to periods of increased solar activity.
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Clinical Problems
​A crew member may develop dehydration, constipation, urinary stones, infection, trauma, dental pain or an allergic reaction. These are routine problems on Earth. On the Moon, they can become operational crises. A simple injury could compromise an entire mission if the crew lacks adequate triage tools, medication or surgical capability.
Lunar healthcare will therefore need to be preventive, protocol-driven and largely self-managed. A doctor may not always be available within the crew, and evacuation to Earth may be delayed or, in some circumstances, impossible. The main medical challenges are likely to include cardiovascular deconditioning, bone and muscle loss, neurovestibular problems, sleep and circadian disruption, radiation injury, immune dysregulation, renal stones, trauma and psychological stress.
Lunar healthcare must shift from “doctor-centred” to “crew-centred” care, with a strong emphasis on prevention, triage, point-of-care testing and self-treatment protocols. Care before, during and after spaceflight should be organised as a structured continuum, rather than as an emergency-only service.
The question is not whether astronauts will fall ill or be injured. They will. The question is how a crew will diagnose, treat, monitor and recover when Earth is far away and time is not on their side.
The Moon could therefore become an important testbed for the future of healthcare, not only for subsequent missions deeper into space, but also for isolated and resource-limited settings on Earth.
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Care Without a Hospital
​The central challenge of lunar healthcare is the absence of a hospital. There will be no emergency department, intensive care unit or immediate access to tertiary care. Care protocols will therefore need to be simplified, tools must be multipurpose, and medical training broader than usual.
Astronauts may need to act as doctor, nurse, pharmacist and paramedic for one another. Artificial intelligence could assist with triage, anomaly detection, medication tracking and pattern recognition from sensor data. Portable ultrasound, compact blood analysers and wearable monitors may allow lunar inhabitants to assess hydration, inflammation, cardiovascular status and injury. Such technologies will become increasingly important as crews operate more independently from medical expertise on Earth.

​Organ-on-chip platforms and other bioengineering tools could also help researchers understand how human tissues respond to the lunar environment, potentially improving our understanding of the biological effects of radiation and altered gravity.
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Challenges in Providing Healthcare on the Moon
​Performing surgery in one-sixth gravity would present major challenges. Blood and other body fluids would behave differently from on Earth, creating difficulties in controlling bleeding, maintaining a clear surgical field and preventing contamination of the habitat. Surgical techniques and equipment may therefore need to be adapted specifically for reduced-gravity environments.
Large diagnostic systems such as today's CT and MRI scanners would also be impractical for early lunar habitats because of their mass, volume and power requirements. Smaller, multipurpose diagnostic technologies will be needed instead.
Lunar medical care will face several additional challenges. These include:

• limited mass and volume available for medical equipment and supplies;
• fewer opportunities to replenish medical supplies;
• concerns about the long-term stability and shelf life of medications and laboratory reagents;
• limited opportunities for rapid medical evacuation to Earth;
• the need for considerable medical training and regular skills practice by non-medical crew members; and
• continued Earth-based medical consultation whenever communication and circumstances permit.

As lunar missions become longer and crews spend increasing periods away from Earth, healthcare systems will need to balance the benefits of terrestrial medical support with a progressively greater capacity for autonomous care.
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​The importance of access to medical facilities on Earth was highlighted in January 2026, when NASA brought its four-member SpaceX Crew-11 mission home earlier than originally planned because of a medical concern involving one of the astronauts. NASA astronaut Mike Fincke later revealed that he had experienced a medical event aboard the ISS that required immediate attention from his crewmates and guidance from NASA flight surgeons.
His condition stabilised, but NASA decided that an early return was the safest course, allowing access to advanced medical imaging that was not available aboard the space station. Crew-11 returned safely to Earth on 15 January 2026, after 167 days in space. The precise nature of Fincke's medical condition has remained private.
The episode provides a timely reminder of one of the fundamental challenges facing future lunar healthcare: medical facilities and expertise that are readily available on Earth may simply not be available when they are needed on the Moon.
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A New Medical Frontier
​Healthcare on the Moon is not about building a miniature version of Earth's hospital. It is about designing a new system for a new world. That system must be preventive rather than reactive, distributed rather than centralised, and intelligent rather than dependent on immediate human expertise. It must anticipate illness, not merely respond to it.
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Epilogue
​NASA's Artemis programme is returning human explorers and scientists to the Moon, with increasingly ambitious missions intended to support a longer-term human presence. The goals include scientific exploration, the development of lunar capabilities and preparation for future human missions to Mars.
Current approaches to medical care in space may not meet the needs of future lunar residents. New technologies, new approaches to healthcare and novel training will be required. Familiarity with both space medicine and aerospace engineering will be essential.
The future is always ahead of schedule.
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Phase 1: Build, Test, and Learn
The inaugural phase aims to secure reliable access to the lunar surface through an extensive logistical foundation. During this period, a series of launches and uncrewed landings will deploy robotic scouts and precision landers. These precursor missions will map radiation environments, evaluate engine plume interactions with lunar regolith, and validate autonomous touchdown systems.

Phase 2: Establishing Surface Infrastructure (2029 to 2032)
Transitioning from reconnaissance to active construction, Phase 2 lays the physical foundation for prolonged lunar operations. Between 2029 and 2032, up to 24 landings will deliver as much as 60 tons of cargo to the lunar South Pole. This phase focuses on deploying expanded solar power systems, surface mobility vehicles and high-bandwidth communication networks.​

Phase 3: Sustained Presence and the Road to Mars (2032 and Beyond)
Commencing in 2032, the final phase represents the full realisation of a sustained human presence on the Moon. NASA plans to deploy larger, long-duration surface habitats integrated with advanced environmental control and life-support systems, supported by operational fission surface power. Crews will also advance in-situ resource utilisation technologies, using locally available lunar resources to support surface operations.
This phase will serve as a critical physiological and operational analogue for future missions to Mars. Long-duration surface rotations will allow researchers to study the effects of prolonged exposure to one-sixth gravity and to develop and validate countermeasures against musculoskeletal deterioration, bone mineral density loss and cardiovascular deconditioning. Understanding these biological and engineering challenges on the Moon will be an important step towards enabling human survival and performance during future deep-space missions.
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A New Era of Exploration
This updated Artemis architecture reflects a new maturity in human space exploration. We are evolving from brief visitors to long-term explorers and builders. The Moon will serve as our anchor and our academy, a place where we can push the limits of human performance, refine our life-support technologies and learn the realities of off-world habitation.
As we look towards the lunar surface today, we see more than a celestial neighbour. We see a foundation from which humanity can prepare for its next great expedition, building the infrastructure, knowledge and physiological resilience required to one day reach the red dust of Mars.
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What is Space Oncology?
​Space oncology (SO) is a rapidly emerging field that investigates how microgravity (MG) and cosmic radiation influence cancer progression and treatment. Space-based environments are being studied to accelerate tumour modelling and drug discovery, making space a unique laboratory for cancer biology.
Space oncology has already generated important conceptual and technological spin-offs, ranging from three-dimensional cell culture systems and protein crystal studies for cancer drug development to advances in radiation biology, tissue-response research and biomarker discovery.​

Effects of Microgravity on Cancer Cells
Reviews of both real-space and simulated microgravity experiments have demonstrated important effects on cell adhesion, migration, proliferation, gene expression and the formation of multicellular spheroids. Microgravity alters cytoskeletal organisation and promotes spheroid formation, creating more physiologically relevant tumour models that may accelerate drug discovery while reducing reliance on animal models.
The effects of microgravity on cancer cells, cancer stem cells and drug response may also help shape future therapeutic strategies. Microgravity enables the production of more uniform protein crystals, lower-viscosity biologics and more stable pharmaceutical formulations.
Microgravity also influences the formation of nanoparticles that deliver chemotherapy directly to tumours while enabling controlled drug release. It alters cancer cell morphology, membrane behaviour and gene expression, thereby influencing how cells take up therapeutic agents. When gravity is removed or substantially reduced, cells experience profound changes in fluid dynamics, mechanical loading and cell-to-cell interactions. For cancer cells, these changes are far from trivial. They also facilitate the production of drug crystals and biologic formulations that are difficult to manufacture under normal terrestrial conditions.

Graf et al. discussed in detail the effects of microgravity on multiple omics disciplines in their paper Omics Studies of Tumor Cells under Microgravity Conditions, summarising transcriptomic, proteomic, metabolomic and epigenetic findings across multiple tumour types exposed to both real and simulated microgravity.
Similarly, Grimm et al., in their paper Recent Studies of the Effects of Microgravity on Cancer Cells and the Development of 3D Multicellular Cancer Spheroids, demonstrated how microgravity alters cell adhesion, proliferation, survival, cytoskeletal organisation, extracellular matrix interactions and spheroid formation, with important implications for drug discovery and the reduction of animal experimentation.
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Mechanobiological Diversity of Cancer
Cancer is biologically diverse. Understanding the differing mechanobiological responses of tumour cells to microgravity may help identify signalling pathways that are fundamental to metastasis, tissue invasion and treatment resistance.
Studies have demonstrated cytoskeletal reorganisation, altered focal adhesion signalling, changes in extracellular matrix interactions and the spontaneous formation of multicellular spheroids, all of which are highly relevant to tumour progression and therapeutic response. Microgravity not only alters the biology of tumour cells targeted by drugs but may also improve the performance of advanced drug-delivery systems, including nanoparticles and three-dimensional formulations.
Studies conducted aboard the International Space Station have investigated both real-space and simulated microgravity across breast, lung, thyroid, prostate, melanoma, glioblastoma and haematological cancer models. Cancer cells exposed to microgravity and the unique radiation environment of space behave differently from those grown under conventional laboratory conditions. These differences continue to reveal biological mechanisms that are otherwise difficult to observe and may ultimately contribute to improved cancer therapies.

Breast and Gastrointestinal Cancer in Outer Space
​Breast cancer cells demonstrate changes in gene expression, morphology, signal transduction and invasive behaviour under microgravity. Experimental studies suggest that, under microgravity conditions, some breast cancer cell lines adopt a less aggressive phenotype. Under normal gravity, breast cancer cells attach firmly to the surrounding extracellular matrix through focal adhesions. In space, however, these adhesion complexes fail to mature fully, reducing the cells' ability to migrate and metastasise.
Key proteins involved in cell-cycle regulation, including cyclin D1 and cyclin B1, are significantly downregulated, slowing cell division and reducing the rapid colony-forming capacity of tumour cells. Breast cancer spheroids grown in space have also shown increased susceptibility to certain targeted therapies.
Gastrointestinal and colorectal cancers, however, appear to respond differently to microgravity, with some studies suggesting accelerated tumour progression and a more aggressive phenotype. Reduced expression of drug-resistance genes, increased DNA and RNA damage markers, and reorganisation of F-actin have also been reported, making gastric cancer cells more sensitive to doxorubicin.
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FDA and Space Oncology
​The U.S. Food and Drug Administration (FDA) does not have a separate approval pathway for drugs developed using space-based research. Rather than focusing on where an experiment was performed, the FDA evaluates how well it was conducted. Space-derived evidence must therefore be scientifically rigorous, reproducible and generated in accordance with accepted preclinical standards. The FDA assesses whether the submitted data are credible, relevant and sufficient to support claims of safety and effectiveness within the existing regulatory framework.
In 2025, the FDA approved a subcutaneous formulation of pembrolizumab. NASA had contributed to the underlying protein crystal growth research performed aboard the International Space Station, targeting the ADAR1 gene. The resulting protein crystals were more uniform and better suited to formulation studies supporting this route of administration.
Similarly, rebecsinib became the first space-tested cancer drug to enter clinical trials. Following successful International Space Station-linked testing, it received U.S. FDA Investigational New Drug (IND) status. Tumour organoids grown in microgravity demonstrated sufficient antitumour activity to support further regulatory progression.
Together, the pembrolizumab and rebecsinib examples illustrate that space-based research is becoming a legitimate component of modern drug development rather than simply a scientific curiosity.
​

New Regulations and Investment
​In 2026, UK regulators and the UK Space Agency publicly supported the development of a regulatory pathway for pharmaceutical research conducted in outer space. Investors and regulators alike have recognised the need for clear legal and quality standards governing commercial space-based biomanufacturing.
The Medicines and Healthcare products Regulatory Agency (MHRA), the Civil Aviation Authority (CAA) and the Regulatory Innovation Office (RIO) have worked together to streamline inter-agency regulation. In doing so, they have addressed many of the "dual-regulation" challenges that previously discouraged major commercial investment in space-based pharmaceutical manufacturing.
In microgravity, protein crystals and complex biologics form more slowly and uniformly because they are not affected by gravitational sedimentation. This allows companies such as BioOrbit to engineer highly stable, concentrated cancer therapies that may ultimately be administered as subcutaneous injections rather than lengthy intravenous infusions.
BioOrbit's BOX unit, launched in May 2026, is a microwave-sized autonomous orbital manufacturing platform designed to crystallise protein-based drugs under microgravity conditions. Following £9.8 million in seed funding, the company is using BOX to develop cancer therapies that can be delivered by self-injection at home rather than requiring prolonged hospital-based infusions.
Instead of launching entire manufacturing facilities into orbit, companies can now deploy compact autonomous production units capable of operating independently in space.
The UK is leveraging its £2 billion Life Sciences Sector Plan to position itself as a global centre for commercial space-enabled biomanufacturing.
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Economics of Space Oncology
With this background, it is essential that we begin planning for the future rather than focusing only on the low-hanging fruit. Despite a relatively modest US$13 billion space economy, ISRO has emerged as the world's third-largest space technology power and ranks among the five major government space agencies. As launch costs continue to fall and commercial space platforms become more widely available, space oncology is becoming an increasingly realistic proposition.
Launch costs have fallen dramatically, from approximately US$50,000 per kilogram in the early 2000s to less than US$2,500 per kilogram on the SpaceX Falcon 9 in 2025, making space-based pharmaceutical manufacturing significantly more viable. With the continued growth of successful commercial space companies in India, these costs may decrease further.
Space manufacturing is no longer confined to research. BioOrbit's BOX platform, Varda Space's manufacturing capsules and emerging UK regulatory frameworks demonstrate that the industry is moving from proof-of-concept towards commercial production.
Although space-based cancer drug development remains more expensive than conventional terrestrial research, the potential benefits are considerable. Improved disease models and more predictive preclinical testing may reduce drug-development failure rates by as much as 10%, potentially saving around US$100 million per successful drug. Space experiments currently cost approximately US$2 to 8 million on the International Space Station, or US$10 to 15 million using commercial re-entry capsules, compared with roughly US$10,000 to US$500,000 for comparable terrestrial preclinical studies.
The microgravity pharmaceutical manufacturing market, valued at approximately US$1.5 billion in 2025, is projected to reach US$9.8 billion by 2034, representing a compound annual growth rate of 23.7%. Commercial space stations and nano- and microsatellites (CubeSats) are rapidly becoming essential research platforms, while smaller, more frequent launches are making pharmaceutical payloads increasingly practical.

Epilogue
​More than 700 peer-reviewed papers, 40 book chapters and 12 monographs have already been published in the field of space oncology. I am optimistic that, during my grandchildren's generation, cancer management on terra firma will increasingly benefit from research undertaken, and medicines developed, in outer space.
Confucius could well have been referring to space oncology when he observed more than 2,000 years ago:
"A journey of a thousand miles begins with a single step."
Humanity will continue to exploit the unique environment of outer space in its enduring quest to solve the cancer conundrum here on Earth.
​

Further Reading
​Readers wishing to explore this rapidly developing field may find the following resources of interest:

• Graf et al. Omics Studies of Tumor Cells under Microgravity Conditions
• Grimm et al. Recent Studies of the Effects of Microgravity on Cancer Cells and the Development of 3D Multicellular Cancer Spheroids
• U.S. Food and Drug Administration (FDA): Oncology Drug Development
• BioOrbit
• UK Government Life Sciences Sector Plan

​

Human activity on the Moon, Selene for the ancient Greeks, constitutes one of the most significant chapters in scientific history. Between 1968 and 1972, the Apollo program, conducted by NASA (National Aeronautics and Space Administration), took twelve astronauts to the lunar surface, beginning with the Apollo 8 mission, the first crewed mission to orbit the Moon, and culminating with Apollo 17. These missions not only demonstrated humanity's technological capabilities but also provided crucial scientific data on lunar geology, the formation of the Earth-Moon system, and the history of the Solar System itself.
However, after 1972, human exploration of the Moon came to an end, marking the beginning of a hiatus that has now lasted more than five decades.
This prolonged interval reflected geopolitical changes, shifting economic priorities, and technological challenges. Nevertheless, fascination with Selene remained alive, both as a scientific destination and as a strategic platform for future interplanetary missions. In the twenty-first century, with advances in technology and increasing international cooperation, NASA launched the Artemis program. With Artemis I and Artemis II now successfully completed, its objective is not only to return to the Moon, but also to establish a sustainable human presence there.

The Artemis I Mission: The Past
Conceived as the cornerstone of the Artemis Program, the Artemis I mission represented the first major integrated test of the systems designed to take humans back to the Moon. Launched on 16 November 2022 (Figure 1) aboard the Space Launch System (SLS) rocket, the mission carried no astronauts. Instead, Orion flew with the instrumented mannequins Commander Moonikin Campos, Helga, and Zohar, equipped with sensors capable of recording the radiation and acceleration conditions to which future astronauts would be exposed in the space environment.
During a journey of approximately 25.5 days, Orion travelled more than 2.25 million kilometres, entered a distant retrograde orbit around the Moon (Figure 2), and reached a maximum distance of 432,210 kilometres from Earth, the greatest ever achieved by a spacecraft designed for human transport, before returning and splashing down safely in the Pacific Ocean on 11 December 2022.

Throughout the mission, Orion's heat shield, life-support systems, the propulsion system of the European Service Module (ESM) developed by the European Space Agency (ESA), and its long-range communication systems were thoroughly tested and validated. The critical re-entry phase, during which the capsule reached speeds close to 40,000 km/h and temperatures of up to 2,760°C on the surface of its heat shield, was successfully completed, confirming the robustness of the AVCOAT ablative coating, one of the most critical elements for ensuring the safety of future crews.
Although post-mission analyses identified slightly higher-than-expected erosion in some regions of the heat shield, these findings proved invaluable for improving the system before the first crewed flight.

From a scientific perspective, Artemis I provided a valuable dataset on the radiation environment in deep space, essential for protecting future crews. The dosimeters installed on the mannequins showed that astronauts will be exposed to significantly higher radiation doses than those experienced during missions in low Earth orbit, reinforcing the need for mitigation strategies already incorporated into the planning of subsequent Artemis missions.
More than a technological demonstration, Artemis I established the benchmark against which the entire Artemis Program would be evaluated, proving that a human return to the Moon was not only desirable but also technically feasible, thereby laying the foundations for the first crewed mission that would follow.

The Artemis II Mission: The Present
Building on the foundations established by Artemis I, the Artemis II mission was the second major step in the Artemis Program and the first with a crew on board. Conducted in April 2026 over approximately ten days, its central purpose was to validate, under real flight conditions, systems previously tested only in simulated or uncrewed environments: life support, navigation, communication, propulsion, and human performance in deep space. More than a journey around the Moon, Artemis II was a decisive and successful test of the viability of this new paradigm of human activity in space, delivering a rich set of physiological and operational data fundamental to the planning of subsequent missions.
The mission used the powerful Space Launch System (SLS) rocket to place the Orion spacecraft on a translunar trajectory (Figure 3). Named Integrity by the crew themselves, a name embodying the values of trust, respect, and humility that united the four astronauts and the thousands of professionals from many nations involved in the project, the spacecraft was powered by the European Service Module (ESM), developed by the European Space Agency (ESA) with significant participation from Airbus Defence and Space.

This European module, equipped with 33 engines and four large solar arrays, functioned as the "heart" of the spacecraft, providing propulsion, electrical power, and life support throughout the journey, a concrete example of the international cooperation that distinguishes the Artemis Program. At the controls of Integrity was a crew composed of Reid Wiseman (Commander), Victor Glover (Pilot), Christina Koch, and Jeremy Hansen (Mission Specialists), a historic team that, for the first time, included a woman, an African American astronaut, and a Canadian representative on a mission beyond low Earth orbit (Figure 4).

The trajectory followed the free-return trajectory, in which the Moon's orbital dynamics guarantee a safe return to Earth even in the event of a propulsion failure, the same strategy that safeguarded the most critical Apollo missions. After launching from the Kennedy Space Center on 1 April 2026, Orion completed its translunar injection on the second day and continued towards the Moon. On 6 April, it reached a record distance of 248,655 miles from Earth, surpassing the historic mark set by Apollo 13. On the same day, the crew also observed a spectacular solar eclipse (Figure 5). During the fly-by of the far side of the Moon, the astronauts experienced approximately three hours of communications blackout, a period used for autonomous observations, unprecedented photographic records of the Orientale Basin and Pierazzo Crater, and observations of unexpected shades of green and brown, suggesting mineralogical variations within the lunar crust.

In parallel, the crew conducted pioneering human health experiments, including ARCHeR, the immune biomarker protocol, Standard Measures, and AVATAR (organ chips derived from the crew members themselves). These investigations collected valuable data on sleep, stress, immunity, the microbiome, and the effects of cosmic radiation on living human tissues, information that will be crucial for planning future missions to Mars.
The mission culminated in splashdown in the Pacific Ocean on 10 April 2026, approximately 200 kilometres off the coast of San Diego. Atmospheric re-entry, performed at speeds exceeding 11 km/s and temperatures approaching 3,000°C, confirmed the robustness of Integrity's heat shield. Specialist teams from the United States Navy, operating from the recovery ship USS John P. Murtha, safely recovered the four astronauts, who emerged emotional and in excellent health. Hours later, after being transferred to the Johnson Space Center in Houston, they began the protocols for readaptation to Earth's gravity and the technical and scientific debriefing, bringing to a highly successful conclusion the first human flight beyond low Earth orbit in more than five decades.

The Artemis III and IV Missions: The Future
​Artemis II proved that humans can safely travel beyond Earth's atmosphere, while Artemis III (Figure 6) will have an equally crucial, yet distinct, mission. Scheduled for mid-2027 in low Earth orbit, it will be the first operational docking test between the Orion spacecraft and commercial lunar landing systems: SpaceX's Starship and Blue Origin's Blue Moon.
This demonstration mission is of extraordinary operational complexity. The Space Launch System (SLS) will launch Orion with four astronauts, using a structural spacer in place of the upper propulsion stage, while the commercial lunar vehicles will reach orbit through separate launches. The astronauts will spend longer aboard Orion than during Artemis II, validate Orion's docking system for the first time, and may also enter one of the lunar landing vehicles. In the words of Jeremy Parsons, Acting Deputy Associate Administrator for NASA's Moon to Mars Program, "Artemis III is one of the most complex missions ever undertaken by NASA," because the success of the subsequent lunar landing depends upon it.

With the docking systems validated by Artemis III, the path opens for the most anticipated stage of the programme: Artemis IV, scheduled for early 2028, which will mark the first human landing on the lunar surface since Apollo 17 in 1972. Four astronauts will travel to lunar orbit aboard Orion. There, two of them will transfer to the commercial Human Landing System (HLS) and descend to the vicinity of the lunar south pole, a region never explored in situ, where uncrewed probes have identified evidence of water in permanently shadowed craters.
​The lunar south pole is of particular scientific interest because permanently shadowed craters are believed to contain water ice, a resource that could support future human exploration by providing drinking water, oxygen, and rocket propellant.
Over the course of approximately one week, the crew will conduct spacewalks using Axiom Space's advanced AxEMU spacesuits, collect unprecedented geological samples, and deploy scientific instruments on the surface, including DUSTER (DUst and plaSma environmenT survEyoR), which will characterise the dust and plasma environment around one of the nine candidate landing regions identified by NASA near the lunar south pole. The mission will also mark the historic moment when the first woman and the first non-white astronaut set foot on the Moon.
More than a return, Artemis IV will lay the foundations for a sustainable human presence on the Moon and represent the first concrete step on a journey that will eventually take humans to Mars.

Synthesis
The Artemis Program, encompassing Artemis I, II, III, IV and the missions that will follow, inaugurates a new era of human activity in space, demonstrating the viability of crewed missions beyond Earth's orbit after more than fifty years. Its achievements will be crucial to the success of the next stages of the Artemis Program, particularly Artemis III, which aims to enable humanity's return to the lunar surface. In addition, the programme establishes the technological and operational foundations required to build a sustainable presence on the Moon and, ultimately, to support future missions to Mars.
The public and inspirational impact of the missions, especially Artemis II, has also been remarkable. Millions of people around the world followed the first crewed flight beyond low Earth orbit in more than fifty years through television, the internet, and social media, rekindling a collective fascination with space and inspiring a new generation of students interested in science, engineering, and exploration.
The Artemis Program represents a remarkable synthesis of tradition and innovation in humanity's exploration of the cosmos. As the heir to the Apollo legacy, it goes beyond merely repeating history by embracing new technologies, unprecedented international cooperation, and ambitious scientific objectives. More than journeys to the Moon, these missions represent a full-scale rehearsal for the expansion of human presence beyond Earth.
May the deities whose names these missions bear, Apollo, Artemis, and Selene, herald not only new chapters in humanity's exploration of space, but also a renewed appreciation of the importance of caring for Earth (Figure 7), our shared home, whose shades of blue continue to cradle every known form of life.

Why Artemis Matters
Beyond its remarkable engineering achievements, Artemis is also transforming our understanding of human health in deep space. Each mission generates invaluable knowledge on radiation exposure, physiological adaptation, behavioural performance, and operational medicine, helping prepare astronauts not only for sustained exploration of the Moon but ultimately for human missions to Mars.
For the aerospace medicine community, Artemis represents one of the most important research opportunities since the Apollo era. The programme is advancing our understanding of how humans can live and work safely beyond Earth while driving innovations with potential benefits for healthcare on our own planet. As the Artemis missions continue, they will not only shape the future of space exploration but also deepen our understanding of the remarkable adaptability of the human body and mind.

When I was seven or eight years old, looking at videos of the cosmos would move me to tears. Growing up in Batticaloa, a city in the Eastern Province of Sri Lanka, the concepts of astronomy and space exploration were almost entirely foreign. Like many Asian households, the traditional path of becoming a doctor was the one most spoken about and encouraged by teachers and society.
Yet, an unexplainable pull toward the stars grew inside me. Back then, I didn't even know the word “astronaut”—I just told people I wanted to be a “scientist” because that was the only word available to me in my hometown.
A turning point came when my grandfather bought me my first computer. While other kids were playing games, my search history was filled with the ambient sounds of planetary atmospheres. By the 7th and 8th grades, I was completely hooked. Without the AI tools we have today, and with nothing but a basic Google search bar, I began hunting for NASA student competitions and online astronomy programs entirely on my own.

The Struggles of an Isolated Dream
My home is what I fondly call a “small, lovely birdhouse.” It is just me, my mom, and my dad. We don't live around extended family, and the bond we share is incredibly deep. My mother is the strongest woman I have ever known; she does everything for me. Her love is so fierce that even now, during my university years, she cries every single time I have to leave home, even if it is just for a single day.
Because they love me so deeply, my parents were initially terrified of my interest in space. In the capital city of Colombo, parents might have access to physical guidance, planetariums, and space camps for their children. But in Batticaloa, I was entirely alone.

Uniting Two Worlds: The Birth of a Space Doctor
Entering medical school, I initially felt terrified. How would my passion for space survive a rigorous medical curriculum?
That fear forced me to innovate. I began looking at my strengths in biology and chemistry, and that is when I discovered an emerging, boundary-pushing frontier: Space Medicine. It felt like finding a missing puzzle piece. I started devouring books on aerospace physiology, neuro-medicine, and deep-sea medicine.
Suddenly, my two worlds aligned. Space medicine became the mental engine that drives my entire day. I start my mornings reading about aerospace physiology, which gives me the joy and mental energy to tackle dense medical textbooks for the rest of the day. Even during grueling exam seasons, drafting space proposals is what keeps me happy, active, and motivated.
Seeing my relentless dedication, my parents underwent a beautiful transformation. About three months ago, they truly began to realize how deep this passion runs, and today, they are my biggest supporters. 

Building the Launchpad in Sri Lanka and Looking Ahead
My long-term vision is no longer just personal; it is national. I want to build a solid foundation for space medicine right here in Sri Lanka.
Because it is incredibly difficult to get responses from global space experts as an isolated student, I knew I needed a structured platform. I applied, interviewed, and was selected as the Biomedical Lead for SEDS KDU (Students for the Exploration and Development of Space). This role has finally given me the bridge I needed. I am now actively developing space health project ideas and contacting renowned professors to create a dedicated space medicine association in our region.
My absolute future plan is to dive headfirst into space medicine, learning as much as I possibly can from every resource and mentor available. This interest has never faded; instead, it is actively growing inside me every single day, becoming stronger and louder. Along this challenging road, the universe sent me my very first true mentor and guide: Prof. Thais Russomano. Her kindness, encouragement, and acknowledgment of my passion have been the greatest gifts of my space medicine era.
​

There are places above us where the light reaching our eyes began its journey billions of years ago. There are also places beneath us where sunlight has never reached. One journey takes us into the deepest oceans, the other into the depths of space.
These two frontiers, one beneath our oceans and the other beyond our atmosphere, are separated by direction but united by mystery. For centuries they have captivated, fascinated, and inspired humanity. The ancient phrase "As above, so below" offers a compelling lens through which to view them, suggesting that the patterns of the universe, the mysteries it contains, and the truths it reveals are echoed across different realms of existence. This perspective becomes even more powerful when we compare the dark sea with the dark expanse of space.

​The concept of the "Twin Abysses," inspired by recent discoveries of candidate supermassive black hole pairs, evokes a striking sense of connection between the unknown depths of space and the unexplored oceans of Earth. Imagine standing on a quiet beach at night. Before you lies the seemingly endless darkness of the ocean; above you stretches the vast blackness of space, illuminated by distant stars and galaxies. Although remarkable technological progress has been made, humanity has explored only a small fraction of the deep ocean. In many respects, we have mapped the surface of Mars in greater detail than the deepest regions of Earth's oceans.
Both environments remain inhospitable to human life. Whether facing the crushing pressures of the ocean or the vacuum of space, survival depends upon technology, preparation, and courage.

The astronaut is more similar to the deep-sea diver than many people realise. Both leave familiar surroundings and venture into environments where every breath depends upon carefully engineered life-support systems.
Most people associate darkness with emptiness. Yet neither the deep ocean nor deep space is empty. In the ocean's greatest depths, countless organisms generate their own light through bioluminescence, using it to communicate, hunt, and survive. Likewise, the darkness of space is filled with stars, nebulae, and galaxies that create an extraordinary cosmic tapestry. In both realms, darkness is not the absence of life or activity. Instead, it provides the backdrop against which wonder becomes visible.
​

Echoes of the Universe
Nature often repeats familiar patterns across vastly different scales. Similarities can be found between the structure of the Universe and the organisation of living systems. Galaxy clusters form web-like networks that resemble neural connections. Ocean circulation shares characteristics with atmospheric circulation and planetary dynamics. Branching river systems resemble blood vessels and even the branching paths of lightning.
These recurring patterns suggest that universal physical principles operate across many different scales of nature. Gravity shapes both the motion of galaxies throughout the universe and the tides of Earth's oceans. Even more remarkably, the elements that make up every living organism on Earth were forged within ancient stars.

The sea and the sky are not separate stories. They are chapters from the same book.
Deep ocean and deep space evoke remarkably similar emotions. For many people, the thought of endless water beneath them or infinite darkness above them inspires unease. Both environments test our instincts, challenge our limits, and remind us how little we truly know. Yet curiosity often grows where uncertainty begins.

Every great exploration and every significant discovery begins with a simple question:
​
"What lies beyond?"

Humanity has always been driven to explore. Both the deep ocean and deep space invite us to venture further, even when we do not yet know all the answers.
​

Our World Extends Outwards and Inwards
Exploration is often described as the search for new worlds. In reality, it is equally a search for ourselves. When we look towards the stars, we seek answers about our origins, our future, and our place in the universe. When we descend into the oceans, we uncover hidden dimensions of our own planet and the remarkable life it sustains.
The path outward is also a path inward. The sea reminds us to be humble before nature's mysteries, while the immense distances of space provide perspective. Together, they reveal that knowledge is effectively limitless and that discovery is among humanity's defining characteristics.

​For researchers in space medicine and extreme-environment physiology, the parallels between the deep ocean and deep space extend well beyond symbolism. Both environments demand advanced life-support systems, autonomous decision-making, psychological resilience, and innovative approaches to human survival. Technologies developed for underwater exploration continue to influence human spaceflight, while advances created for astronauts increasingly benefit marine research and other challenging environments on Earth. These shared lessons demonstrate how exploration in one frontier can help unlock progress in another.
​

As Above, So Below
The dark sea and the dark reaches of space reflect one another. One lies beneath our feet, the other beyond our reach. Both challenge our understanding, ignite our curiosity, and remind us that the universe is far bigger, stranger, and more beautiful than we often imagine.
"As above, so below" is more than a philosophical phrase. It is an invitation to recognise the deep connections that unite seemingly different worlds. Whether in the darkness of the ocean depths or beneath a star-filled sky, we discover the same enduring truth: the greatest mysteries are not only above us or below us. They remain within our reach to explore.
Humanity's journey into the unknown has no final destination. Whether descending into the deepest trench or reaching towards the most distant stars, exploration continues to expand both our knowledge and our imagination.
​

How it all began
March 2,7.30 a.m. I had initiated the act of micturition (urination), possibly for the100,000time in the past 75 years. Ten seconds had passed. I saw 2 ml of diluted ‘coke’ in the urine stream. In that split second I realised that this was a breakdown of blood products, a condition known as haematuria. I recollected surgery classes taken 55 years ago, where the lecturer said – “When an elderly person passes blood there are only 3 diagnoses - a) malignancy b) malignancy c) malignancy.”
​In 1970, there was no ultrasound; cystoscopy was not routinely available. We were taught that if malignancy was not picked up, it meant investigations were insufficient and were told to keep investigating. Trained in that era, the thrill of making an early clinical diagnosis took over. I did not dwell on dire implications, should I be right, nor did I make any prayers that I should be wrong. Cool, calm, composed and totally asymptomatic, I did a literature search. Every article, and every chapter concluded that “malignancy had to be excluded”. Two days later I saw diluted ‘coke’ in my urine again. Within 48 hours, I got myself investigated.

Diagnosis confirmed
An outpatient cystoscopy was scheduled. Within 15 seconds I saw on the screen an obviously malignant tumour. Three minutes later, on my way to the consultant’s room, I told my wife with pride: “See I was absolutely right. Hi-grade malignancy confirmed”. Fifty-eight years of managing thousands of serious and critical head injuries, bleeding in the brain and brain tumours had probably resulted in my nonchalance. Or maybe reality had not dawned yet, and I was fooling myself.
The uro-oncologist outlined different management options. I was to be on the dais ata major international conference the following week. My brain interjected: “Time you learn to let go– look, the cancer cells are multiplying every second, get operated on immediately; management depends entirely on the detailed biopsy.”

Immediate response
A normal reaction on being told that one has a hi-grade cancer could vary from shock, disbelief, fear, denial, anxiety, distress, anger, sadness, rage, guilt, frustration and withdrawal. “A bolt from the blue”, “the ground fell away” or “my world collapsed” iswhat is expected – particularly in an individual with outstanding physical and mental health. In my case I was reconfirming a self-diagnosis. My occupation, education, socioeconomic background, access to current knowledge and access to state-of-the-art resources resulted in a different response – within 10 minutes, I started the paper work, fixed a date and time of surgery, and informed my family.
But then, I am also human. Every now and then I broke down with my lacrimal glands going into overdrive unashamedly. I gave vent to my anger and frustration. My spouse of 51 years stood firm as the rock of Gibraltar. When I threw away the high protein nutritious food painstakingly prepared with love and affection she only smiled – knowing that it was the malignant cells responding, not her husband. I recollected a quote widely attributed to Dr. Henry Maudsley that appears in Boyd’s textbook of Pathology -- “The sorrow which has no vent in tears, may make other organs weep.”

Initial management and follow-up
A transurethral tumour resection was done with Mitomycin (an anti-tumour antibiotic) instilled in the bladder. The profuse vomiting, headache and giddiness was followed by total exhaustion and lack of appetite, a curtain-raiser to the scheduled weekly and monthly intra-bladder chemotherapy for the next year. The first three doses were terrible. Unable to watch television or use my laptop for more than 10 minutes; too exhausted even to go from one room to another.
​My classmate, a medical oncologist who was advising a senior uro-oncologist about the bladder chemotherapy, reassured me every day – this too will pass. Like magic from the fourth week, there were no side-effects. I regained the 6 kg I lost, and resumed my normal busy activities.
​

Lessons learnt
When I was born, life expectancy in India was 37 years. Understanding that I was not immortal, I had always been ready for the countdown. For me, there is only solidarity in having joined tens of thousands of cancer patients. I was fully aware that delaying time to recurrence, and postponing a relapse is the primary goal, with quality of life as a bonus, not a total cure. One cannot learn swimming through a correspondence course; one has to get into the water. For the first time, I now had the mind and body of a cancer patient; I was not just removing a growth in the brain.
Being a perfectionist who wants to get things done yesterday, I initially had problems, because I continued to live in the past. It took time to accept that I was now retired, not an active medical professional and I am now, one of the hundreds of revenue-generating cancer patients going through well-laid systems and processes at private hospitals.
I had to tell myself to let go, reduce my expectations completely, accept the present, and put my trust in my medical team.
​

Support group
My family and classmates were not just anti-depressants. They were tranquillisers and mood elevators. In the first few weeks when I was very sick, video calls made a tremendous difference. Knowing that you are really cared for, works magic.
Arthur Ashe, a Wimbledon winner, when he was dying of HIV contracted through a blood transfusion, and asked why he thought he was chosen to die of a devastating disease, pointed out that he never asked why him, when he was one of millions playing tennis who actually made it, and won a Grand Slam. When I qualified as a neurosurgeon in 1980, I was one in a 7 million population and I never asked ‘why me’, then, why should I now?
Today, unlike many of my fellow cancer patients I am privileged enough to have access to the best management. I have now accepted the malignancy. I alone, will decide if I am going to be happy or not. No chemotherapy or malignant cell is going to have the privilege of making me unhappy.
​

My thoughts
It has been said, “More things are wrought by prayer than this world ever dreams of”. I know the present remissions will be followed by exacerbations. I now wish I had spent quality “me” time with my cancer patients. The response to cancer management depends on scores of variables. The individual patient response has an ‘X’ factor which cannot be identified or quantified. For the first time, I now live in the moment, with an inner peace I have never had before.
I will put in reasonable efforts and try not predict what will be. Undue expectations have been replaced with accepting reality. I will put up a fight with several million malignant cells and may the best man win!

From a cancer patient to a cancer survivor is my goal: Que sera sera.