Issues Magazine

Lifelines for Antarctic Medicine

Casey doctor Eve Merfield (right) prepares a patient for an X-ray.

Casey doctor Eve Merfield (right) prepares a patient for an X-ray (2005). Credit: Eve Merfield

By Jeff Ayton

Telemedicine and evacuation support are critical supplements to the expertise of Antarctic physicians, while medical research continues to provide an invaluable evidence base.

The 1911–1914 Australasian Antarctic Expedition set foundations for medicine in the Antarctic today. Led by Douglas Mawson, with the aim of achieving the south magnetic pole, the expedition was medically supported at the main base by two doctors: Dr Archibald McLean as chief medical officer and bacteriologist, and surgeon Leslie Whetter. While Mawson had learnt much from previous polar expeditions, improvements, improvisation and innovation were evident in the conduct of the expedition, necessitated by the challenging environment, but also hardship and the tragic loss of expeditioners Belgrave Ninnis and Xavier Mertz.

Australian Antarctic medicine today is still the practice of medicine in an isolated, extreme and confined environment. Huge distances must be travelled: over 3000 km from Australia’s Antarctic gateway of Hobart, Tasmania, and across the treacherous Southern Ocean to East Antarctica to reach the driest, coldest, windiest and highest continent on Earth.

The continent is only accessible by sea in the Austral summer as the polar sea-ice retreats. The sea-ice then reforms in the Austral winter and becomes an isolating, impenetrable barrier to a much colder continent. The winter also brings the seasonal loss of the sun, further isolating and challenging overwintering populations.

To survive these extremes of environment, temperate and tropical humans rely on technology and innovation to provide the basics of life, food, water and heat. Today, these basics of expedition survival require extraordinary annual summer efforts and cost to provide the fuel, clothing, food and warmth on annual resupply to Australian Antarctic expeditions as they continue the quest to answer important global science questions.

Australian expeditioners, as they were 100 years ago, are totally isolated and confined to stations in small groups of 14–24 for at least the 9 months of the Austral winter. They are dependent on the built infrastructure and on technology for survival. They are dependent, too, on their leadership and each other. Each expeditioner has a critical function, from electrical power generation to the all-important chef, medical support and station leadership.

Human factors in extreme environments, such as leadership, performance and conflict management, have been much studied and continue to inform station selection and management. Importantly, much of this work is done prior to departure for the icy continent. Mawson, and others, knew the importance of selection and recorded that “in no department can a leader spend more time than selection of the men (as it was in the heroic era) who are to accomplish the work.” Selection is critical in ensuring the success of the expedition.

Expedition management today continues to understand the importance of selection. Medical, psychological and personal quality screenings are routinely conducted and informed by these foundations. The challenges and sometimes impossibility of resolving issues across all these spectrums, once in Antarctica, are well-known.

Looking back 100 years, the foresight of Mawson’s expedition planning included the establishment of an expedition party at sub-Antarctic Macquarie Island prior to Commonwealth Bay. Macquarie Island established a critical wireless linkage to a wireless station at the Queen’s Domain in Hobart. It was in September 1913 that perhaps the first medical messages were transmitted from Antarctica where Mawson, on advice from McLean, requested Bickerton to relay a message that Jeffryes, the radio operator, was insane.

One could say this was the infancy of telemedicine in Australia’s Antarctic program, where 24-hour, two-way telemedicine support for the lone Antarctic medical practitioner is possible. This enables electronic delivery of voice and messages, clinical images, video and X-rays via dedicated satellite services, enabling the Australian Antarctic Division’s Polar Medicine Unit and a network of specialists asynchronous and, if necessary, real-time assistance in the delivery of clinical support. Telemedicine support is available across the breadth of the program, at each of the four Australian Antarctic and sub-Antarctic stations, as well as ships in the Southern Ocean and Heard and McDonald Island regions. Telemedicine is the lifeline for the well-trained generalist expedition doctor, who can be faced with responding to health and well-being issues across the spectrum of general practice and specialist fields and is critical in ensuring the success and well-being of the individuals and of the expedition and program as a whole.

Without the herculean effort and cost of developing year-round air evacuation capability at each station, the extreme isolation of Antarctica challenges any program. Sea and air medical evacuation is generally only possible for life- and limb-threatening conditions, and in the Austral summer. Despite this the great distances involved, unpredictable weather, ice and sea-ice conditions usually mean that any evacuation, if at all possible, is likely to be delayed or prolonged.

The ability to respond to medical and surgical emergencies on expedition, while preparing options for evacuation, remains integral to Australia’s Antarctic medical support. This was highlighted with the air evacuation from Davis Station of a seriously injured expeditioner in October 2008, on the cusp of the winter–summer transition. The earliest evacuation to tertiary hospital medical care was only possible 16 days after injury, with assistance from our International Antarctic program colleagues.

Recently, the challenge of a midwinter air evacuation has been overcome by some nations with advances in aircraft capability, significant preplanning, and an on-ice overwintering capability. However, the challenges of the Antarctic winter environment and the significant capability development required mean that ubiquitous Antarctic overwinter medical evacuation, whilst technically possible, is unlikely.

McLean was both a bacteriologist and chief medical officer of the main base, and his MD thesis submitted to the University of Sydney (“Bacteriological and other Researches in Antarctica”) highlights a foundation of the conduct of Antarctic human biology and medicine research as a critical adjunct to the role of the expedition doctor. Key chapters of his thesis included comparative biological studies of bacteriological cultures from ice and snow, mammals and birds, and human work on physiology, immunity and psychology. The future translation of McLean’s study of bacteriology of the Australasian Antarctic Expedition’s small isolated group, if conducted with current advanced molecular techniques and expansion to viruses, would be an interesting historical contrast.

Research endeavour continues with a productive peer-reviewed collection of scientific publications, particularly from the Australian National Antarctic Research Expeditions (ANARE) from 1948 onwards, which provides the evidence base of Antarctic medical support of expeditions. This program has investigated fields of study including physiological responses and performance in the cold, the lack of solar ultraviolet radiation impacting overwinter vitamin D levels (which support bone function and strength) to the epidemiology and immunology of small groups at risk of immune changes and possible viral reactivation of latent viruses.

Current research is focused on photobiology, human performance, circadian rhythm and behavioural studies in the extreme polar environment. It is a unique opportunity to research in a non-simulated environment of expeditioners, as the previous Head of Polar Medicine Dr Des Lugg stated: “real expeditioners, exposed to real hazards and real isolation without hope of winter evacuation”.

Australia’s Antarctic program is unique given the isolation of East Antarctica, our current logistics and medical support, with small station populations undertaking a scientifically focused mission reliant on technology for survival. It has been recognised as providing a high-fidelity test-bed as an analogue to exploratory missions to space. Since 1993, Australia’s Antarctic program has been conducting collaborative space analogue research with NASA in Antarctica on the fundamental medical sciences of extreme environments, epidemiology and operational medical support. This research collaboration has informed space agencies in their understanding of the risks and challenges of isolated, confined extreme environments, and can also advance the provision of medical care and support to remote populations globally.

Medical research of small, isolated confined groups is challenging, with small population numbers often lacking scientific power and the ethical challenges in ensuring confidentiality for participating expeditioners.

International coordination and collaboration is encouraged and has been forged throughout ANARE. Neighbouring nations often collaborate and dedicated medical expeditions, notably the International Biomedical Expedition to Antarctica, resulting in the BBC documentary Antarctic Man, have been conducted. Many of these challenges have been overcome by conducting longitudinal studies over numerous seasons across multiple small station populations.

The Scientific Committee of Antarctic Research (SCAR) and the Council of Managers of National Antarctic Programs (COMNAP) have a newly reinvigorated Joint Expert Group of Human Biology of Medicine (JEGHBM), which facilitates international collaboration in both medical support and research. This group is a key conduit for researchers wishing to undertake Antarctic human biology and medicine research. This approach continues the close nexus that McLean commenced: the nexus between expedition medical support and applied research informing medical support and policy. This nexus also allows the translation of Antarctic human biology and medicine research to the practice of medicine in other environments. Advances in telemedicine, the risk of adverse health events, the duality of vitamin D exposure and the selection and performance of leaders and followers on expeditions can be applied to exploratory space travel and to other remote populations.

One could argue that, since Mawson’s expedition, many more people live and work in cold and colder environments from which we can learn. However, the differentiation of Antarctic populations, from the heroic era until now, is one of the scientific and exploratory purpose and focus of the mission, the dependence on technology and processes for survival. The isolation and confinement – the “life in a bubble” – gives insight into how a small group, temporarily removed from its usual temperate or tropical climes to unfamiliar and hazardous conditions, can achieve and maintain Australia’s endeavours and goals in Australian Antarctic and sub-Antarctic territories.

There is no doubt, given the extreme challenges, that the endeavours of Antarctic nations will remain expeditionary in nature. The foundations of the heroic age still provide lessons for the modern-day Antarctic program.