Food Labels – Do They Properly Inform Consumers?

The unsurprising and non-controversial role of food labels is to present the ingredients and elements of a food product both independently and in the context of dietary guidelines to ensure consumers are informed to what they are purchasing and how “healthy” the product. In the United States the National Labeling and Education Act (NLEA) in 1990 required the inclusion of nutrition information on packaged foods, with a few exceptions, and set the standard for how the information should be presented. This legislation was important because before the NLEA nutritional information was only required when producers wanted to make claims about specific nutritional benefits derived from consuming their product. However, the lack of standardization in presentation of nutritional information made it difficult to contrast and compare even when the information was available. Thus the famous standardized side panel conveying nutritional information for food products was born.

Interestingly enough very little has changed in the presentation and information of this standard U.S. labeling since the NLEA up until now. Recently the Food and Drug Administration (FDA) released information regarding how this food label would change by 2018; this news was met with cheers from some health circles and jeers from others. Overall the changes are rather uneventful with an increased font size for calorie count, elimination of calories from fat, more nuanced language for per serving and per package identifiers including more empirically based serving sizes, gram amounts in addition to percentages for vitamins (this change seems rather meaningless), Vitamin D and potassium switch required status with Vitamin A and C and more clarification regarding the % Daily Value footnote. The one supposed “big ticket” change is that labels are now required to breakdown the sugar content between natural sugars and added sugars.

The level of usefulness for the consumer within the divergence between natural and added sugars is questionable because without specifically breaking down the sugar content into its molecular complements: glucose, fructose, maltose, etc. the total sugar amount is still the only real meaningful piece of information. Knowing how much sugar was added versus how much sugar naturally occurs in the product is rather irrelevant regarding how the body will process it. Is someone really going to buy product A over product B because it has 28 grams of natural sugar versus 14 grams of natural sugar and 14 grams of added sugar? For some the answer will be yes, although most will not have a good reason why (the only real valid reason would be the contention that added sugars have a higher probability of being simple sugars and negative for health), but for most the answer will be no.

Some individuals could counter-argue that various groups like the AHA, AAP, WHO and Institute of Medicine have recommended decreasing intake of added sugars with general estimates that only about 10 percent of total daily calories should come from added sugar. While all of this is true, the problem is that differentiation between added sugar and natural sugar is more propagandized than meaningful. Again without differentiating between the specific molecules that make up the sugar content, total sugar is the only metric regarding sugar that actually matters. The propaganda stems from individuals promoting the reduced consumption of processed foods, which are more likely to have added sugars. Certainly it is true that added sugars do nothing positive to the nutritional content of the food, but again total sugar is what matters without specific differentiation.

The “debate” about added vs. natural sugar aside, in reality this new label certainly falls short of Michelle Obama’s endorsement “you will no longer need a microscope, a calculator, or a degree in nutrition to figure out whether the food you’re buying is actually good for our kids…” It is difficult to support the accuracy of that statement based on the changes; a sentiment shared by many other individuals who think the food labeling requirements should have been much more substantial.

For example applying the labeling itself is only a part of the battle for the information on the label is only meaningful when consumers read and understand it. There is some question to whether or not the label needs to change for studies have demonstrated that while a vast majority of individuals in the U.S. read food labels, this information does little to influence their food choices.1-3 However, in the EU, which has a more intensive and thorough labeling system, food labels do influence consumer choice.4

While it is difficult to directly determine if the critical factor in this difference in behavior is born from the food labeling methodologies due to cultural differences between the U.S. and the EU, it is also difficult to dismiss the differing labeling strategies as playing an influencing factor. The key difference between the two labeling systems is that the U.S. system places a greater emphasis on the consumer to understand the nutritional context of both product A and how it may differ from the nutritional context of product B versus the more categorized labeling system of the EU in general.

For example in the UK labeling follows four core principles enumerated by the UK Food Standards Agency (FSA) for front of the package:5,6

1) Separate information must be provided on fat, saturated fat, sugars and salt; (this is also a guideline in the U.S. via Facts Up Front, but it is a voluntary program)

2) A red, amber or green color coding, similar to traffic lights, must be utilized to indicate whether the levels of those elements outlined in the first principle are high, medium or low respectively per 100 g (or ml for liquids) of product content;

3) Color metrics are established by nutritional criteria set forth by the FSA;

4) Provide portion ratios relative to the elements outlined in the first principle for color coding;

When this proposal was first made in 2006 there was significant resistance regarding the traffic light identification system as numerous food manufactures and producers questioned the use of the traffic light system and instead favored more of a U.S. style system using percentage of daily recommended values.5 Furthermore food manufactures also disagreed with the use of 100 g/ml as a standard invoking the argument that consumers think more in portions of the consumed product. It would be difficult for consumers to deduce a gram weight-based portion size. This complaint produced an alternative system using the needlessly large number of portion sizes by various food products creating a much more difficult comparison environment for consumers; such was ironic because it produced the result that was exactly the rational used by food companies to argue against the 100 g/ml standard, an overly complicated system.

Regardless of the bumpy road to establishing a universal labeling system and the lack of ideal standardization in the UK (note the confliction between points 2 and 4 from above), numerous studies have demonstrated that front of the package simple signal (like color coding) labeling of the “healthiness” of a food product does influence consumer choice both by increasing the probability that the customer purchases healthier products and increasing the probability that food producers create healthier products;7-10 also traffic light systems have proven superior to other systems like single compounded numbers or guiding star type systems.8,11 Therefore, clearly creating regulations regarding the nutritional or “health value” of a food for the front of the package is a meaningful step to increasing the probability of an informed consumer.

Part of the battle for the front of the package (FOP) is not just to produce a standardized system to convey the health of the product, but to ensure genuine portrayal of the product itself. For example advertising for some food products tends to mislead consumers that the product may contain a larger quantity of a component than in reality. Such is common with fruit juice products; for example in an attempt to draw attention away from the top ingredients commonly being concentrated water and high fructose corn syrup with pictures of fruit. One means that helps support such trickery is that ingredients are only listed in order of percent amount, but the percentages are not given. Actually requiring the percentages may help limit the impact of this type of advertising.

Ensuring proper labeling design is important because studies have demonstrated that simple, transparent and clear labeling engage subconscious emotional elements in the brain including the amygdala.12-14 Therefore, the FDA may need to properly regulate front of the box labeling because the side panel may be at a psychological disadvantage to the “health proclamations” that commonly adorn the front of the box in stylized and eye-catching presentations.

In the past some parties have acknowledge the importance of the front of the box and lamented the U.S. government’s acquiescence of its power to corporations. These parties have proposed taking back the front of the box in such a way to “inform” consumers of whether or not their choice is a healthy one. For example one proposal is that the upper right portion of the box should contain the three most prevalent ingredients in the product, the calorie count and the number of total ingredients beyond those first three in bold and clear font.15

The proponents of such a system believe that it will produce a fast means for consumers to identify healthy food versus unhealthy food that is so easy it is impossible to ignore. However, the problem with such a system is that it can be easily manipulated where producers can fine-tailor their produces where 3 seemingly healthy ingredients can be the 3 most plentiful ingredients by an incredibly small amount before the “unhealthy” ingredients.

Also calorie counts in such a system would have to identify serving size to be placed in proper context and even then such counts may prove to complicate the issue. Note that the above proposition suggests posting the calories per serving on the front of the package. However, if all similar products do not have standardized serving amounts (all listing 100 grams for example vs. ½ cup or 8 to a box) then listing the calories is not simplistic strategy to optimize food choices on the basis of health. Varying serving amounts force the consumer to undertake some general arithmetic. For example suppose Cereal A has 120 calories per ½ cup (10 servings) and Cereal B has 160 calories per ¾ cup (7 servings), front of the box labeling would imply that Cereal A has fewer calories, but that is not the case in either equivalent serving calories or total calories for the entire box. Therefore, front of the package labeling must be less simplistic unless a standardized serving metric is established. Facts Up Front suffers from this serving difference problem limiting its effectiveness.

The possible problems with the above differing option notwithstanding, it is clear that the EU, including the U.K., has a better labeling system than the U.S. with regards to helping consumers acquire and understand nutritional information. So why does so little change in the “updated” U.S. labeling system? Most would argue, probably correctly, that lobbying by food companies prevents the FDA from going further thanks to interference from Congress. If the FDA had the “freedom” to make any changes what changes should they make?

Obviously it is important for there to be some form of comparison information that goes beyond Facts Up Front. A traffic light system certainly holds promise due to its successful application in the UK. However, it is understandable that food companies would balk at such a condition, especially those with significant “red” light products. The proper response to such complaints is two-fold: first, who cares if the food companies have complaints again the proper utilitarian construct of ensuring transparent information. Second, one could attempt to lessen the impact of the traffic light system in the context that a primarily “red” food should not be viewed as something that should never be consumed, otherwise no one would ever eat something like a piece of cheese cake, but instead a food that should be consumed rarely in the context of good health. Thus, the green, yellow and red lights simply transition into anytime, once-a-day and rare, food choices.

Another interesting idea would be to establish a standardized declaration system for the front of the package involving commonly referred health terms against an empirically derived metric. Basically it is commonplace for food producers to put labeling on the front of a package that states: “high in fiber”, “low sodium”, “x number of essential vitamins and minerals”, etc. This newly proposed system would eliminating that ability of food producers to make such claims and instead replace this system with a five or six bullet point checklist in the upper right corner of the package confirming a given “positive health feature”. A check would be earned by meeting a standard floor or ceiling for the given attribute per 100 g of product; where the FDA would establish the standard. For example the “high fiber” box would be checked if a food contained 3 grams of fiber per 100 g of product, not checked otherwise. Five possibilities for such a checklist are shown below.

1) High Fiber;
2) Low Sodium;
3) Whole Grain;
4) Low Sugar;
5) Low Saturated Fat

In the end both of these strategies: the traffic lights and the checkbox, should significantly increase the probability that consumers are informed about the general nutritional value of their food product choices without an unreasonably long analysis period. Overall there is no good reason that the FDA and its surrogates should not establish and enforce such a labeling system.



Citations –

1. Cha, E, et Al. “Health literacy, self-efficacy, food label use, and diet in young adults.” Am. J. Health. Behav. 2014. 38(3):331-339.

2. Campos, S, Doxey, J, and Hammond, D. “Nutrition labels on pre-packaged foods: a systematic review.” Public Health Nutr. 2011. 14(8). 1496-1506.

3. Huang, T, et Al. “Reading nutrition labels and fat consumption in adolescents.” J. Adolesc. Health. 2004. 35(5):399-401.

4. Storcksdieck, G, and Wills, J. “Nutrition labeling to prevent obesity: reviewing the evidence from Europe.” Curr Obes. Rep. 2012. 1(3):134-140.

5. Lobstein, T, and Davies, S. “Defining and labelling ‘healthy’ and ‘unhealthy’ food.” Public Health Nutrition. 12(3):331-340.

6. Food Standards Agency. Board Agrees Principles for Front of Pack Labelling. 2006. Food Standards Agency.

7. Lobstein, T, Landon, J, and Lincoln, P. “Misconceptions and misinformation: the problems with guideline daily amounts (GDAs). A review of GDAs and their use for signaling nutritional information on food and drink labels.” National Heart Forum. 2007.

8. Temple, N, and Fraser, J. “Food labels: a critical assessment.” Nutrition. 2014. 30:257-260.

9. Hersey, J, et Al. “Effects of front-of-package and shelf ntrition labeling systems on consumers.” Nutr. Rev. 2013. 71:1-14.

10. Hawley, K, et Al. “The science on front-of-package food labels.” Public Health Nutr. 2013. 16:430-439.

11. Sutherland, L, Kaley, L, and Fischer, L. “Guiding Stars: the effect of a nutrition navigation program on consumer purchases at the supermarket.” Am. J. Clin. Nutr. 2010. 91:1090S-1094S.

12. Grabenhorst, F, et Al. “Food labels promote healthy choices by a decision bias in the amygdala.” NeuroImage. 2013. 74:152-63.

13. Pessoa, L, and Adolphs, R. “Emotion processing and the amygdala: from a ‘low road’ to ‘many roads’ of evaluating biological significance.” Nat. Rev. Neurosci. 2010. 11:773-783.

14. Seymour, B, and Dolan, R. “Emotion, decision-making, and the amygdala.” Neuron. 2008. 58:662-671.

15. Kessler, D. “Toward more comprehensive food labeling.” N. Engl. J. Med. 2014. 371(3):193-195.

Improving Customer Knowledge on Health Insurance

One of the tenets of the Affordable Care Act (ACA) is that a consumer will lower healthcare costs by comparing and contrasting prices for both insurance and medical procedures spurring competition between these respective agencies. Unfortunately the strategy is marred by the fact that the current marketplace only focuses on insurance provider characteristics in a limited capacity (co-pay, out-of-pocket limits, deductibles, etc.) and there is no information on cost relationships between insurance companies and a given hospital. Also there is no meaningful existing marketplace that focuses on medical service providers (MSPs) where a customer can compare the costs of a MRI between hospital A 134 miles away from his home or hospital B 46 miles away from his home. There are numerous independent groups that attempt to produce a meaningful “shopping environment”, but despite these efforts there is limited overall information, there is a lack of universal regionality, and most customers are unaware that these sites even exist with the exception of a random annual story about them on a blog. Without the ability for healthcare consumers to identify the best medical service prices it is difficult to expect them to be intelligent consumers and aid in the reduction of healthcare costs.

One of the biggest obstacles to producing a more transparent medical pricing environment is the arrangements negotiated between various hospitals and insurance companies. These deals create medical service institutions that are “in-network” and “out-of-network”. Insurance companies cover “in-network” providers because they are able to produce a lower controlled product using their economies of scale versus their inability to do so with out-of-network providers. In theory one would think that insurance companies would value a transparent marketplace because it would force MSPs to compete against each other to acquire customers thereby lowering costs for the insurance industry. Clearly it is assumed that the insurance company would have a price ceiling for each type of service, but few MSPs would exceed this limit, if reasonable, because it would lead to a significant number of services rendered without proper financial redress, which would put them out of business. If more medical transparency would theoretically benefit insurance companies, why is there no push from insurance companies to produce such an environment?

Three immediate reasons jump to mind when attempting to explain resistance by both MSPs and insurance companies to more transparent pricing, which is representative of the free-market principles that these groups claim to support:

The first reason for opposing transparency can inherently be viewed as the most plausible where there is a highly complicated and competitive relationship between MSPs and insurance companies in which these agencies work together to ensure proper prices with a sufficient customer base so that both parties profit. In such a relationship if significant transparency is developed it will add a third major component to this relationship, the decisions and tendencies of potential customers. Without understanding the nuances of the negotiation and the economic obligations of both the insurance companies and MSPs the customer pool will make sub-optimal decisions that will result in inefficiencies, which will produce increased costs reducing profits and even possibly endangering certain businesses.

While there is some truth to the level of complexity associated with this relationship, the above philosophy flies in the face of the general tenets of capitalism. Never has any real capitalist argued that a potential customer pool should be divided among a group of businesses without genuine competition. Instead the mindset has always been for businesses to produce advantages in their produces/services that will attract customers and if they are not able to produce enough advantages then that business folds up shop.

Some could argue that because buying health insurance and having access to medical care is more important than buying a hamburger it cannot be judged by the same principles as regular commerce. Unfortunately for its proponents the validity of this idea appears quickly dismissed when recalling the ruthlessness and questionable tactics that insurance companies have engaged in to deny coverage to their customers on technicalities as well as the excessive charges most MSPs levy against their patients that are “negotiated away” by insurance agreements. If MSPs and insurance companies want the above structure of “secret balance” then they should become non-profit organizations, which would at least justify the above argument.

The second reason for opposing transparency would be concern about divulging trade secrets regarding how prices are negotiated. The “trade secrets” argument is old hat for corporations attempting to avoid transparency. In some cases it is actually a legitimate argument; however, in the case against medical transparency it is not valid because the idea of medical service transparency is simply the declaration of a single price for a given service, i.e. standard single knee replacement, along with a general quality rating from an independent auditor. There is no expectation to produce a methodology regarding how a particular price was produced. In addition it is inappropriate for either insurance companies or MSPs to suggest that by simply knowing the price for a given service that competitors receive a negotiating advantage. Even if they could receive an advantage then all parties would have the same advantages in an environment where all service prices are publicly available, thus there is no reason to be concerned about the revelation of trade secrets.

The third reason for opposing transparency is the most obvious and more than likely the correct one in that the insurance industry and MSPs in general are happy with the current system because they are able to make large amounts of profit and are uncertain if a new transparent and more competitive system would decrease or increase that profit. To better understand how this uncertainty arises one must study the potential changes that occur in a more transparent environment.

In a more transparent environment one of two possible scenarios will emerge between the MSPs and insurance companies. In the first scenario insurance companies will maintain their existing relationships with MSPs and simply be competing against other MSPs and their insurance provider relationships. Basically insurance companies will keep their provider “zone(s) of control”, but consumers will be able to better understand the economic benefits from moving between those zones to best meet their needs.

In the second scenario the new competitive environment may cause MSPs to “unbind” themselves from insurance companies eliminating some to most of the provider control and its associated power. Without provider relationships insurance companies would lose their “zone(s) of control” which could lead to a mass exodus of individuals from one insurance company to another. For example open competition between MSPs would disallow any guaranteed business due to these zones of control, thus MSPs would not be beholden to insurance companies, thus insurance companies would have to compete for business without guarantees. Clearly this second scenario is much more dangerous to the profitability of both insurance companies and even MSPs because they would have to compete as well, just on a lesser extent.

On a political level both Republicans and Democrats should accept and support increasing transparency regarding medical procedures. Republicans should support such a measure because the existing lack of transparency is anti-American and anti-capitalistic as it restricts choice and freedom of individual consumers along with increasing distortion in free markets. Democrats should support such a measure because it will lower government costs and could reduce income inequality by reducing individual costs through a reduced price. Medical care is typically a fixed cost, thus it weights more on poor individuals versus rich individuals.

On a public affairs level almost all individuals should support increased transparency of medical procedures. The first obvious reason for this support would be the reduced prices for medical care that would accompany increased competition. The second, less obvious, reason for support would be the ability to better prepare for future medical care. One of the biggest problems with the current system of care is that most of the focus is on elective or chronic procedures versus acute procedures. Basically there is little shopping when someone believes that they are in urgent need for medical care. In this situation a person can become justifiably emotional and scared reducing the ability to behave like a rational actor when it comes to procuring competitive medical services. However, in a transparent environment individuals will be able to plan ahead of time to determine what hospitals to attend if procedure A is needed versus procedure B eliminating the need to decide on the spot.

Unfortunately while increased medical transparency should have significant government support from both major political parties as well as widespread public support, any Federal law demanding significant transparency requirements from these institutions does not appear on the horizon and for reasons discussed above one should not expect insurance companies and MSPs to become significantly more transparent on their own. The small collective of state transparency laws are a positive step, but should not be expected to significantly lower national healthcare costs.

For example when discussing state required transparency, in 2014 Catalyst for Payment Reform and Health Care Incentives Improvement Institute judged that only Colorado, Massachusetts, Maryland, Maine, New Hampshire, Virginia, and Vermont had some form of sufficient law(s) requiring appropriate and useful price reporting in effort to support transparency. However, among these states only Massachusetts and Maine had suitable and consistently operating websites to host pricing information allowing consumers ease of access to the information and the ability to effectively utilize it in order to make informed healthcare decisions.1 Despite this deficiency in overall transparency, there is an important step that insurance companies can take to increase transparency that should not threatened any real profitability and not require state or Federal action, changing the format of how patients are informed of how their medical costs are covered after a procedure.

The breakdown of what medical procedures were performed, their costs and who/what is responsible for what payments are commonly detailed in an “Explanation of Benefits” (EOB) form. The biggest problem with the generic EOB form is ironically a lack of explanation. This lack of explanation is largely because the EOB is basically a form letter to the patient with various numbers and procedure codes thrown on a piece of paper. There is no unique explanation associated with the patient’s personal experience and the procedures executed. Initially it would be unreasonable to expect insurance companies to perform unique detailed explanations and evaluations for all successful claims. However, it is not unreasonable to expect insurance companies to produce a more clear and transparent document.

The core of this lack of transparency in the EOB is that insurance companies and even MSPs force too much onus upon the patient understanding both the intricate elements of his/her insurance policy and having the ability to use that understanding to interpret the EOB. This interpretation is made more difficult due to the lack of qualitative information in the EOB. Insurance companies could make it much easier on patients if they simply tied the insurance policy to the EOB and then used both qualitative and quantitative information to demonstrate step-by-step with words, not just numbers, how the policy was used to pay for and not pay for certain procedures. For example instead of simply stating that “sum x is to be paid by the patient due to the maximum coverage reached due to the condition of the plan for this service” the EOB should document the existing coverage value and how that coverage value was utilized to covered the applied care.

Such a change in strategy should not be difficult because insurance companies already use policy information to create the EOB for individual patients, thus the only real change would be the addition of qualitative information. For those who think such a change would be too difficult, cumbersome or expensive, the problem with this objection is that individualized plans do not really exist, thus there is only a small finite amount that must be addressed. For example if purchasing insurance was likened to purchasing a meal from McDonalds the customer would only have the ability to purchase a certain specific number of pre-assembled meals (i.e. value meals) instead of build their own meal experience from individual items (i.e. a la carte). There are no significant a la carte insurance plans, thus the overall cost increases for making these changes are minimal. In addition to the step-by-step analysis, which would use generic statements relative to co-pay and co-insurance, a more expansive EOB should include a small glossary to explain specific terms.

Some could argue that such a change would inconvenience insurance companies and it is the responsibility of the policyholder to know the extent and limits of his/her policy. In addition the Internet provides resources to “guide” patients through the general meanings of an EOB. On its face this argument is insufficient for multiple reasons. First, despite what some people want to believe not every individual has access to the Internet, thus looking online for assistance is not universally applicable. Second, arguing against the above changes to an EOB is an argument against efficiency and productivity. What makes more sense: insurance companies spending a single capital investment that would be less than 1% of total yearly profit to make their EOBs more useful friendly and easier to understand or millions of people spending two to six hours attempting to understand their EOB in its current form without a guarantee that they will? Suggesting that the latter makes more sense should only be answered with a silent and sad horizontal shaking of the head.

There is a big difference between an individual thinking he knows what his medical insurance covers and actually seeing what it covers. A more detailed and consumer-friendly EOB will help individuals better understand the actual applications of their medical insurance coverage and will increase transparency and consumer choice by producing better-informed consumers. It would be ideal if the Federal government would actually involve itself on this issue by producing legislation that would create a standardized EOB format instead of relying on companies to do it themselves or states producing individualized legislations that may not be uniform. Overall if one of the major goals of legislation like the ACA is to reduce medical costs then transparency is a key element to increasing consumer choice and lowering costs. While a truly transparent system seen in how most consumer goods and services are purchased may still be a while away, producing a more detailed EOB is an easy and straightforward means to producing more informed consumers and possible lowered medical costs.


==
1. Delbanco, S, Brantes, F, et, Al. “Report Card on State Price Transparency Laws.” Catalyst for Payment Reform and Health Care Incentives Improvement Institute. Mar 2014.

Discussing the Realities of Telemedicine Expansion

The passage of the Affordable Care Act (ACA) has opened the door to insurance coverage for all Americans, especially those who have chronic pre-existing conditions. One of the major concerns with this expansion of insurance is the additional stress it will place on organizing medical appointments and general care from non-specialists. While the most effective solution for this problem, training more general practitioners, is a long-term one requiring years before any implementation will see a positive effect, some individuals have argued that the widespread adoption of telemedicine could offer more immediate relief to this future stress. The chief benefits surrounding the implementation of telemedicine that could aid this overall problem are saving time born from a reduction of hospitalizations due to more efficient physician time utilization, reduction in on-site registration congestion and increased physician collaborative efficiency increasing the rate of patient turnover without sacrificing care quality.

In a general sense telemedicine (and its synonym “telehealth”) involves the use of telecommunication and information technologies to provide healthcare when patient and physician (or other medical resources) are in different physical locations. More technically it is generally thought that telehealth involves only patients and their personal health management using technology and telemedicine involves physician interaction. For the purpose of this post telemedicine will be used to cover both of these definitions. Telemedicine is typically broken down into three main categories: 1) store-and-forward (asynchronous); 2) remote monitoring; 3) real-time interactive services (synchronous).1

Store-and-forward is the most “hands-off” type of telemedicine where various important medical data is collected and transferred to doctors and/or medical techs for analysis at a future time offline. Store-and-forward is convenient because the data can be collected without the involvement of a doctor; however, any diagnosis is deferred to another time. The delivery of this information typically needs to be contained within a properly structured electronic medical record if done online. With the omission of actual patient-physician communication, store-and-forward demands patients produce medical histories as well as audio and/or video information.

The concerns about store-and-forward is that the electronic nature and format of the information (in more modern mediums apart from the telephone) along with the reliance on the patient to perform most of the work could provide undue burden on elderly and less tech savvy individuals (note all of the problems people had filling out forms to apply for insurance in state marketplaces after the ACA went into effect). In addition the possibility exists to produce some initial information gaps because of the lack of a physician to ask clarifying follow-up questions, which could cause future problems. While certainly not insurmountable, these concerns must be managed.

Remote monitoring is a more advanced version of store-and-forward where physicians monitor the vital signs and other specific characteristics relative to a patient’s given medical condition using appropriate devices. Application of remote monitoring is typically reserved for patients will chronic conditions that could benefit from constant monitoring where significant changes provide early warning to a potential acute detrimental change in health.

Real-time interactive services are what most people think of when discussing telemedicine and involve the patient and physician communicating in real-time. Interactive services follow the same pattern as in-person visits with a review of medical history, physical examination, general health questions, etc. except the interaction is through an online video service or telephone. Not surprisingly real-time interaction is the most valuable form of telemedicine, but is also the most complicated. Overall the success of telemedicine to make significant cuts in healthcare costs and increase access is largely contingent on the success of real-time services versus store-and-forward and remote monitoring.

Three major areas of technology are utilized for telemedicine: portable medical imaging devices, portable data transfer devices (in modern times these elements usually involve smart phones with certain apps) and the stable wireless infrastructure to ensure accurate transfer of information, especially in real-time. The most problematic element of the above technology is ensuring access to portable medical imaging. There is some hope that smart phones will be able to provide high quality resolution images that could substitute for on-site medical imaging, but at the moment it is difficult to anticipate MRI, fMRI, CT, PET scans, etc. being conducted from a private residence versus at a hospital or local medical site.

One of the immediate concerns about the judgment of whether or not telemedicine is medically and financially efficient is the contradiction between the numerous studies that have been conducted regarding these questions. Conflicting studies are usually created because different researchers use different assumptions when producing their results. For example a recent meta-analysis studying reviews of telemedicine determined that twenty reviews concluded telemedicine works and has positive medical and/or economic effects, nineteen reviews concluded telemedicine could work and has potential to produce positive effects, but required more research to fully identify this potential and twenty-two reviews concluded a lack of evidence for any significant positive effects of telemedicine.2 Clearly such a wide divergence of opinion is concerning. The development of a universal standard to govern the questions and assumptions surrounding investigations into telemedicine would provide a means to effectively judge meaningful and valuable studies versus less valid studies and eliminate this conflicting confusion.

Despite this contradiction one of the major problems with telemedicine reviews in general is that only a small number actually explore how telemedicine influence clinical outcomes, which is the most important question regarding whether or not the application of telemedicine is appropriate.2,3 The most promising sub-categories of telemedicine that have some empirical evidence for increasing positive outcome potential are teleradiology, telepsychiatry, echocardiographic analysis and communications between primary and secondary healthcare providers.4,5 As alluded to above currently a significant problem in the debate about the viability of telemedicine is that both parties (proponents and opponents) are attempting to push the application or rejection of a technology without proper evidence that telemedicine does or does not produce positive outcomes at a comparable cost to traditional medicine.

Telemedicine proponents theorize numerous potential advantages including, but not limited to: 1) increased physician accessibility in isolated communities that lack easy transit access to hospitals and medical complexes; 2) reduced of outpatient visits due to remote patient monitoring and reduced total mortality due to increased monitoring; 3) reduced probability for pharmaceutical mistakes due to removed prescription verification and increased administration oversight; 4) reduced probability of infectious disease transmission due to eliminating interaction between infected and non-infected patients in common hospital areas; this benefit could also be enhanced due to the higher probability of the infection being antibiotic resistant; 5) some argue it will increase the level of medical education by allowing subordinates and students to better observe practitioners; 6) reduction of negative psychological associations with visiting a doctor due to existing “creature comforts” of home; 7) grant the ability for physicians to provide consolations to other physicians and/or patients without additional travel;

Overall outside of some specific goals the general idea of telemedicine is to reduce physical office crowding, which will increase overall efficiency and reduce costs, and increase physician/patient interaction efficiency in part achieved by easing the ability to interact with multiple physicians at the same time. Despite the above goals, at the moment the greatest demonstrated benefits from telemedicine comes from remote monitoring in patients with chronic conditions and interacting with specialists that rely on verbal interaction versus physical contact or cues.2,6

While proponents sing of the economic benefits of telemedicine, these potential benefits are only in the long-term, if they exist at all. In the short-term the economics of telemedicine are actually negative due to capital costs associated with the telecommunication and data management equipment as well as the technical training for all relevant medical personnel. Other economic challenges are unclear legal regulations, both within states and between states, and the ongoing lack of recognition by insurance companies for certain aspects of telemedicine as “valid” services.7 Private insurance appear to have numerous barriers due to administrate rules regarding reimbursement of telemedicine services. This lack of recognition could create a “chicken or egg” problem where telemedicine may not make significant advancement until insurers cover it, but insurers may not cover it until significant advancement is made and its overall efficacy to produce positive medical outcomes is demonstrated.

In addition there is a concern about increased costs associated with a greater probability of diagnostic error due to the inability of the physician to actually physically touch and interact with the patient. For example certain physical tests that could produce certain symptom clues will not be available and expecting untrained patients to produce the same results even under instruction is not reasonable. This lack of interaction also raises questions regarding the theoretical time saved with regards to real-time telemedicine. The issue of time saved is not from the perspective of the patient, for unless a patient resides very close to his medical practitioner’s practice, the elimination of travel time and time in the waiting room will produce less wasted time.

However, this time issue could be a legitimate concern from the perspective of physicians. For example some have estimated that virtual interactions involving teledermatology take around thirty minutes where traditional in-person consultations typically take 15 minutes.8 The nature of overcrowding mentioned above is based upon the idea that a physician’s time will be spread too thin with the continuous addition of newly insured patients, if telemedicine increases examination times it will be a detriment not a benefit to physician access.

In addition one of the biggest problems with the expansion of telemedicine is that it appears not to be living up to one of its highest theorized benefits, expansion of medical care in rural communities, especially to elderly individuals. For example despite Medicare rules being in place from 2001 to pay distant practitioners 100 percent of the rate under the physician fee schedule the volume of telemedicine services utilized by Medicare beneficiaries remains low. One recent review found that only 38,000 telemedicine visits were claimed in 2009 up from only 26,000 in 2006.9 Some proponents may try to spin the 32% increase as impressive, but the base increase of only 12,000 individuals reveals the truth that telemedicine is struggling to catch on among the elderly; a group proponents state will be significantly aided by telemedicine largely due to access issues. Worse is that these claims are actually lower than reported for a number of practices inappropriately billed Medicare for video consultations taking place in the homes of urban patients.9

Another foreboding trend is that only 369 practitioners submitted claims for 10 or more telemedicine services in 2009 with only 14 counties having more than 300 telemedicine sessions among its residents.9 Therefore, even in the counties that have telemedicine services that are being used, the volume of use is very small, which could make it difficult for these centers to justify both the capital costs and administrative costs of telemedicine over the long-term.

Also there appears to be a significant lack of local medical specialists who are willing to service rural areas through telemedicine (and maybe in general). General practitioners typically provide telemedicine services, which is unfortunate because one benefit of telemedicine is that it is supposed to “bridge the gap” between the glut of specialists in urban environments and the lack of them in rural environments.

There are numerous reasons why specialists appear unwilling to use telemedicine to acquire more patients in rural areas: 1) specialists already have a sufficient in-person patient population and do not have time for new patients; 2) the money provided by Medicare (in general) is not enough for specialists to bother with taking new patients (opportunity cost is too high); 3) some argue there is a lack of confidentiality and pervasive liability concerns in telemedicine; 4) other inconveniences associated with telemedicine, outside of direct monetary payment, not worth it (licensing, moving between in-person and electronic interaction, general change in routine, managing new operations and costs for the video networks, etc.); 5) prior negative experiences have soured specialists on future attempts at adoption;10-12

One bright spot in rural telemedicine utilization appears to be telepharmacy. Numerous pharmacies can be managed and/or supported by outside pharmacists producing lower fixed costs, especially in rural communities with populations so small that traditional pharmacies cannot be financially supported.9 Telepharmacy appears to be more successful than telemedicine involving specialists largely because of relative reduced in-person workloads between pharmacists and specialists making the acquisition of more patients less time intruding.

The issue of reduced cost may also be questionable for those attempting to utilize telemedicine while on Medicare or Medicaid. Currently due to the Benefits Improvement and Protection Act, Medicare has to pay 100% of the fee to the distance practitioner as well as an additional facility fee to the telemedicine site where the patient travels.9 As of 2013 this fee was $24.9 At a basic level this additional fee makes telemedicine 24 dollars more expensive than traditional patient-physician appointments; multiply that single payment by x number of patients (assume 36,000 from above) and telemedicine costs the government at least 864,000 dollars more than traditional medicine and would only increase with more adoption. In addition to that extra cost there is some evidence to support remote interpretation in medical encounters to be more expensive than its alternatives.2,13 Therefore, the economic realities of simply administering telemedicine need to be more carefully and specifically studied before presuming that they reduce costs.

There is also some concern that real-time telemedicine may increase costs due to individuals increasing their utilization of healthcare services born from the convenience of telemedicine. Interestingly enough some preliminary data suggests the exact opposite based on a change in psychological tendencies regarding a commitment to general health. In simpler terms the convenient nature of telemedicine may induce individuals to view medical check-ups with less meaning. For example in one study telemedicine users were less likely to follow up with an additional physician visit in a reasonable period of time (only 6% of users) versus 13% that visited a physician’s office and 20% that visited an ER.14 A similar mindset is commonly seen in committing to physical exercise where when one attends a gym it sends a psychological cue to an individual that it is time to exercise increasing the probability of meaningful exercise versus if that individual attempts to exercise within his/her home.

Another more minor concern regarding telemedicine is the overall privacy and safety associated with the transfer of medical data over a wireless network both for single issue transfers and real-time remote monitoring. Also while standardization from the practitioner is potentially politically complicated, ensuring transmission quality from the patient if telemedicine is conducted from the patient’s home is questionable. Would it be the responsibility of the patient to ensure security and bear the cost of any breach? Or should real time telemedicine from the patient’s home be managed with a strict protocol only allowing certain technologies and if the patient does not have access to these technologies it would be recommended that the patient abstain from utilizing telemedicine at his home?

Another problem that some believe could be an obstacle to the expansion of telemedicine, especially real-time telemedicine, is the regulatory issues that make it difficult to obtain licenses to practice medicine across multiple states and gaining privileges at multiple facilities. The total extent to which this obstacle is actually restrictive is unknown. The mindset that establishes this obstacle as meaningful is questionable because it seems to imply that a large number of physicians will never choose to utilize telemedicine in their practices, thus the expansion of telemedicine is dependent on the smaller few that do choose to practice it. Due to their smaller number these physicians will need more lenient regulation in order to practice in multiple healthcare markets across multiple states to ensure that potential telemedicine consumers will have access.

Interestingly this “obstacle” appears to only be one in the minds of proponents who believe all concessions should be made to foster the growth of telemedicine. The reason this obstacle of licensure fees and licensing is somewhat hollow is that most of the individuals seeking telemedicine have an in-state physician and it is very difficult to envision an environment where the only telemedicine option is out-of-state. To weaken safety regulations for the sole purpose of providing convenience to more than likely less than 1% of all individuals who will utilize telemedicine in the future seems foolish.

One possible solution to the licensing issue is the creation of a national telemedicine license. However, the immediate problem with this solution is how to “define” telemedicine as significantly different from traditional medicine in that the national telemedicine license cannot also act as a national traditional license to practice medicine. For example real-time interactive telemedicine is basically a patient visiting a physician, but from home or designated secondary site instead of in the office. However, if the appropriate practicing credentials are different between real-time telemedicine and traditional medicine within a given state it can be suggested that there is a fundamental difference in how real-time telemedicine and traditional medicine is practiced, which makes no logical sense. It would be akin to saying that water in the Pacific Ocean is comprised of two hydrogen atoms and one oxygen atom while water in the Atlantic Ocean is comprised of something different. A secondary issue with this solution is numerous states already have differing policies on telemedicine licensing; how can states that have such differing viewpoints as Oregon and Texas come to an understanding regarding the qualifications for a universal license without creating a contradiction with the first above problem?

Another important issue is differentiating the different fundamental legal principles between traditional medical care and telemedicine. While clearly certain things are going to be the same including, required informed consent, confidentiality, etc., other elements will be different like more responsibility on the patient for providing their own medical care and the security of transferred data. One potentially controversial issue would be what defines malpractice in telemedicine? Depending on the quality of the video feed it is reasonable to suggest that certain physical indicators could be more easily misinterpreted by physicians leading to a misdiagnosis; therefore, should physicians be held less liable for misdiagnoses in telemedicine?

A significant disadvantage of telemedicine is the inability to immediately start treatment for severe cases. While telemedicine may offer some alleviation from the fear of hospitals and/or doctors, it does not address general ambivalence of potential medical conditions. There are some individuals that will simply not go to the hospital until the very last moment. In these cases a delay in treatment may be critical. This lack of immediate treatment is also relevant in antibiotic treatments where injections may be required over oral or topical treatments.

Some individuals are concerned that widespread personal objection to telemedicine will prevent significant growth, especially resistance from physicians themselves. A review of literature suggests that, regardless of specialty, once telemedicine is initially explained to patients they have little problem with the results identifying the greatest advantages as the reduction of travel time and stress.15 However, physicians are typically slower to adopt technology in their practices. Within hospitals this slower adoption is irrelevant as only a small number of the attending physicians will have to be sufficiently trained and accepting of telemedicine for hospitals will primarily remain areas of direct contact medicine. The real issue regarding adoption is how fast will physicians accept telemedicine in their personal practices and will it even matter? Widespread adoption may not be important because it would be not be necessary to establish rules and regulations for telemedicine.

One caveat is clear when analyzing survey results underlying patient acceptance and satisfaction with telemedicine is that one must acknowledge the presence of utilization/sample bias. Individuals who engage in the use of telemedicine do so because they are inherently more accepting of it. A similar example could be seen in a survey result that indicates 81% of people that rode Roller Coaster A were satisfied with the experience. Such a high number is not surprising because people who do not like roller coasters will not ride Roller Coaster A and therefore do not participate in the survey. Overall because of this inherent utilization bias simple satisfaction surveys do little good in determining whether or not telemedicine is advantageous for a given community. Note that studies identified that most telemedicine services are utilized by younger, more affluent patients with a high level of tech knowledge lending credence to existing sampling bias.14,16

Instead of focusing on simplistic issues like “Do you like telemedicine or not?”, surveys and their associated analyses should focus on specifics regarding what consumers like and do not like about telemedicine. Furthermore one must ask the question: is the goal simply to provide telemedicine to those who want it or to convince those who don’t of its supposed virtues?

Not surprisingly tutorial training has been suggested to ease the learning transition for more technologically wary physicians before fully engaging in the utilization of telemedicine. However, these tutorials must be smartly designed and lack easily producible technological glitches to limit frustration with both the tutorial and telemedicine in general. Fulfillment of these expectations depends upon overcoming and improving upon the limitations of certain telecommunication equipment as technological issues can restrict physicians’ enthusiasm in some cases. For example and not surprisingly researchers testing low-cost technology have found that poor imaging can limit the usefulness and perceived effectiveness of technology.2

When individual practices or hospitals seek to establish telemedicine programs certain planning steps are critical for success. The most important principle step is to establish a vision for what will embody the telemedicine program. As mentioned above there are multiple aspects of telemedicine, so the first element in planning for a program is to determine which of these aspects will be represented. The development and application of a clear vision reduces the probability of mistakes and increases motivation due to a specific understanding of the goal of the telemedicine program.

In addition to the three general categories of telemedicine the motivation of vision will typically involve at least one of three factors: 1) telemedicine is used to deliver care to remote locations with little traditional access; 2) telemedicine is used to provide alternative methods to deliver care at reduced costs; 3) telemedicine is used to expand market share and improve competitive advantages against other healthcare providers. Note that this third option is a viable one because hospitals are businesses although it would be unfortunate and troublesome if hospital A used telemedicine services to poach hospital B patients when hospital B still had adequate resources to support the care of those patients.

After establishing the vision the medical organization must establish the financial plan that will be necessary to achieve that vision, both short-term and long-term. Part of establishing this financial plan will be incorporating how the telemedicine vision will achieve maximum utilization because if people do not consistently use the program then justifying it financially is a losing proposition.

Another important element in a telemedicine program is properly integrating it into the overall healthcare service organization within the hospital. Physicians cannot view traditional medicine and telemedicine medicine as opposing forces or an “us vs. them” type of model. Physicians must realize that the overall goal of both models is to provide the highest quality medical care at appropriate cost to patients.

While telemedicine exams will not involve patients being present at the hospital, the room in which the physician conducts the examination must have as much similarity to a typical exam room as possible only making exceptions for specific types of lighting and technology. The technology footprint of the room must be as reserved as possible. The intent of telemedicine is not to dazzle and impress the patient with flashy technology, but to provide quality medical care. In addition telemedicine should follow the same standard protocols used in traditional medicine for equipment use, examination and documentation.

Not surprisingly a telemedicine program will only be as effective as the staff running it, so training will be an important aspect in providing quality care. The first element in training will be establishing a leader or coordinator that will run the training sessions and even the telemedicine program itself. An effective leader will make sure that all personnel have an outlet to voice concerns as well as ensure that those working with telemedicine are not ignored or displaced by the technology. After establishing a leader, a training schedule should be established with clear objectives for each session including an early and late call participation session so individuals have a benchmark to how their performance has improved from before training to after training. Training should be as realistic as possible and include multiple technical difficulties to ensure that a strategy exists to manage those difficulties.

Finally it is important for a telemedicine program to have an efficient response structure where both staff and patients have the ability to provide feedback regarding their experience and the operation of the system. All staff should be surveyed frequently (once every two weeks) to ensure the fluid and efficient operation of the program. Patients should have the option of completing a survey electronically after their telemedicine session. The results of these surveys should be compiled and analyzed by a small committee that will act if deemed necessary on the rendered opinions.

One of the biggest problems with the manner in which telemedicine proponents conduct their real world applicatory analysis is that they seem to believe that praising the benefits of telemedicine is enough to drive hospitals and other private practices to adopt the necessary technology. Clearly this belief has proven false for most medical institutions have been slow to adopt even the simplest elements required for “modern” telemedicine, electronic medical/health records. If telemedicine proponents want to more efficiently expand telemedicine they need to produce individualized analyses for specific medical institutions that demonstrate the benefits of telemedicine rather than simply using blanket statements of how it is good and saves money no matter what.

Proponents of telemedicine dream of a system that lowers the total costs of healthcare, for both the patients and the practitioners, as well as increases the level of access and ease at which medical care is administered. This ideal is thought to be achieved through eliminating time wasting activities like physical travel to a medical institution, elongated check-in (instead modern check-in simply would utilize a code number and password), reduced overhead, more efficient data collection, etc. Unfortunately this ideal has not proven easily achieved and may not even been viable. The first problem is that there is no uniform evaluation system to determine whether specific aspects of telemedicine help to achieve this ideal instead just a hodge-podge number of reviews claiming contradictory results. A second problem is that private insurance has been slow to cover real-time telemedicine procedures and current Medicare payment structures make telemedicine more expensive for the government versus traditional medicine.

Another concern is the idea of using telemedicine to address the anticipated general practitioner shortage. If telemedicine does not reduce the average time that a physician spends with a patient while at least maintaining overall quality of care then telemedicine will not be a useful strategy for this particular goal. Unfortunately at the moment there are very few studies that have addressed patient-physician time versus quality of care. In their theoretical musings regarding patient turnover telemedicine proponents appear to think that there are numerous general practitioners simply sitting in their offices out of boredom with no patients to see, thus they are freely available to video conference with patients outside of their “treatment area”. This vision is rarely, if ever, accurate, thus turnover times are critical to determining whether or not telemedicine will be a boon to any overcrowding.

Further problems stem from the fact that even when given the opportunity to utilize telemedicine, most individuals elect to continue to engage in traditional medicine despite travel concerns. Compounding this problem is the demographics that are taking advantage of real-time telemedicine: young urban well-off individuals with knowledge of technology; these individuals facilitate a small benefit from telemedicine from a standpoint of the healthcare industry in general. If this trend continues the public perception of telemedicine could shift to it being an economic burden that has to be absorbed by the poor and the middle class to accommodate an additional convenience to the wealthy, which could create significant resentment towards telemedicine in general.

Overall the idea of telemedicine, especially real-time interaction, is a strong one with significant potential, but proponents have to separate hopeful theory from reality. While positive steps have been taken for the store-and-forward and remote monitoring aspects of telemedicine, the major savings and benefits from telemedicine come from real-time interaction, which is much further behind in its utility and usefulness. Without sufficient work telemedicine will never be anything but a niche market hardly capable of producing the benefits dreamed of by its proponents.

Citations –

1. Allely, E. “Education and training in telemedicine: synchronous and asynchronous telemedicine.” J Med Syst. 1995. 19:207–12.

2. Ekeland, A, Bowes, A, Flottorp, S. “Effectiveness of telemedicine: a systematic review of reviews.” International journal of Medical Informatics. 2010. 79:736-71.

3. Hailey, D, Roine, R, and Ohinmaa, A. “Systematic review of evidence for the benefits of telemedicine.” J. Telemed. Telecare. 2002. 8(Suppl. 1):1–30.

4. Roine, R, Ohinmaa, A, and Hailey, D. “Assessing telemedicine: a systematic review of the literature.” CMAJ. 2001. 165:765–71.

5. Bee, P, et Al. “Psychotherapy mediated by remote communication technologies: a meta-analytic review.” BMC Psychiatry. 2008. 8:60-73.

6. Hersh, W, et Al. “Telemedicine for the Medicare population: Update” (AHRQ Report No. 131). Rockville, MD: Agency for Healthcare Research and Quality. 2006.

7. Rogove, H, et Al. “Barriers to Telemedicine: survey of current users in acute care units.” Telemedicine and e-Health. 2012. 18(1):48-53.

8. Moffatt, J, “Barriers to the uptake of telemedicine in Australia – a view from providers.” The University of Queensland, School of Medicine. 2011.

9. Gilman, M, and Stensland, J. “Telehealth and medicare: payment policy, current use, and prospects for growth.” Medicare & Medicaid Research Review. 2013. 3(4):E1-E14.

10. Luo, J. “Telemedicine: Is it time now?” Primary Psychiatry. 2008. 16(2):27–30.

11. Whitten, P, and Buis, L. “Private payer reimbursement for telemedicine services in the United States.” East Lansing, MI: Michigan State University. 2006.

12. Grigsby, B, et Al. “The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation.” Telemedicine and e-Health. 2007. 13(6):645-656.

13. Azarmina, P, and Wallace, P. “Remote interpretation in medical encounters: a systematic review.” J. Telemed. Telecare. 2005. 11(3):140-45.

14. Uscher-Pines, L, and Mehrotra, A. “Analysis of teladoc use seems to indicated expanded access to care for patients without prior connection to a provider.” Health Affairs. 2014. 33(2):258-264.

15. Witten, P, and Love, B. “Patient and provider satisfaction with the use of telemedicine: Overview and rationale for cautious optimism.” J Postgrad Med. 2005. 51:294–300.

16. Exploring the Digital Nation America's Emerging Online Experience, 2013, U.S. Department of Commerce: Washington, DC. p. 9-15.

Who’s afraid of a big bad guaranteed basic income?

Note: Reading about the structure and execution of a GBI here would go a significant way to enhancing this particular blog post.

The political trepidation behind the very attempt to legislate a guaranteed basic income (GBI) should be quite surprising, but sadly is not. A GBI should be one of the major goals of the progressive movement, but there has been no effort to achieve it, largely based on the notion that a GBI is thought of as “politically unfeasible”. However, what is interesting from a logical and rational perspective is that there is no direct fundamental reason why a vast majority of United State citizens would object to a GBI regardless of their political, religious or other moral leanings.

For example suppose:

You are a Democrat –


A GBI is generally the Holy Grail with respects to eliminating poverty and hunger. With a GBI poor individuals will be able to create a stable savings account and advance their economic position without the significant threat of falling into the poverty trap. In addition all individuals will be able to afford to attend college, if so desired, creating a more educated and creative society. Individuals that have already attended college would have a greater ability to pay off student loan debt in a timely fashion removing the potential of being financially crippled by consistent payments during hard times. Finally no longer would an individual be handicapped and imprisoned by the poor decisions of their parents for regrettably the economic climate of the United States no longer only demands hard work and reasonable intelligence, but social and political connections.


You are a Republican –


A GBI is an effective means to reduce the level of bureaucracy in the Federal government resulting in the simple and transparent consolidation of all government “safety net” programs which include, but are not limited to: unemployment insurance, general welfare, supplemental nutrition assistance program (SNAP a.k.a. food stamps), school meal programs, low-income housing assistance, home energy bill assistance, refundable portions of the Earned Income Tax Credit and Child Tax Credit, supplemental security income, etc.

There is reason to suspect that the supplementary income provided by a GBI will also increase the probability of marriage and strength family bonds in general. One of major reasons why marriage rates have decreased over the last few decades, especially the last decade, is that most younger individuals are holding off marriage because they do not have the necessary financial resources. Some individuals could argue that small-scale studies disprove this benefit, but that argument misinterprets the results of those studies. Based on logic and the existing marriage climate a GBI should increase marriage probability.

Finally a GBI would significantly enhance market efficiency by increasing the available spending and investment capital in the environment. Not only would individuals have more available money to drive the consumption elements of the economy creating more indirect business opportunities and jobs, individuals would have additional capital that could be utilized to establish their own businesses. Basically instead of relying on venture capitalists or harder to acquire bank loans, which creates market inefficiencies by removing money from the general consumer environment, the money acquired from these businesses stays with the company founders and in the general consumer economy. Keeping more money in this part of the economy will accelerate economic growth. However, if bank loans are needed a GBI would increase credit flow from lending institutions due to increased confidence in repayment.


You are a Libertarian –


A GBI significantly enhances personal freedom by reducing the severity of economic obstacles. Instead of being bound to a job one hates and has little skill at solely because one needs the paycheck to eat, an individual can use the GBI to make decisions not bound by the need for a paycheck. The GBI will accomplish a noted goal, reducing the size of the Federal government. Finally a GBI will further the development of a genuine meritocracy, that winners and losers are determined by talent, hard work, drive, intelligence, etc., instead of a somewhat fixed system where an individual can be consistently placed at a significant disadvantage by elements outside of his/her control.


Regardless of one’s political affiliation a GBI would create a dramatic reduction in lost human potential. For example instead of having an individual who is interested and gifted in engineering, psychology, teaching, law enforcement, etc., bound to a low level undesired service job simply to put food on the table or to help his/her family, this individual will now be able to pursue jobs with their valued skill sets and interests. This rejuvenation of human potential will increase economic efficiency and growth as well as increase physical and mental health.


You are an Environmentalist –


An environmentalist may balk at the above mention of economic growth through additional consumption. However, it is important for environmentalists to recall that a vast majority of “environmentally friendly” energy and transport options are significantly more expensive than their less friendly alternatives; with the additional funds from a GBI individuals will be able to more easily support positive environmental changes increasing the probability for continued economic growth while at the same time reducing the damages born from global warming and other pollution factors.


You are a “Insert Religion Here” –


One of the major tenets of every major religion is to help the poor; supporting and creating a GBI is one of the best strategies for helping the poor. In addition a GBI would free up significant charitable donations to various religious organizations from domestic commitments and allow them to be redistributed to global charitable projects, if so desired. Overall anyone who truly believes in the message of their particular religious faith should support a GBI.


You are in the Upper 15% Income Bracket –


Intuitively one might think that rich individuals, make no mistake those in the top 15% income bracket are rich, would be opposed to a GBI because of the small changes it would make to the tax code resulting in a very slightly reduced direct return. However, a GBI would also significantly increase the amount of disposable income to the general public, which would significantly increase the moneymaking opportunities for rich individuals through investment. It stands to reason that intelligent rich individuals would support a GBI because they could identify the worthwhile new business opportunities in which to invest, either directly or indirectly through stocks, thus increasing their overall wealth as well as improving society in general. Therefore, rich individuals should support a GBI as a means to increase their personal wealth, increase the overall prosperity of the country (enhancing international negotiating power) and reduce market uncertainty and inefficiency increasing overall productivity.


With a vast majority of the public falling into one of the above demographics that would logically support a GBI it is rather peculiar that no reasonable effort has been made by the Federal government to establish one. As stated at the beginning of this thought exercise it appears that preconceived notions about a GBI not being “political feasible” has derailed its viability before even identifying whether or not these preconceived notions are accurate. The interesting thing about this philosophy is how can a piece of legislation be defined as “dead on arrival” if no one actually brings the issue up for discussion? Allowing these assumptions to control the actual perception of various ideas prevents the United States from identifying and establishing quality legislation like a GBI. Overall there is little reason to object to a GBI as long as it is operated transparently and is cost effective for it benefits everyone in society even if some individuals may not immediately realize it.

A Brief Discussion Regarding Feeding Future Martian Colonist

Colonizing Mars will be a significant endeavor with many moving parts and critical decisions to make. One of the most important decisions is how to design the appropriate food supplementary methodology for the colonists as Martian environmental conditions differ significantly from Earth. This difference demands a clear and transparent strategy to ensure the safety and productivity of future colonists. Fortunately there is sufficient predictability and routine with regards to creating this food production strategy making it easier to compare and contrast competing options.

The first element to understanding the dietary requirements for Martian colonists is deducing the minimum requirements for survival on Earth. The typical energy recommendations for a sedentary individual approximately 70 kg are about 2,000 calories, which should be familiar to most individuals because it is the basis of daily recommended allowances for nutrients used by the FDA. There is the argument that more active individuals will require double that at 4,000 to 4,500 calories. Some reference that most astronauts involved in the Apollo missions consumed an average of 2,793 calories, but their missions were extremely short (less than a week).

A more apt reference comes from Biosphere 2 where participants consumed 2,216 calories per day, but even at these consumption levels participants lost an average of 8.8 kg over the 2-year experiment. Unfortunately it stands to reason that Martian colonists will be more active than Biosphere 2 participants due to required frequent extra-vehicular activities (EVAs) to construct additional elements to expand the initial habitat and scientific exploration. Also there is little information regarding how nutrition needs and absorption capacity change in a low gravity environment, especially with regards to gut bacteria.

Another problem is that these calories need to include the 9 essential amino acids for healthy adults: phenylalanine, valine, threonine, tryptophan, methionine, leucine, isoleucine, lysine, and
histidine. Studies on a minimal diet required for survival included 10 different foods: soybean, peanut, wheat, rice, potato, carrot, chard, cabbage, lettuce and tomato with recommendations for additional nutrients from sugar beets, broccoli, various berries, onions and corn.1 Unfortunately it is unlikely that such a wide array of foods will be available for a Mars colonization mission past the food that initially travels with the colonists. In addition early on in the expedition colonists will have to eat additional food brought from Earth to compensate the lack of sufficient growth on Mars.

However, the weight and cost of carrying a large amount of food with the colonists could be crippling. A general estimate can be made using MRE information. Each MRE contains about 1,200 calories.2 A colonist would consume at least two MREs per day. The general average weight of an MRE is estimated at 635 grams or slightly under 1.4 pounds.2 Therefore, the average weight of food for a day per colonist is 2.8 pounds. The generic cost associated with launching something into space is 8,000 – 10,000 dollars per kilogram (i.e. 3,636 – 4,545 dollars per pound), thus 3.716 million to 4.645 million dollars per colonist per year in food costs. Some could argue that this price is lower due to the activities of Space-X, but most people forget that these estimates are not made to scale. There is a big difference between $2,000 per pound when launching 2,000 pounds and $2,000 per pound when launching 200,000 pounds. Also any estimate can be made depending on how much money a company is willing to lose on a launch. Unfortunately cost is not the only limiting factor for colonists bringing their own food.

Some could argue that the nutrients provided by some of these foods can be substituted through vitamin consumption, but there are lingering questions about nutrient absorption when vitamins are principally responsible for nutrition. Another more minor concern revolves around shelf life for freeze-dried and MRE-type packaging, which will limit the use of initially sent food to a maximum of approximately 2 years. As stated above this concern should not be significant because greater than average food consumption will be expected due to activity levels and a lack of grown food. Finally for some there is the continuing pseudo concern of unappetizing food in space due to the specific cooking and harvesting techniques required for reduced gravity environments. This concern is rather meaningless because if someone has the choice between eating something boring, repetitive and unappetizing or dying, any sane individual will select the first option.

Based on the anticipated workload and a difficult living environment (pressurized homes and bulky pressurized spacesuits) all settlers on Mars will require additional calories beyond average consumption levels. While freeze-dried food shipments can be delivered periodically from Earth the costs associated with such missions, as estimated above, should prohibit executing this strategy indefinitely. Overall the reality is that some form of food synthesis/production methodology needs to be created for Martian colonists.

Obviously growing food on Mars will be difficult because the lack of quality soil, rainfall and consistent sunlight will force all growth to occur indoors in a pressurized environment under artificial light in a hydroponic or aeroponic infrastructure. The advantages to using soil versus a nutrient baths are numerous including, but not limited to: 1) soil playing a significant role in air purification; 2) acting as a central and low energy recycling and composting system for various types of waste; 3) difficulty re-supplying nutrient solutions away from Earth potentially limiting the lifespan of a hydroponic or aeroponic system; 4) increased gaseous aeration and reduced water leaching in the presence of no toxic agents due to the gravity difference.

Clearly somehow incorporating soil would be a large boon to the colonization process. Some individuals have very optimistic notions that the soil can be rehabilitated to the point where it can support food growth. Some initial experiments argue that it is possible to grow food in Martian soil.3 However, this research has its concerns in that the soil used to emulate the Martian soil was free of contaminants along with a lack of pressure and gravitational changes inherent to Mars, thus perceiving these results as accurate to cultivation on Mars is irresponsible. A rehabilitation process will take years, if not decades, and more than likely will not start until after colonists have made landfall.

The problems with this rehabilitation process are as followed: 1) high concentrations of detrimental agents including various salts, oxides and toxins, especially chlorine and aluminum; 2) impurities heavily reduce water uptake efficiency, which due to the lack of available water on Mars would dramatically reduce yields; 3) a theoretical lack of ability to support continuous microorganism growth which is essential for quality soil health; 4) a lack of important secondary nutrients that foster plant growth like boron and molybdenum; 5) pH of regolith soil can vary from place to place, similar to Earth, but the variations on Mars are more radical. pH will be very low in places with large amounts of jarosite and very high in places with large amounts of NaHCO3 and Na2CO3. Neutralization of these high acidic or basic regions would require large amounts of CaCO3 or olivine deposits and peat moss respectively. 6) A direct lack of principle nutritional agents most notably nitrogen and phosphorus. Some argue that nitrogen can be created through weathering, a process that will take far too long, or nitrogen fixation through various microorganisms, a process that is questionable due to existing soil conditions and a lack of phosphorus. Phosphorus only seems available through fertilizers and also requires leaching CaSO4 deposits to avoid phosphorus interaction before plant absorption. Therefore, it is unreasonable to assume outdoor food growth for the first few decades.

Some have argued that even if the Martian soil cannot be utilized the Martian atmosphere could be due to its high CO2 percentage. While approximately 95% of the Martian atmosphere is CO2, the total concentration of CO2 is much smaller than the concentration of CO2 in Earth’s atmosphere because the Martian atmosphere is dramatically thinner. Therefore, on its face there is not enough CO2 available to allow free flow of air from the Martian atmosphere to produce a net benefit in plant growth. Even if CO2 concentrations were large enough the frequent dust storms with additional regolith deposits would cause significant problems for the free airflow greenhouse and it would be incredibly difficult to filter these elements due to their very small particle size. So currently it stands to reason that all food growth in a Martian colony for the first few decades will require complete isolation from native Martian conditions.

With the lack of viable soil the most popular strategies for growing food on Mars have been to forego soil use altogether and use hydroponics. Hydroponics eliminates the soil issue, but it raises its own concerns regarding water use and nutrient supplement. Even with high rates of recycling, water scarcity will be an issue on Mars and growing food through hydroponics will place further stress on that scarcity. While some hydroponic proponents report that hydroponics actually save water, these assertions are born from a comparison between hydroponic use and flood irrigation in traditional fields rather than drip irrigation. When compared against drip irrigation, hydroponics results in slightly greater water use. Also although soil is not used, a special nutrient mixture is required and it may be difficult to mass synthesize this mixture on Mars after the initial sample is consumed without having some base to work from that must either be created on Mars or sent from Earth.

Another option for food growth is aeroponic growth. Aeroponics attempts to optimize plant growth through the use of a pressurized water mist doped with nutrients sprayed on the entire exposed root system of the plant. One of the chief reasons aeroponics is successful is it does not require soil, which can provide growth inefficiencies due to poor drainage or lack of porosity limiting root aeration leading to reduced growth. NASA has even suggested that aeroponic-based food production through an ultrasonic technique will result in similar yields to conventional growth at 45% greater rates of growth despite using 99% less water and 50% fewer nutrients. However, this conclusion must be tempered with the fact that the comparison is more than likely (it is not specified) being made against crops raised through flood irrigation and fertilizer saturation, two common yet incredibly inefficient agriculture techniques, thus the actual benefits of aeroponics over more responsible farming are more muted.

The most significant detriment to aeroponics in normal conditions is a higher probability of pathogenic death due to root exposure, but this concern is somewhat mitigated due to the natural aseptic environment on Mars limiting the absolute probability of exposure. Additional sanitary elements can be added to an aeroponics system to limit contamination from colonists. A secondary problem may be synthesis of additional nutrient compounds for the mist for traditional farming develops nutrients from organic compounds and bacteria.

Significant research has been conducted by NASA and other NASA sponsored outside researchers since the early 1990s resulting in several effective water droplet nebulizer technologies and a low mass polymer aeroponic apparatus.4 Some inflatable growth chambers have also been developed for flora growth in space. With that said some argue that a growing area is not necessary in a Martian habitat because aeroponic structures could be incorporated within various other parts of the habitat resulting in more efficient use of overall available space. While aeroponics is viewed by some as the future of food growth in space no serious long-term aeroponic experiments have been conducted in space, so most of the supposed benefits remain theoretical. Note the lack of experimentation for such a system on Earth. None of the numerous “Martian Simulation” experiments have extensively utilized aeroponics in an isolated environment to support food production. If aeroponics is viewed as a valid option for providing food on Mars why have these simulation experiments failed to incorporate such a testable strategy?

Random deployment of aeroponic systems throughout the habitat seems inefficient due to lighting condition confliction. Regardless of growth medium, plants will benefit from exposure to a different wavelength of light over standard white light. Monochromatic blue and red lights have all demonstrated positive growth influences on plants and some positive results have been recorded for green, typically ordering from red to blue to green.5 Therefore, it stands to reason that all potential crops should be exposed to either a red or blue light source preferably from a LED. However, consistent exposure to red or blue light during wakeful hours could have a detrimental effect on the crew. Due to the possible lighting conflict as well as potential sanitation issues localization of food growth to isolated areas of the habitat principally responsible for food growth is advisable or its own future constructed habitat completely isolated from the principle habitat.

One final note when deciding between hydroponics and aeroponics is the issue of yield vs. available space. If an aeroponic system is properly designed it can maximize space utilization of the habitat module by using walls and ceilings. A hydroponic unit will have to compete for space that could be utilized for storage, manufacturing, sleep, leisure, etc. Alleviating this potential space problem would involve sending to habitation modules to Mars where one would act as the living unit and one would act as the farming unit devoted to hydroponic use. While clearly the costs of such a plan would be significant due to weight issues, success would allow for special oxygen/CO2 customization of the farming unit, which would reduce the complexities of isolating the farming and living units in the same habitation module. This farming unit could also be constructed on Mars using in situ resources to avoid weight based travel complications.

When addressing the food itself, while it would be ideal to grow a wide selection of fruits, vegetables, nuts, etc. to increase moral through variety of food choice, for the first group of colonists the lack of viable Martian soil converts space into the limiting factor with water close behind. Therefore, it is important to identify the foods that give the best “bang for the vitamin buck” with regards to growth space. As mentioned early on most foods that will be grown on site will require either hydroponics or aeroponics, thus growth method combined with space considerations will make it difficult to grow various vining plants like tomatoes, cucumbers, peas, grapes, etc. Also large surface area or volume crops like corn, squash, melon, zucchini, etc. would be ill advised. Due to the additional energy requirements for colonists, especially those actively searching or building on Mars, a large source of complex carbohydrates should be grown. There are numerous quality candidates for carbohydrates namely cassavas, soybean, sweet potatoes and lentils.

Of the possible carbohydrate options the cassava root is an attractive one. One of the principle advantages to the cassava is that it is significantly drought tolerant and capable of growing well in sub-optimal soils. Clearly these elements are advantageous in a water uncertain environment like Mars where any water savings that can be created is a benefit and a non-optimal nutrient mix could become the norm. There are two types of cassava, sweet or bitter and while bitter is preferred on Earth due to its enhanced pest deterrence, the lack of these organisms on Mars would make sweet a better choice for a more appetizing meal. The purpose of growing cassavas is to harvest the root, thus the leaves of the plant can be pruned early in its growth cycle to limit space use. However, if insects are also being cultivated, the leaves can be harvested as a secondary food source. The roots are good sources of calcium and phosphorus, which are critical elements for bone structure, as well as vitamin C.

In contrast to cassavas, sweet potatoes are more finicky in their growth requiring lots of light and warm temperatures (70-80 degrees F) along with significantly more water. Most varieties of sweet potatoes have some vining characteristics, which could create space issues, but there are bush-type varieties that should be used instead. Due to near immediate consumption sweet potatoes grown on Mars will not be cured eliminating that processing step. Sweet potatoes provide significant concentrations of fiber, beta-carotene, calcium, phosphorus and vitamin A. Overall it seems reasonable that there would be a competition between either using sweet potatoes or cassava with cassava having more overall nutrients and sweet potatoes having better flavor and concentration of certain nutrients like vitamin A.

Lentils are an edible pulse of the legume family and are widely grown throughout the world for its high protein and general nutritional content. Lentils contain essential amino acids phenylalanine, valine, threonine, tryptophan, leucine, isoleucine, lysine and histidine, lacking only methionine. Some report that sprouted lentils contain methionine.6 In addition to the large essential amino acid complement, lentils also have significant amounts of fiber, folate, iron and vitamin B1. However, while lentils have a wide variety of essential nutrients their preparation is more complicated than most foods requiring long-term soaking in warm water to reduce phytate and trypsin inhibitor content. This additional use of water beyond simple rinsing may give pause to the use of lentils as a food source in the initial stages of a Mars mission.

Another quality option outside the starchier ones above is broccoli. Broccoli is high in fiber, vitamin C, vitamin B2, Pantothenic acid (B5), vitamin B6, folate (B9), manganese and phosphorus along with numerous alleged anti-cancer and immune regulatory molecules like selenium and diinodlylmethane. A secondary advantage, beyond the high nutrient value, is that broccoli is resilient, grows quickly and is harvested easily. The one possible concern for broccoli is the total area of the leaves can become large, but these leaves can be pruned to eliminate this concern. Currently there is little reason to exclude broccoli from the food options for Martian colonists.

Soybeans are commonly considered a quality choice for Martian food because they are a source of complete protein (a food that contains significant amounts of all essential amino acids) in addition to it being a quality source of protein. However, there are some concerns. First, similar to lentils above soybeans must be cooked with “wet” heat to destroy trypsin inhibitors, which will take time and additional water resources. Second, modern cultivars typically reach a mature height of 3-3.5 feet, which could create space concerns depending on where the soybean crop is planted, especially for hydroponic strategies. If soybeans were grown, pruning would more than likely be required.

Keeping with the theme of green vegetables, spinach is another quality option. Rich in lutein (for the eyes), vitamins A, C, E, K, B2, B6, magnesium, manganese, folate, betaine, iron, calcium and phosphorus. It is also a quality source of folic acid, which has been in rather short supply for the other candidates mentioned so far. Also the inclusion of peanuts could be an interesting possibility. Peanuts are high in fiber, folate, niacin (B3), phosphorus, vitamin E and magnesium along with large concentrations of protein, much more than can be acquired from fruit and vegetable candidates. Some may argue that growing peanuts hydroponically is difficult because of the burrowing flower stem; however, peanut blossoms have successfully buried themselves in nutrient media and formed viable peanuts. Therefore, there is nothing to be concerned about under normal conditions, whether or not Martian gravity changes that is unknown.

A brief note regarding genetic engineered crops. There are two schools of thought regarding the inclusion of these types of crops. Proponents would argue that it is advantageous to genetically engineer all of the seeds that colonists bring with them to Mars for drought resistance, additional vitamin synthesis (i.e. Vitamin A in golden rice) and maximum photosynthetic efficiency. Due to the use of hydroponics each plant can be semi-isolated restricting the possibility of cross contamination if something goes wrong. Opponents would argue that this isolation is rudimentary and that if something were to go wrong from a genetic standpoint then the colonists would be put at severe risk depending entirely on food from Earth. Logically it makes sense for colonists to avoid homogeneity by having a variety of seed types some that have been engineered and others that have not and plant accordingly.

This combination of plant products does not, however, completely meet all nutritional requirements, as it is low in sodium and lacks animal origin vitamins and fat such as B12 and cholesterols. This is a common feature of plant-based diets. To overcome these deficiencies sodium can be supplied in mineral form. If one concluded that the use of plant based protein sources is unreasonable due to a lack of overall content, then additional sources of protein will have to be acquired elsewhere. Utilization of large animal based protein like cows and chickens is unreasonable due to the resource demands, thus insects and fish are appropriate animal food sources in a space agro-ecosystem, given the limited area available for their rearing and for efficient use of other resources to fill the nutritional requirements.

Muscular atrophy in a reduced gravity environment is a running problem. Skeletal muscle principally involved in maintaining proper posture are most negatively affected by the reduction of gravity because this muscle has evolved to balance an environment where gravitational forces are 9.8 m/s^2. That said it appears that slow twitch muscle fibers are more susceptible to the change in gravitational force versus fast twitch muscle fibers.7,8 This difference in degradation can be troublesome because not only are slow twitch associated with posture, but are also associated with muscular endurance. In addition to muscle atrophy there is a serious drop-off (>50%) in protein synthesis rates and a significant loss of calcium balance.9-11 Whether or not this loss of calcium is due to actual direct losses or indirect absorption losses (i.e. a lack of Vitamin D) is unknown. Therefore, in order for colonists to increase the probability of limiting apoptosis a constant supply of protein will be required.

One of the key advantages to utilizing insects is that they can be fed on substances that are inedible for humans yet are byproducts from other processes. For example two of the most promising insect candidates are the silkworm (Bobyx mori) and common termites because they survive on mulberry leafs and cellulose or lignin respectively. The silkworm is the better choice of these two because it cannot escape its rearing room to become a nuisance to the colonists, it produces a useful byproduct in its silk cocoon, and colonists can consume a part of its principle food source (the berries from the mulberry plant). Termites are popular for those who plan to incorporate wood into colony construction, a strategy that does not appear to be effective in its versatility or overall usefulness. Therefore, with the obvious advantages of silkworms as both a protein source and secondary material source it stands to reason that all insect rearing should focus on silkworms.

Additional protein sources can be created through aquaculture fostering suitable concentrations of small fish. It is not reasonable to expect ideal water quality in the aquaculture, thus the selected fish must be able to effectively survive during periods of high toxicity or salinity. In addition the fish must have a small maximum growth potential to avoid resource over-consumption due to overcrowding. Understandably in most situations fish harvesting would occur often enough that overcrowding should not be an issue, but overall it pays to be careful. With these two conditions in mind the two best fish candidates appear to be loach and tilapia due to their abilities to resist negative environmental elements like poor water quality, high salt concentrations and limited water availability.

Another option for a more advanced colony is to develop an aquaponic system. In such a system plants are grown in a way where their roots are immersed in the nutrient-rich effluent water of an aquaculture. The plants should filter ammonia and other toxic metabolites that could damage the aquatic life. The water is then reintroduced to the aquaculture water pool. There are many different types of aquaponic systems, but deep-water raft seems to be the best for Mars due to its simplicity, low power requirements and greater flexibility with germination staggering because different plants have different rates of growth.

Some also argue that including algae, either hydroponically or aquaponically, should be a boon to food production. One of the most powerful reasons to include algae is that it can form a closed ecological cycle. Add the algae to an environment with water, CO2, and energy (light source) and such a system can theoretically keep a person supplied with food and oxygen for as long as the system is maintained.

For some individuals Spirulina (a type of algae) is thought to be an ideal health food and some hope that these positive traits can be maintained as a food for Martian colonists. The inherent advantages of spirulina are that it is easy to digest due to a lack of cellulose, it contains a large number of vitamins sans vitamin C and eight of nine essential amino acids, and produces a high protein by weight percentage (55-65%). However, there are some drawbacks as well most notably it ability to effectively absorb environmental elements like radiation and heavy metals including producing anatoxin as well as producing large concentrations of nucleic acids which can lead to gout if more than 50 grams are consumed in a day. In addition it has an unappetizing green slime texture and taste. While that last negative should not matter in a survival situation, from a psychological standpoint there exists a high probability that eating Spirulina day after day after day will have a negative effect.

Apart from preparing an appropriate area to grow food and selecting what should be grown, a strategy to manage produced organic waste from both humans and plant matter needs to be developed. Unfortunately there is a significant limitation in possible strategies due to a lack of available oxygen on Mars. This lack of oxygen reduces the effectiveness of traditional composting making it difficult to select as a viable strategy. Some argue that the use of Geobacter, an anaerobic respiration bacterial species, which can oxidize organic substances using iron oxides and can even generate electricity as a byproduct. However, while iron oxides are available on Mars their extraction requires work either human or machine, which adds an additional element to colonization.

Some have argued for the inclusion of hyper-thermophilic bacteria may be the best option for eliminating organic waste in an 80-100 degree C environment.12 Basically the colonists utilize a small autoclave with these bacteria resulting in organic decomposition and the elimination of harmful organisms that may reside in the waste. In addition the waste heat from the autoclave process can be released into the living environment to reduce electricity demand over a short period of time or for distilling water. However, the problem with this strategy is the oxygen requirement. For a long period of time on Mars oxygen should be in short supply, thus transferring some oxygen for waste removal processes may not be prudent. Overall the best strategy appears to be using Geobacter as a principle source of waste elimination.

In the end it is important for Mars simulation experiments on Earth to study the initial best food choices to determine how they would grow in similar conditions sans gravity changes. Unfortunately current food consumption methodologies in these simulation experiments are too well developed. While it stands to reason that there will be some initial variety born from the food transported with the colonists (albeit most of this, if not all of it, will be dehydrated or freeze dried due to the travel time between Mars and Earth), this initial source food will be consumed over a period of time (1-2 years) and less hardy choices will be relied upon for a significant time period afterwards. This misrepresentation reduces the probability of collecting accurate information pertaining to how biological functions would change over time and how colonists would have to adjust when consuming significantly fewer calories.

The next Mars simulation study should only bring a small amount of food and focus on attempting to successfully grow broccoli, peanuts, sweet potatoes, soybeans and spinach in Mars like conditions using hydroponic and aeroponic systems. The type of information born from this experiment is much more important to a successful Mars colonization mission than the simple isolation/psychological experiments because those selected for Mars will be able to handle the psychological aspects of the colonization, but they will not be able to handle starving to the point of death.

--

Citations –

1. Hender, Matthew. “Colonization: a permanent habitat for the colonization of Mars.” 2010. http://digital.library.adelaide.edu.au/dspace/handle/2440/61315

2. Wikipedia Entry Meal, Ready-to-Eat (MRE);

3. Wieten, Jesse. “Dutch researcher says Earth food plants able to grow on Mars” Mars Daily. Jan 21, 2014. http://www.marsdaily.com/reports/Dutch_researcher_says_Earth_food_plants_able_to_grow_on_Mars_999.html

4. Clawson, James Sr. Aeroponics.com. January 1, 2012. http://www.aeroponics.com/aero43.htm

5. Kim, H, et Al. “Green-light supplement for enhanced lettuce growth under red and blue-light emitting diodes.” HortScience. 2004. 39(7). 1617-1622.

6. Wikipedia Entry – Lentil

7. Narici, M, and de Boer, M. “Disuse of the musculo-skeletal system in space and on earth.” Eur J Appl Physiol. 2011. 111(3):403-20.

8. Fitts, R, Riley, D, and Widrick, J. “Functional and structural adaptations of skeletal muscle to microgravity.” J Exp Biol. 2001. 204(18):3201-8.

9. Schollmeyer, J. “Role of Ca2+ and Ca2+-activated protease in myoblast fusion.” Exp Cell Res. 1986. 162(2):411-22.

10. Barnoy, S, Glaser, T, and Kosower, N. “Calpain and calpastatin in myoblast differentiation and fusion: effects of inhibitors.” Biochim Biophys Acta. 1997. 1358(2):181-8.

11. Haddad, F, et Al. “Atrophy responses to muscle inactivity. I. Cellular markers of protein deficits.” J Appl Physiol. 2003. 95(2):781-90.

12. Kanazawa, S, et Al. “Space agriculture for habitation on Mars with hyper-thermophilic aerobic composting bacteria.” Space Agriculture Task Force.