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#67 Out of this World: Research and Health in Space

Dr. Dave Williams, former CSA astronaut, physician specializing in emergency medicine, President and CEO of Southlake Regional Health Centre, aquanaut, pilot, and best-selling author!

October 23, 2019

Fifty years after humans first set foot on the Moon, we're on the verge of a new era in space exploration. The Canadian Space Agency (CSA) and NASA have upcoming plans to go back to the Moon and even the private sector is in on the action, with SpaceX aspiring to send a crew to Mars by 2024. Space exploration is exciting, but we are far from understanding all the effects of space travel on the human body. In today's episode, we spoke to Dr. Shane Journeay, a physician specializing in physical and rehabilitation medicine. He told us about the requirements for becoming an astronaut, the physical toll of space travel, and the rehabilitation required after returning to Earth. We also spoke to former CSA astronaut and physician Dr. Dave Williams, who told us all about his experience on the International Space Station - from eating and sleeping to running experiments in outer space. Scientists Dr. Laurence Harris and Marieke de Korte told us about the space health research they're involved with, and Pierre-Alexandre Fournier, CEO of Hexoskin, told us about Astroskin, an intelligent textile that continuously monitors the vital signs of astronauts. You don't want to miss out on this stellar episode!

Written by: Thamiya Vasanthakumar

Astronaut Dave Williams' book Defying Limits
NASA Twin Study
Vection Project
Immuno Profile: Staying Healthy in Space
Canadian Space Agency: Life in Space

[0:02] It's one small step for man, one giant leap for mankind.

[0:10] So simultaneously you are going to freeze, boil, burn, get the bends and no longer be able to breathe. Not a good way to go. And I was outside of my first spacewalk when my left eye went blind and I didn't know why. Suddenly my left eye slams shut in great pain and I couldn't figure out what why my eye wasn't working.

[0:31] NASA has been looking at the Kelly brothers, Scott and Mark, the twins who have given science really a once in a lifetime opportunity to figure out what space travel does to our body.

[0:44] Ground Control to Major Tom. Lock your Soyuz hatch and put your helmet on.

[0:58] Six, five, four, three, two, one.

Melissa Galati [1:09] So the question is, would you go to space and live on a colony in outer space without return to Earth?

Word on the street guest 1 [1:17] That's a really hard question. I think I have too many ties to people around me to be able to do that. But I think it's cool.

Melissa Galati [1:27] Would you go if there was, if we were slowly trying to move the population of earth to space?

Word on the street guest 1 [1:32] Yeah, if I could guarantee like that the people I want to go with me could go with me. I'm a really like interpersonal person, so…

Word on the street guest 2 [1:40] Absolutely not. I think the earth is a fantastic place and I do not have any desire to leave.

Word on the street guest 3 [1:45] No, thank you. I would not like to go and live in a human colony on Mars.

Word on the street guest 4 [1:52] Yes, but it depends whether or not it's a one-way trip or a round trip. Being one of the first people to explore the moon or the Mars and stay there might actually sound cool, but I don't think I'm ready to give up my Earth life yet.

Melissa Galati [2:08] And what do you know about the health effects of going to space?

Word on the street guest 4 [2:12] Not much to be honest, besides the fact that you can't really breathe there. But in terms of health effects, I don't know.

Word on the street guest 5 [2:20] Not terribly much to be honest, I know there are some physical things like you know, you lose some muscle mass and maybe your bones lose a little bit of density, stuff like that. But as far as like particulars go, I'm not too familiar with it.

Word on the street guest 6 [2:31] Well, they just did a research on like the twins from the, like the NASA astronauts, right, and they found so many different things that went wrong with them. There's definitely going to be a lot of health issues, but I think it's definitely worth it to research on it.

Yagnesh Ladumor [2:45] Is that something you'd be willing to put up with if there is a return ticket?

Word on the street guest 7 [2:50] Yes, because we're all gonna die anyway.

Swapna Mylabathula [2:55] Welcome to Episode 67 of Raw Talk Podcast, this time we're talking about space health.

Swapna Mylabathula [3:04] My name is Swapna, and I would love to be an astronaut. And I'm with Thamiya, who would also love to be an astronaut?

Thamiya Vasanthakumar [3:13] Yeah, I would go to space.

Melissa Galati [3:16] And this is Melissa. I'm not really sure I want to go to space.

Yagnesh Ladumor [3:20] And this is Yagnesh, and I would definitely go to space.

Swapna Mylabathula [3:24] Three out of four, not bad.

Melissa Galati [3:26] So we have a lot of space enthusiasts on this episode. Is that by accident?

Swapna Mylabathula [3:29] I think not.

Yagnesh Ladumor [3:30] I think there's some sample bias here.

Melissa Galati [3:32] Yeah. So, what are we talking about today? Why do you want to go to space, Swapna?

Swapna Mylabathula [3:37] Oh, my goodness. Okay, well, there's so many questions about human health and the wonders of space that we don't know, that we can answer and that are yet to be answered. But one specific reason why I would want to go to space or become an astronaut is to do a twin study, which you'll hear a lot more about a twin study that actually happened, but I want to do that with my twin sister. But I think we have some other astronaut hopefuls potentially around the table.

Melissa Galati [4:05] Why do you want to go to space, Thamiya?

Thamiya Vasanthakumar [4:09] Because it's really cool. Basically, I just want to be in like a microgravity environment and fly around in a space shuttle

Melissa Galati [4:18] And not do any work whatsoever?

Thamiya Vasanthakumar [4:19] I'll do work but yeah.

Swapna Mylabathula [4:21] You might have to.

Thamiya Vasanthakumar [4:23] I think that's like one of the requirements.

Melissa Galati [4:25] They don't train you for two years for nothing.

Swapna Mylabathula [4:28] For a joy ride, but you'll be happy doing it though.

Melissa Galati [4:32] And Yagnesh?

Yagnesh Ladumor [4:33] I just want to be Indian Neil Armstrong. But more seriously, I think doing research in space and in a new environment would be pretty cool. I'm sure they can use me there. So, call me.

Melissa Galati [4:48] Canadian Space Agency, you have three astronaut hopefuls here.

Swapna Mylabathula [4:51] And question for you Mel, why don't you want to go to space?

Melissa Galati [4:55] I think and some of the people who were word on the street victims said similar things, I think I have a lot of family and friends here and I just have no interest like exploring foreign lands when I already have a lot of foreign lands on earth to still explore. So before today everyone also I feel like I should announce to people I thought we had already gone to Mars. And yeah, this is how uninterested I am in space, I really thought the Martian was real and all of that stuff. I promise I'm a reasonably intelligent human being.

Swapna Mylabathula [5:28] We can corroborate that.

Melissa Galati [5:29] But yeah, I just think I have a lot of things that I would want to do on earth and I'm less interested in going to space but maybe it's because I just don't follow the space news as much as you guys do. Are we close to taking people to space? What's going on in the world?

Yagnesh Ladumor [5:42] Well, there's a lot of new private companies that are like reinvigorating this race to space. Recently, even Donald Trump has pledged $1.1 billion to NASA's budget to try and get America back to moon first, and then to Mars but I think SpaceX has really had a big impact on…

Melissa Galati [6:04] And what's SpaceX?

Yagnesh Ladumor [6:05] SpaceX is Elon Musk's, I don't want to call it startup but his venture and they've done some really, really cool stuff. So recently, one of their big successes has been reusable rockets. Once they deliver their payload, they can readjust their trajectory and then land back on specific places on earth so that removes a lot of the cost from launching people and things into space. So I think that's been a really big thing.

Thamiya Vasanthakumar [6:34] And so all of these new ventures means that more people will be going into space, and people will be going there for a much longer amount of time. And although there have been so many astronauts already, we don't really understand a lot about what happens to people, their bodies when they go out into space and what happens when they go out into space for a long period of time. So, today's episode we're talking a lot about space health and the effects on the body.

Swapna Mylabathula [6:58] Okay, are you guys ready to launch into this episode?

Thamiya Vasanthakumar [7:09] I'll ask you just to start off by introducing yourself, so your name and your current work.

Dr. Shane Journeay [7:13] Sure, my name is Shane Journeay. I'm a physician who specializes in both Physical Medicine and Rehabilitation and Occupational Medicine. I'm an Assistant Professor in the Department of Medicine at the University of Toronto and Director of Academics and Research at Providence Health Care, Unity Health, Toronto.

Swapna Mylabathula [7:31] In addition to being a physician, Shane holds two Master's degrees, one in Human Thermoregulation and Cardiovascular Physiology, and another in Occupational and Environmental Medicine. He holds a PhD in Toxicology and Nanotechnology and a diploma in Space Studies from the International Space University. Oh, and we almost forgot Shane was also an astronaut candidate in the 2017 selection round.

Thamiya Vasanthakumar [7:57] Okay, so and of course, today's episode is about space and space health and we know that you were an astronaut candidate for the 2017 selection. So, can you tell us a little bit about what inspired you to pursue that path of becoming an astronaut?

Dr. Shane Journeay [8:11] Sure. So most of my background, even going back to my undergraduate days have really been all around fascination with human health and performance, both physical endeavors and physical function, the science and the excitement of you know, exploration and pushing humans to new limits, I always found that incredible from the get go. And throughout my graduate training and medical training, sort of each experience I had kind of kept coming back to space. And then I had the opportunity to attend the International Space University, which is in France that basically pulled everything together, and looked at the interdisciplinary nature of space. And so, you know, it was always sort of a goal of mine, to be involved in some of the research that may benefit space. And as I progressed in medicine, the benefits to people here on Earth, but really, I felt like I could have done a very good job as an astronaut.

Swapna Mylabathula [9:09] So how has the training and experience in training to become a physician been applicable directly to your experience trying to become an astronaut through the astronaut candidacy?

Dr. Shane Journeay [9:20] So certainly from a human performance standpoint, both of my areas of medicine, Physical Medicine and Rehab, and Occupational Medicine, and that includes aerospace medicine and flight medicine, sort of all brought to the forefront the challenges that astronauts face, but certainly going through many years of medical training and research training, really position someone to potentially apply to become an astronaut or potentially fly in space. You need some physical attributes. You need stamina, you need to think under pressure with sick patients. You need to be a good communicator. All of which you get as a medical trainee in a residency program.

Swapna Mylabathula [10:05] And are there any particular physical or health requirements that are typically expected of an astronaut candidate?

Dr. Shane Journeay [10:13] Yes. So you have to be fit and extremely healthy. And that being said, you don't have to be an Olympic athlete either. So some of the preliminary medical screening is just simply do you meet the bare minimum to potentially go on and do other such testing in order to go in space. However, in the final phases, astronauts undergo very rigorous testing, some of which is even far beyond what is required of their occupation. And then of course, you have to be fit to fly. So if you, let's say, you pass through the astronaut training down in Houston, and you're now called an astronaut, and you're ready to fly, you're still monitored to see if you're ready to go, and then when you come back, you undergo spaceflight rehabilitation, which is near and dear to my heart. And then you have to be ready to fly once again. So you actually have to recuperate from your time in space in order to be fit to fly a second time. So there's lots of things that come together.

Thamiya Vasanthakumar [11:19] Can you speak a little bit more about that recuperation process? Like what is the rehab like and why do they need it?

Dr. Shane Journeay [11:25] So the human body in many ways was not meant to be in microgravity, right? The only thing our bodies know, you know, from the time we're in the womb till the time we're born is gravity. And so immediately upon entering microgravity, there's some very new changes. The vestibular system is really quite upset, people get nauseous and they throw up in space. But over prolonged periods, people can lose muscle mass, strength, bone density, there's a newer issue on the space station now that we've only seen with long duration flight, and that's vision loss. So a not insignificant number of astronauts have changes to their vision while on the space station. You're also isolated and you're exposed to more radiation than most people have ever known. So when they do come back, there's a preliminary phase. Some folks come back now and their blood pressure can drop so they can faint for the first few days, they can walk into walls. And there's actually a designated sort of rehabilitation program that occurs for them over the first few days first few weeks and first few months, which includes balance training, resistance training and cardiovascular training. The other piece to this is there's actually a really quite extraordinary piece of exercise equipment on the space station for both resistance training, and cardiovascular training and those exercise prescriptions are actually given out by exercise physiologist at NASA for each individual astronauts and so you'll see them, you know, on Twitter on NASA TV, they're running on that treadmill or doing the weight training, you know, the two hours a day sometimes and that is regimented. So if they stick to that, you know, some people were actually mitigating some of these effects on bone and muscle while they're on station. But it still doesn't change the fact they're a little dizzy and a little worn out from being on station for six months.

Swapna Mylabathula [13:32] Shane gave us an insider's look at the candidacy process to become an astronaut, and it involves a lot of steps and preparation to ensure that astronauts are well suited to the real thing: spaceflight. He also gave us some insights into the physiological effects of space on health. So we sat down with a former Canadian Space Agency astronaut Dave Williams to learn about what life's like in space. We also chat with Dave about his Canadian record for spacewalks. Applications of space science for robotics used in medicine here on Earth, and how being an astronaut is actually a lot like being a graduate student.

Dr. Dave Williams [14:26] Yes, that's correct. I was very lucky, had the chance to do three spacewalks, spending over 17 hours outside the space station helping build the space station.

Swapna Mylabathula [14:35] That's incredible. And growing up, there were no previous Canadian astronauts for you to look up to. So what inspired you to become an astronaut? And what did your path look like?

Dr. Dave Williams [14:45] You know, I think the most important thing I've learned is don't let other people define your dreams for you find what it is you want to do and just go for it. I was seven years old in 1961 and I watched Alan Shepard lift off to go into space thought that's what I want to do with my life, I want to be an astronaut and be a scientist and do research in outer space and I was told that was impossible. Fortunately, I didn't believe the people that told me that and took many years later, I was 38. And I applied to the Canadian Space Program in 1992 and was very lucky to be selected as an astronaut.

Swapna Mylabathula [15:17] And when you're up in space, how did your eating, sleeping and hygiene change?

Dr. Dave Williams [15:23] So there's a whole host of questions about how our bodies adapt to being in space, simple things like eating in space, and I wrote a series of kids books, focusing on STEM, and it's the Astro Dave MD series of books. The first one is called to burp or not to burp, and that one deals with all the eating questions of going to the bathroom questions and things like that. But eating in space is very much like it is on Earth, except we're eating essentially freeze-dried food - it's like camping food. After a while the food gets a little bit boring. And in the beginning of the mission, your taste isn't the same as it is normally, you feel like you've got a cold with all the volume shifts that take place and fluid coming from your lower extremities up into your chest and your face. Your face gets really really puffy, your nose is congested, and things just don't taste the same so everybody likes horseradish or spicy sauces like wasabi.

Swapna Mylabathula [16:13] Right, right. And I heard one of your fellow astronauts really loved Tabasco sauce in space.

Dr. Dave Williams [16:17] Tabasco sauce is very popular. There's no question about it.

Swapna Mylabathula [16:22] And how is sleeping different in space because you can't just lie down to sleep because of the microgravity.

Dr. Dave Williams [16:28] Well in microgravity, you can sleep in any orientation you want. We have something called a sleep restraint system that essentially looks like a sleeping bag. You can attach it to the wall, the ceiling, the floor, whatever orientation you want to be in. And essentially all you do is you close your eyes and you fall asleep. Your arms will float up in front of you and your legs. If they're not in a sleep restraint system, your legs will bend a little bit. And the fun part is just simply taking a nap so you don't actually climb into your sleeping bag, you just close your eyes and float around.

Swapna Mylabathula [16:58] That's amazing. Truly an experience we don't really get here on Earth. And how does hygiene change in space? You mentioned that you wrote about this in your Astro Dave MD books but just a little bit of detail for our listeners.

Dr. Dave Williams [17:11] Yeah, so hygiene, everything seems to take a little bit more time when you're in space. So, we don't have a shower, onboard the Space Station, we certainly don't have a shower on the Space Shuttle or anything like that so you have to take a towel bath. So, you wet a towel and you basically wipe yourself off with that, we have rinse less shampoo that we use in our hair so you can shampoo your hair and then basically towel everything off. And that works pretty well. If you're exercising, you'll notice that sweat pools on your body and that's kind of a bizarre sensation and things but then afterwards, you take your top off and you clean yourself well and it works out well. But hygiene in space is just as important as it is on the ground so making sure that we're able to stay clean is very important.

Swapna Mylabathula [17:55] Right, and what kind of precautions did you have to take before a flight in order to Make sure you stay healthy.

Dr. Dave Williams [18:02] We do have quarantine before we go into space and typically in the US program, the quarantine lasts a week. And we lift off from Kennedy Space Center in Florida so part of that week, we're actually in Houston for three or four days, and then we fly down to Kennedy Space Center and we stay in quarantine the whole time before the space flight to make sure we don't get sick. In the past in the air of the Apollo spaceflight program, they also stayed in quarantine after they came back because they weren't sure if there were any living organisms on the surface of the moon and they didn't want to potentially contaminate the earth. And of course, they found out that there weren't any in the subsequent Apollo missions. There was no quarantine after the crew members came back.

Swapna Mylabathula [18:43] How did they select the time period for a quarantine before going up, so the week long period?

Dr. Dave Williams [18:48] So basically, they select the time period to make sure that you don't have any viral infections or infectious diseases like that when you go into space. That's the biggest challenge of course, prior to implementing quarantine, we did have crew members lift off to go into space with a cold or runny nose. And it makes it very difficult to be able to do a spacewalk because you have to equalize the pressure in your middle ear when you're in a lower pressure environment to the spacesuit. So that can be particularly problematic.

Swapna Mylabathula [19:16] Right? And I imagine just even inside that would be problematic because you already have that pressure buildup where your fluid is held in your upper body. And so that would be more uncomfortable for anyone who has a cold.

Dr. Dave Williams [19:27] Yes, any pressure changes would become very difficult. And of course, on board the space station, the space shuttle, the atmospheric pressure is the same as it is on Earth. But back in the days Mercury, Gemini and Apollo, the atmospheric pressure inside the spacecraft was a lot less so if they had a cold or upper respiratory tract infection it would be a significant problem for them.

Swapna Mylabathula [19:47] Yikes. And what kind of health or physical changes did you personally experience while flying?

Dr. Dave Williams [19:54] You know when you're in space, you become de-conditioned and your muscles lose strength, your bone density decreases roughly at around 1.5 to 2% per month, I was only in space for a couple of weeks, 14 days and 16 days so I had relatively minimal changes in my bone density but you could certainly feel the changes that take place in your strength, and more so in your lower extremities when you come back to Earth and you notice just standing up seems to take a lot more strength than it did before you lifted off to go into space. And that's one of the reasons why we exercise when we're in space to try and prevent some of these changes from taking place.

Swapna Mylabathula [20:30] Right, and what did for you specifically, what did recovery look like when you got back to Earth?

Dr. Dave Williams [20:35] So, I was very fortunate I recovered fairly quickly and generally the time that it takes to recover is about one and a half to two times the mission duration. So you know, if you're in space for six months or so it's going to be nine months to a year that it'll take you to get totally back to normal and it's similar with a short duration crew member so if you're in space for a couple of weeks, it's going to be you know, two to three weeks, maybe a month or so for you to get back into shape.

Swapna Mylabathula [21:02] And you flew with Scott Kelly, who participated in the famous twin study that was recently published, did you take part in a lot of research projects when you were in space? And what were some of the tasks that you did? What were maybe some of the findings from those projects, and I know that you were part of Neurolab, STS-90, so maybe you can speak a little bit about that.

Dr. Dave Williams [21:23] On Neurolab, STS-90, I was essentially there as a neuroscientist, but also there as a research subject as well. So we were understanding how the brain adapted to being in space. We had baby rats that we took into space with us who went through the critical window of developing their walking behavior in the absence of gravity. And then the question would be when they came back to earth and had to relearn how to walk on Earth, would they be forever space rats, and whether walking would be abnormal, or would they be able to relearn how to walk on earth after they've gone through that critical window of development? So it turns out, they were able to learn to re-walk, which suggests that these critical windows of development in the nervous system may have a degree of plasticity to them, may not be as fixed as we thought they were in the beginning of things. And it's really remarkable being able to take those scientific results from space and bring them back here on Earth.

Swapna Mylabathula [22:17] That's pretty phenomenal. That's a really cool research study. And how do astronauts in general collaborate, you were saying that you were there as a research scientist and a subject but how do in general astronauts collaborate with research scientists to develop our understanding of the effects of space on the human body?

Dr. Dave Williams [22:33] There has to be a really close relationship between the astronauts and the researchers, primarily because we become graduate students for some of the best scientists in the world. So whether we're doing life science experiment, fluid physics experiments, whatever it might be, we actually have to make those experiments work in space, work with all the hardware, solve any problems that take place, and make sure that we're getting publishable data for the investigators. So it's pretty exciting being able to do that.

Swapna Mylabathula [23:02] And I like what you said about being kind of like a graduate student, because that's something that a lot of our listeners can relate to as graduate students ourselves.

Dr. Dave Williams [23:10] I think we all have fond memories of those days in graduate school.

Swapna Mylabathula [23:14]

Dr. Dave Williams [23:21] So there's many different reasons why space health research is critical. You know, you could start off by focusing on the technological issues associated with the challenges of medicine and what we're doing in space medicine and think about the evolution of technologies that have been built in support of the space program that are used every day in a hospital. Great example of that would be critical care monitoring, originally developed for the Apollo astronauts when they're walking on the surface of the moon, so we could record their heart rates but at the same time implemented in the 1960s in critical care units to be able to record and monitor electrocardiograph activity and then of course who evolved from there and you think about the application of big robots like the Canadarm to robotic surgery, and there have been tremendous spin offs. In fact, MacDonald Detweiler built neuroArm, it's a neurosurgical robot capable of being used with intraoperative MRI, a direct derivation of what we're doing on the space station, but essentially miniaturized. So part of the reason why we go to space is to be able to develop these technologies and improve health care back on Earth. But more importantly, we also begin to understand the changes that take place in the human body and spaceflight is all about physiologic transitions. You go from 1g on Earth, to 0g in space, and then if you're going to land on the moon or Mars, whatever it might be, there's a partial gravitational environment, then back to 0g coming back to earth and then back to 1g. So how do we optimize those? And I think what we learned from that is the importance of being able to mitigate things like bone loss and osteoporosis and if we can apply what we learn in space to the aging population, maybe we can decrease the rate of bone loss associated with aging. We understand the whole process of cardiovascular conditioning, vestibular dysfunction and vertigo and things. So, all of these lessons that we learn in terms of how the body functions in space are directly applicable to healthcare here on Earth.

Swapna Mylabathula [25:23] Those are some pretty cool applications for here on Earth and I loved hearing about how the Canadarm kind of inspired a miniature version for neurosurgery.

Yagnesh Ladumor [27:26] I think that's really interesting that they didn't find any long-term changes in Scott Kelly's immune system since there have been certain studies that looked at viral load in astronauts before and after flights. And they found that over 50% of the astronauts from shuttle flights have increased viral shedding of one or more herpes viruses in their saliva or urine. And this percentage is increased for astronauts on longer missions, like the ISS missions, suggesting there's a time component to this observation. The exact mechanism of how this happens is not known. But this just highlights how much more research is needed in the field because there's huge implications for long term space travel with immunocompromised individuals if this is the case.

Swapna Mylabathula [28:09] That's really interesting. And you're right, that really does point to the need for more research to better understand exactly how human health is impacted by exposures in space. And here closer to home, the Canadian Space Agency is also involved in examining some of these questions.

Melissa Galati [28:24] The Canadian Space Agency works with international collaborators on a number of research projects, including how spaceflight affects human health, we wanted to highlight the seven studies currently being conducted on health.

Swapna Mylabathula [28:37] The first is called TBone and nope, it's not about steaks in space. This study examines the effective microgravity on bone health. In space, 1.5% per month is lost compared to a typical 1% per year on Earth. Researchers are looking to understand how bone structure changes in space, how it reverses when astronauts return to Earth and how this can help doctors manage bone fractures that happen because of reduced bone density.

Melissa Galati [29:04] The second study is known as At Home in Space. This explores how astronauts adapt to life on the ISS considering the stresses of spaceflight, close quarters and even homesickness. Researchers are looking to understand how to create a space culture that incorporates the cultures and backgrounds of all the astronauts coming from all over the world. On Earth, this kind of research can help in situations where folks are isolated in remote settings, like in the military or in some research contexts, such as the polar regions.

Swapna Mylabathula [29:33] The third study examines the effects of spaceflight on cardiovascular health. Our cardiovascular systems are quite functional in gravity but when in microgravity, things get trickier. Researchers are assessing how the stresses of space affect the cardiovascular system and how that can be related to aging.

Melissa Galati [29:54] Spaceflight is not without its occupational hazards, this includes exposure to radiation. The fourth project that researchers are working on is to understand a major type of radiation, neutron radiation, which accounts for about a third of the radiation exposure in spaceflight. The study aims include measuring intensity to find relative safe spots on the ISS.

Swapna Mylabathula [30:12] Way finding is the focus of the fifth study, examining the effects of microgravity on spatial orientation. Visual proprioceptive and vestibular information is used by our brains to help us find our way in what we experience as normal gravity here on Earth. But this changes in microgravity and researchers are hoping to understand how to help astronauts adapt so they can optimally navigate on spacewalks and all around the International Space Station.

Melissa Galati [30:40] We sat down with two guests who are involved in the sixth and seventh research studies that the CSA is undertaking on vection and the immune status of astronauts in space. To learn more about the Vection project specifically we sat down with lead investigator of Vection Dr. Laurence Harris. Dr. Harris is a professor of Psychology, Kinesiology and Health Sciences and Biology at York University. But first, what is Vection?

Dr. Laurence Harris [31:05] Okay, so Vection refers to a project which is looking at our perception of self-motion. The term vection describes the sensation of self-motion, when you yourself are actually still but the world next to you is moving. You might have experienced this where you're in a car or in a train, and the train next to you or the truck next to you moves away and it gives you the sensation that you're in fact the one that's moving. So, it's part of our normal, everyday experience but it's unusual to have only visual cues. But when I move normally just forwards and backwards or whatever around the room, I'm receiving visual motion, as well as my other cues that tell me about it. And those cues are integrated in the normal way in a multi-sensory integration way and so they contribute to our perception of how we move around the world and how I know where the door is and how I know where you are and all that sort of thing as I change my relationship to you by moving around the room. So that's what we're actually looking at here, we're looking at how your perception of self-motion is influenced by the lack of gravity. So, in order to do that we are using visual cues in space and asking people about their perception of their self-motion. Now, in order to present those cues, what we're using is virtual reality. So, they're wearing an Oculus headset, so that we can control what they see visually and they're suspended in the middle of the module in a space module there so they don't bump into things because once you wear a helmet, you can't see anything and you're in danger of possibly bumping into things, which obviously, makes NASA very nervous. So we have to make sure that the people are safely held away from the walls of the spacecraft. It's also important from our science that they don't bump into things because that would give them other cues about whether they were moving and so forth. And so inside this Oculus inside the virtual reality display, we show them targets, they see a corridor stretching off into the distance and down that corridor there are various targets. And so they're asked to look at these targets one at a time and the target then disappears, and we move the corridor past them, that produces the vection sensation that they themselves are moving down the corridor. If you've ever played any video games, you know that this can be quite a compelling experience. And all they have to do is press a button when they get to the target. And that gives us an idea of how much optic flow, how much visual motion they need, in order to perceive that they've gone through a certain distance. And we do this at several different distances so we can actually end up calculating how their brain is using the visual motion to tell them about their physical motion. So that's one of the experiments that we're doing. A second one is an order to sort of understand the first one, because we're giving them targets at different distances. And then we're asking them to move to those targets. What if it's the perception of the distance that's incorrect, not their own movement, but the perception of the targets. So we have a second experiment in which we're trying to measure that. The third experiment is even more ambitious. The third experiment is looking at whether we can create visual gravity. What we do is we accelerate people down this corridor, and then suddenly everything goes blank. And they're asked to arrange the floor of the virtual world to indicate where they see the floor relative to where the floor was before they started. The idea being that if they interpret the visual acceleration as a new gravity, then that will be in an orthogonal direction to their where they were moving. And they should therefore see gravity as moving into that plane as well. And they'd have to tilt the floor to match that orientation. But that's, that's the third experiment. A little more ambitious than the other two rather exciting in terms of its possibilities.

Sina Hadipour [35:04] These are very innovative techniques to examine the perception of motion in microgravity. I know you've worked with astronauts just like David Saint-Jacques, who was the most recent Canadian astronaut to come back from the International Space Station, are you able to share some of the preliminary results that you've found with him?

Dr. Laurence Harris [35:19] Well, data from an n of one is always a controversial thing to do so I don't think I want to tell you anything about the actual results that we've found with this with one astronaut, but we are gradually collecting from a larger population, where we're going to have seven at least and we may be able to extend the project to cover even more astronauts later on. It's only then that will be able to make statistically sensible statements. So, I'm afraid I can't actually say anything at this point about the data.

Sina Hadipour [35:48] I see. Do you have a hard time convincing astronauts to participate in your experiments?

Dr. Laurence Harris [35:54] No, no, I don't. The way that this works is that we have to address each astronaut with a description of the project and so forth. On a couple of occasions, I've gone down to JSC, the Johnson Space Center, to talk directly to the astronauts about this and often we do it by video link. The astronauts get a detailed experimental explanation of what we're going to be doing for 15 minutes, a very tight 15 minute window that we're allowed to talk to them and to present the project. And then they may ask us some clarifying questions or something, and then they go away and eventually they decide either they're going to do the project or not to do the project and they'll sign the ethics accepting form accordingly. Our project is in competition with more physiologically based projects, such as involving blood samples, or bone samples, or I don't know exactly what but other sort of more biological and more invasive procedures. So, the idea of playing a video game in space in virtual reality is generally rather appealing, and so far we've had a very high success rate for the people signing up to do the experiment.

Yagnesh Ladumor [37:07] As we alluded to earlier, Vection is the sixth of a series of projects run by the CSA dedicated to health research. The final project examines the immune system. We sat down with Marieke de Korte, a graduate student in Dr. Chen Wang's lab, which is involved with ongoing CSA research on immunology.

Marieke de Korte [37:26] Previous studies have shown immune dysregulation as a result of spaceflight. This has been reported in many aspects such as T cell functioning, B cell functioning, different levels of inflammatory cytokines, things like that. So, these previous studies have typically taken blood samples before and after flight and then you know, some studies have also taken blood samples during flight as well but there's never been a platform on board of the International Space Station to analyze these results in real time. The samples that are taken during flight in the past have had to basically being transmitted back down to earth upon the astronauts return. So with that, I guess the two main goals of the immunoprofile project are that for one, it wants to establish the capacity for this blood analysis to take place on board of the International Space Station through a new piece of hardware called the bio analyzer, which I can talk a little bit about later. And then the second piece is, of course, to explore the dynamic changes in immune function throughout spaceflight.

Yagnesh Ladumor [38:33] I can see the utility in sort of tracking the immune function over time versus what happened with the twin study where they took samples before and after coming for sure. So, can you describe more about the bio analyzer equipment that you mentioned earlier?

Marieke de Korte [38:51] Absolutely. So essentially, it's a new piece of hardware that's been developed for this project, and it will allow for the capability to perform blood analysis on board of the International Space Station. So, essentially, it'll be able to track immune cell counts, as well as cytokines measurements to measure the overall immune status of the astronauts. As it stands now, the bio analyzer is still sort of in its development phase so the first iteration of the piece of hardware has been sent to the International Space Station and was actually tested by the Canadian astronaut David Saint-Jacques. There's a few tweaks that have to happen before it can be used in a research context but it's very exciting and we're hoping to get it up and running soon.

Melissa Galati [39:35] Marieke also gave us insight on her second project examining the effects of microgravity on specific immune compartments.

Marieke de Korte [39:43] So, I'll just give a brief background on the other project that I'm working on. So I'm conducting simulated microgravity experiments so that I can do some research on Earth as well but within the sphere of space medicine. Essentially what I'll be doing is subjecting natural killer cells to simulated microgravity to assess how that condition changes the cells in general and their functionality and things like that.

Yagnesh Ladumor [40:09] How do you induce certain microgravity environment?

Marieke de Korte [40:14] That's a great question. So, I have a piece of specialized equipment that does it for me and it's basically a rotary cell culture device. So, what it does is it rotates the cell culture on a horizontal axis, and essentially keeps the cells in a constant state of freefall so when the cells are rotating synchronously with the vessel, it basically induces randomization of the gravity vectors which essentially models microgravity. So, we're able to induce that condition that way and study its effects on Earth.

Yagnesh Ladumor [40:50] Oh, that sounds great. I was actually thinking of a completely ludicrous idea. I've heard of some microgravity experiments being done on parabolic flight path and I was just trying to wrap my head around how cell culture in that would work.

Marieke de Korte [41:04] Yeah, absolutely. You know, parabolic flight is definitely used as well. It's a little difficult for use in a biological context because when you're doing parabolic flight, you only get about 20 seconds of microgravity at a time so it's not really enough time to activate anything biologically relevant, unfortunately. But I know they do call them the vomit comet.

Yagnesh Ladumor [41:27] I also can't imagine trying to do tissue culture in microgravity.

Marieke de Korte [41:32] Oh, yeah. Right, like on one of those flights, that'd be pretty intense.

Yagnesh Ladumor [41:38] Where are the implications of your research on the health of the astronauts and what we can find out about it?

Marieke de Korte [41:44] What we're preparing for essentially our longer duration spaceflights. So you know, the world has committed to going back to the moon, as well as all the way to Mars so these are as you can imagine, longer duration spaceflight missions and you know we're kind of gearing up to troubleshoot what kind of health implications the astronauts could potentially experience as a result of these longer duration missions.

Swapna Mylabathula [42:10] All of this research in space couldn't be done without the tools developed in collaboration with the Canadian Space Agency, and other organizations to help with data collection in the unique environment of the International Space Station. What do these tools look like? You heard a little about the Oculus setup from Dr. Harris earlier. And next you'll hear from the CEO and co-founder of Hexoskin, a Montreal based company that develops intelligent textiles for wearable data collection systems for the continuous collection of a plethora of vital signs and general physiological information. Here we have with us Pierre-Alexandre Fournier, CEO and co-founder of Hexoskin, a company that's the developer and maker of intelligent textiles for improved access to physiological data, prevention, rehab, research and medicine. Thanks for joining us Pierre.

Pierre-Alexandre Fournier [43:04] Hello. Thanks for having me.

Swapna Mylabathula [43:05] We wanted to start with how did the idea of Hexoskin come to be and what exactly is Hexoskin?

Pierre-Alexandre Fournier [43:11] Well, when we founded Hexoskin, we were thinking about how it should look like to have AI health professionals take care of people with chronic disease and we realized that we needed inputs for that software AI, that would be used to take care of an aging population, people with chronic cardiac, chronic respiratory diseases. So, we understood that we have to solve the data problem. How do you build a system that can collect data, ideally passively from patients at home in real life situations so that you can feed the software that can help our health system, manage these populations efficiently and to improve outcomes and do it with the resources we have. So it's been a long journey but now we have a very stable system that can operate at a large scale that has been used by thousands of users in dozens of countries around the world for health research for taking care of people at home, with first responders, with astronauts, with athletes, by pharma companies and universities all around the world.

Swapna Mylabathula [44:19] That's incredible and you mentioned astronauts, and your company has recently launched Astroskin, an intelligent textile based product for use in space and space science. So tell us and tell our listeners what an intelligent textile actually is and why it's ideal for use in the application of space science.

Pierre-Alexandre Fournier [44:39] So in the case of Hexoskin and Astroskin, for example, we use conductive textiles, to create an interface with the skin that is flexible, soft, and that can conform to your body shape. We want these things to look like the things that we had before. But now we want these things to do jobs for us. And one of these jobs is help monitoring. So we want these shirts to be as much as possible, like the shirts people know, except that they accomplish this very important task of remote vital signs.

Swapna Mylabathula [45:13] That's great. So while wearing them, everyone, including these astronauts will still have full range of motion and they're able to do everything that they need to do.

Pierre-Alexandre Fournier [45:22] Well, yes and that's why we've been working with the Canadian Space Agency since 2011 and other space agencies like NASA, and Europeans on this. Basically, the astronaut's time is very valuable, so you cannot ask an astronaut to do a lot of tasks. They're running a lot of experiments in space and about half of these experiments are on themselves actually, about human health in space so we wanted to provide the astronauts a system that could do the job of vital signs monitoring without being in the way of the other tasks.

Swapna Mylabathula [45:55] That's fantastic and astronauts only spend so much time in space in each given mission and each year so it's really great that your technology is able to make space science more efficient so they can get more done in a given period of time. So I'm wondering, what role does Hexoskin play specifically today in the Canadian Space Agency research, Astroskin is based on the CSA's biomonitor. Can you tell us a bit more about that and the development of it?

Pierre-Alexandre Fournier [46:24] Yeah, so Astroskin is the sensing part. The biomonitor system is a complete space grade vital signs monitoring system, so it includes Astroskin but it also includes a space computer that we design to download that from the Astroskin to ground operations. So that's the whole system and with the Canadian Space Agency and NASA, what we're doing is we're studying physiology in space, but also before space missions and after space missions to better understand what is the effect of space travel in microgravity, especially on the human body, and that's for the ISS. We hope to collaborate also with private space companies that are going to be sending astronauts in space most probably starting next year to collect additional data and basically, we want to build the largest data set of vital science data in microgravity in the world so that can support these medical assistance for long term space missions.

Swapna Mylabathula [47:24] That's out of this world, that's really cool. What is the advantage by the way of using Astroskin and the bio monitor in data collection in microgravity rather than other types of devices that might be available today?

Pierre-Alexandre Fournier [47:35] I'd say it's setup time, you save on setup time. It's a system that people wear and forget. It's a complete vital signs monitoring system so we've designed the Astroskin to replace all the monitors you would have by in hospital bed. We can do a three channel ECG, we monitor breathing, temperature, PPG, SpO2, systolic blood pressure, movement so we have a complete view of human physiology.

Swapna Mylabathula [48:05] That's a pretty comprehensive panel of physiological data.

Pierre-Alexandre Fournier [48:07] Yes and it's all collected in one place so that's pretty unique. Most of the sensors that we've put on astronauts before collected only a subset of these vital signs.

Swapna Mylabathula [48:17] So you can wear this at all times, including sleep and exercise, whatever activity you're doing?

Pierre-Alexandre Fournier [48:22] Oh, yes, absolutely. So, they wear it during training, and the astronauts do a lot of exercise, they do typically two hours of exercise a day or more than two hours of exercise a day. That's just to try to preserve their muscle mass and bone and they're still losing a lot of it. And one of the main challenges for astronauts in the ISS is sleeping. The thing is, our sleep is regulated a lot by the amount of light and sunlight that we get here on earth. And the problem with the International Space Station is that it goes around the Earth 16 times a day.

Swapna Mylabathula [48:57] Wow.

Pierre-Alexandre Fournier [48:58] So you have 16 sunsets a day and basically you don't know what time it is. So when should you go to sleep? So it's a real challenge to keep a schedule. And one of the things that Astroskin allows to study is circadian rhythms. So how does your vital signs and hormones evolvedover a 24 hour cycle? And how is it affected by the conditions in the International Space Station?

Swapna Mylabathula [49:26] That's pretty cool that you can also get information about how spaceflight disrupts our circadian rhythms. How are these devices maintained in space? Or do they have to be maintained in space?

Pierre-Alexandre Fournier [49:36] It's a really, really good question because it's a huge part of taking the technology and making it space grade. So one of the things that we had to do with the Astro skin was that the we had to get rid of the lithium rechargeable batteries because it's not something that they're very comfortable with in the space station. They use some of these batteries in the space station, but because lithium is inflammable, and you have to do a lot of qualifications, we decided to go with normal double A batteries.

Swapna Mylabathula [50:10] Okay, so avoid that fire hazard.

Pierre-Alexandre Fournier [50:13] And another thing is clothing. So on Earth, if you buy Hexoskin or Astroskin shirts, you can wash them in the washing machine cold cycle. Very simple, very convenient. But they don't have a washing machine in the space station. But again it's like on Earth, what do they do with their smart shirts, they do the same thing that they do with the other shirts. They wear it for as long as possible without being uncomfortable and then they have to throw it away.

Swapna Mylabathula [50:43] Oh, so that's an insight on how laundry is done in space.

Pierre-Alexandre Fournier [50:46] Yes, yeah. But the nice thing about the Astroskin shirts and the Hexoskin shirts is that contrary to your normal t-shirt, they have this anti-bacterial, anti-odour treatment on them. So you can wear them for two weeks in a row and it's not going to smell. If you do that with a normal t shirt here, some of your friends are going to leave you.

Swapna Mylabathula [51:08] And you can't, there's not much place you can go in space.

Pierre-Alexandre Fournier [51:12] Yeah, the ISS is a little bit like camping. You know, let's imagine that you go camping in the VR, except that you don't really get out of the VR.

Swapna Mylabathula [51:24] Yeah, that's a great analogy. Anybody who's trying to train for space, go camping. And so what's next for Hexoskin in space science?

Pierre-Alexandre Fournier [51:34] So well, we're going to keep running experiments in the International Space Station with the various space agencies. The system is funded until at least 2023 and we hope to renew that funding after that. So we're going to be collecting a lot of data on a lot of astronauts, which is great. And well, we hope that we participate in future missions to the moon in 2024 and the Artemis missions and I mean, we're talking with NASA and CSA on a regular basis about how to prepare for these future missions to the moon and for the missions to Mars that will follow.

Swapna Mylabathula [52:10] Wow, so next up for Hexoskin might very well be the moon.

Pierre-Alexandre Fournier [52:14] Yes, we hope so.

Swapna Mylabathula [52:16] So now you know what space medicine and health research looks like on the International Space Station, and what Canadian collaborators are researching, as well as how they collect a lot of their data. But what does this have to do with all of us here back on Earth? Lots! Shane Journeay, Laurence Harris, Marieke de Korte, and Pierre-Alexandre Fournier talk about the many applications of space health research for us Earthlings.

Dr. Shane Journeay [52:43] Spaceflight is important for so many reasons, to inspire young Canadians in science and technology, for educational purposes but from a medical standpoint, which is near and dear to my heart is you know, there's a lot of things we can learn about the human body and about science on the space station and in microgravity, that affects all of us here on Earth. I work at a rehabilitation hospital, people who are aging, suffering from weakness and bone loss and I tell my patients every day, you know, you're all astronauts, you know, you've been in hospital or the intensive care unit for a month, you haven't walked in four weeks, and you have to recuperate from that. And so our understanding of how we lose bone, how we lose strength, how we lose balance can really make some gains in this area and so that's really paramount to what I do on a daily basis. There's many others telemedicine, isolation, the psychological impacts of space that are really still evolving as we stay in space longer.

Dr. Laurence Harris [53:49] Yes, there is a thesis around at the moment, that being in space is actually a good model for aging, the aging process. So for example, there's a loss of bones and challenges to the cardiovascular system and so forth. So, these changes are thought to possibly model or be useful to model effects of aging. Now on Earth, there are clinical situations where self-motion is not so easy. For example, in Parkinson's syndrome, they have problems with the shuffling movements and so forth, they're not clear about their movements and one of the big problems with Parkinson's patients is that they tend to be unstable and to fall over. So, understanding how the vestibular cues and the visual cues can adapt to each other and be malleable, will hopefully be very helpful for helping such patients on Earth. How it adapts in space may give us some clues about how we might be able to adapt it here on Earth.

Marieke de Korte [54:50] Even the technologies that are developed for space can be translated back down to earth as well. Even the bioanalyzer you know has been introduced as a piece of hardware that can be used in rural medicine in remote locations where, you know, they're they don't have huge access to different pieces of equipment that they might need.

Pierre-Alexandre Fournier [55:10] So, our products are used for remote patient monitoring of people with chronic respiratory diseases but what we found also is that people were buying our platform for other uses. Some of them are research projects from universities or clinical trials from pharma companies, and others are research on rare diseases. With rare diseases, in some cases you only have access to a few hundred patients and to run research and to collect data on these patients you need to recruit patients in maybe 15 different cities. So how do you manage data collection of vital signs in that kind of population that's very sparse, they're everywhere. It needs to be convenient. You want to record a lot of data. I think that's the beauty of it.

Melissa Galati [55:57] Finally, for all you astronaut hopeful or anyone needing a bit of inspiration to help reach some distant goal. We asked Dave Williams for some advice.

Swapna Mylabathula [56:05] And your journey to become an astronaut has been incredibly impressive and you probably learned a few lessons along the way. Can you tell us about a time that you failed and what you took from it?

Dr. Dave Williams [56:16] Yeah, I wrote about this in my book Defying Limits. And that was one of the reasons why I wrote the book. But more importantly, I wrote the book to share with everyone the importance of living life to the fullest while we can, because as a physician, I've seen many patients at the end of their lives with regrets and they say, I only wish I had spent more time with my family or spend more time with my kids, traveled more, or done things like that instead of working more. So that was one of the reasons why I wrote the book. But I also wanted to point out that sometimes life is not a linear journey, there's twists and turns and ups and downs and I actually don't believe that the importance of life is the pursuit of happiness. I believe that the most important thing in life is the pursuit of meaning. And I found that when I was 50 years old and I was diagnosed with cancer, I lost all my medical certifications as an astronaut and a pilot, I had to get it all back. And I flew in space on my second spaceflight as a cancer survivor but that journey wasn't easy. When I was first diagnosed, I actually thought I was going to die and I'm a doctor, I should probably know better. But we're humans first and that's the initial reaction when you hear catastrophic news like that. So it really is all about the journey. Don't let other people define your journey for you. Work hard, be resilient. Try and find the meaning and all the challenges that we face and life can truly be an amazing process.

Swapna Mylabathula [57:37] That's a pretty inspiring story. Thanks for sharing that. Can you tell us a little bit more about your book, you have now your paperback release of this best-selling book Defying Limits?

Dr. Dave Williams [57:47] Yes, well, thanks very much. I'm thrilled that it's now out in paperback and came out in hardcover but 11 months ago actually, and it initially became a best seller in Canada. I was absolutely thrilled that that happened and over the last year I'd been on speaking circuits talking about the book. And basically, the book does center around my life, but it also focuses on the lessons that I've learned throughout my career and the challenges that I've had in going forward and being able to achieve my dreams and fly in space. It speaks about the beauty of exploring space, and how incredible that really is to look out at the black infinite void of space and see our beautiful blue planet cast against this darkness of space.

Swapna Mylabathula [58:31] What advice would you have for anyone who's interested in going into space health research or becoming an astronaut themselves?

Dr. Dave Williams [58:37] So I think the important thing is to believe in yourself, believe in your dreams recognize that the probability certainly of becoming an astronaut is very small. It's a very competitive process so don't solely rely on becoming an astronaut. I think one of the things, it's for me very important as a love of science, a passion for scientific research. So I would have continued my career in research and as a researcher, had I not become an astronaut, it's just I was able to do both of those things but do it in space, which makes it even more exciting. But I think you know, it is important to have those dreams and to be able to pursue those dreams. I've said many times, don't let other people define your dreams for you and that's so critical. Also, don't think of things as being impossible. You know, when I was in first year as an undergraduate, which was in the last millennium, I was taught that it was impossible to map the human genome and now we're doing genomics onboard the International Space Station. So I think the use of the word impossible, we should probably actually get rid of that word out of our vocabulary. Take the letters, ‘im' out of the word impossible and try and aspire to make the impossible possible. And whether you're doing that in pursuing a career in aerospace studies or research or as an astronaut, or whether you're doing that as a clinician doesn't really matter. You know, if we believe that it's impossible to find a cure for cancer, we're not going to find a cure for cancer, if we believe it's possible, and I know how very difficult that would be and how challenging it would be, then it may very well be possible. But we can't find solutions if we believe that there are no solutions.

Swapna Mylabathula [1:00:17] That's some really excellent advice. We are very grateful for you coming out here to have this stellar conversation with us. Thank you so much.

Dr. Dave Williams [1:00:25] Thanks, my pleasure.

Swapna Mylabathula [1:00:27] Space has always been something that has fascinated humans but now we live in a time where there is increased innovation in the field that makes it possible to really expand the horizons of our thinking about the future of the species outside of the planet that we have evolved on. This comes with a lot of challenges and there are efforts ongoing around the world to identify these challenges and to solve them. We discussed what the future holds for this field and found out what research to look out for from the Canadian Space Agency. We really had a blast on this episode and we hope you enjoyed it too. Be sure to check out our next episode where we explore the science behind psychedelic drugs. This episode was hosted by myself Swapna Mylabathula, Yagnesh Ladumor, Thamiya Vasanthakumar, Melissa Galati and Sina Hadipour assisted with content creation and some of the interviews. Photography was done by Nathan Chan and Changmo Kim and Alex Jacob was the audio engineer. Very special thank you to our guests, astronaut Dr. Dave Williams, Dr. Laurence Harris, Pierre-Alexandre Fournier, Marieke de Korte and Dr. Shane Journeay for speaking to us and sharing all of their wonderful insights. We also thank all the people who spoke to us for the word on the street segment and of course, thank you for listening. Until next time, keep it raw.

Amber Mullin [1:01:55] Raw Talk podcast is a student presentation of the Institute of Medical Science and the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the Faculty of Medicine or the university. To learn more about the show, visit our website, rawtalkpodcast.com and stay up to date by following us on Twitter, Instagram and Facebook @RawTalkPodcast. Support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify, or wherever else you listen to podcasts and rate us five stars. Until next time, keep it raw.