Astronauts aboard the International Space Station use a surprising number of medicines. The ISS has nearly 200 medications available, and the astronauts use an average of four drugs per week. Most commonly, these are analgesics (pain relief), decongestants, and sleep aids.

As I’ve gone into in my other post blabbing about space, the ISS has regular resupply missions throughout the year, and the astronauts aboard generally spend less than a year in space. Even a colony on one of our neighbors, like the Moon or Mars, would be exponentially more difficult to resupply. So, the more the colony can produce themselves, the better.

This is doubly important for a space station with no planet to resupply from.

We’ve gone over what the Consolidation of Iron has, but it bears repeating: 3 space stations, 2 spacecrafts, 257 people, and 2 moons covered in human blood. Plus any asteroids that are still bouncing around after the Quiet Rapture. What kinds of medications would a relatively small society need?

The World Health Organization has 667 medications on their list of Essential Medications. Of these, I am going to focus on four categories: preventative, curative, sanitation, and nutrition. I’m also going to operate under the assumption that the stations in the COI’s possession have some artificial gravity. This is particularly important, since zero-G or microgravity can affect drug absorption. Digestion slows in low gravity, and drugs enter the bloodstream at unpredictable rates. Drugs are rigorously tested for specific absorption rates, half-lives, and therapeutic thresholds, and their efficacy is based on that.

So what kind of ailments can you expect on a space station?

In zero gravity, astronauts are commonly afflicted by things like hypertension (high blood pressure), osteoporosis (brittle bones), nephrolithiasis (kidney stones), cancer, immune system depression, regular depression, sleep disorders, and motion sickness.

Some of these can be prevented, such as kidney stones, with improved diet and water intake, but in an environment of extreme scarcity, water isn’t exactly free flowing. Having gravity would also improve rates of osteoporosis. Cancer and immune system depression are directly related to the prevalence of gamma radiation. Ideally a space station would shield its population from the majority of radiation, but that takes a lot of resources that a PA may not have available. Depression is more complex, but anyone in the COI has more than enough reasons to be pretty depressed. It’s treatable, with reliable drugs like SSRIs (selective serotonin reuptake inhibitors.) Whether a post-apocalyptic governing body would find mental health drugs worth the trouble to manufacture and store depends on those in charge, but I would argue that citizens with treated and managed disorders are more likely to contribute to the continued survival of the group. Even if that makes me sound like some kind of capitalist. If the goal is to keep people alive, then the logical choice is to give them the tools to succeed.

Sleep disorders and motion sickness are particularly important in zero-G environments, because of the effects on our digestive and vestibular systems. As someone with Crohn’s disease, ask me how hard it is to sleep while nauseous. Anti-emetics and sedatives are versatile, and leads me to one of my favorite drug classes: antihistamines. She can do it all. Allergies, itching, anxiety, insomnia, depression, heartburn, nausea, dizziness. A few different antihistamines can cover a LOT of different conditions a space station citizen may encounter.

First-generation antihistamines are the ones generally used for sleeplessness. That’d be your Benadryl, Phenergan, Unisom, etc. There are way better meds for insomnia available, but if you’re talking about a limited amount of space, you want your supplies to be as versatile and useful as possible. First-gens cross the blood-brain barrier easily, so they are more likely to cause drowsiness. If you need to get to sleep quickly, or happen to have an anxious dog with allergies, good old diphenhidramine is your weapon of choice.

Second-generation antihistamines are more for allergies. They block the histamine receptors H1 or H2, and prevent the body from reacting to an allergen. This category would include loratadine (Claritin), cetirizine (Zyrtec), fexofenadine (Allegra), and drops/sprays like azelastine (Astelin.) Second-gen H2 antihistamines are also approved for use in gastric conditions, since the stomach lining has H2 receptors. For this, you’d reach for my best friend famotidine (Pepcid), or something like cimetidine (Tagamet.) There are third-generation antihistamines, such as levocetirizine (Xyzal), which block the H1 receptors more effectively and have fewer side effects than their predecessors. However, we want versatility, not necessarily specialization. Levocetirizine is great if all you’re treating is allergies or hives.

Meclizine (Dramamine) and hydroxyzine (Atarax or Vistaril, depending on the salt form) are first-generation antihistamines, with specific uses. Meclizine is used as an anti-emetic, and hydroxyzine can be used for many things: anxiety, insomnia, hives, itching, nausea, vomiting, even some symptoms of alcohol withdrawal. So our hypothetical medkit would definitely need a mix of first- and second-gen antihistamines.

With artificial gravity, antihypertensive meds would be a little less important. Some people would definitely still be predisposed to HTN, but without the effects of microgravity on the blood vessels (and being in a resource scarce, starvation situation) it would likely be less prevalent. We treat high blood pressure with ACE (angiotensin-coverting enzyme) inhibitors, ARBs (angiotensin II receptor blockers), and calcium-channel blockers.

ACE inhibitors are the -pril class, like lisinopril (zestril), enalapril (Vasotec), and benazepril (Lotensin.) These work by preventing the body from producing angiotensin II, a hormone that causes blood vessels to narrow.

ARBs are the -sartan medications, like losartan (Cozaar), olmesartan (Benicar), and valsartan (Diovan.) These prevent angiotensin II from binding to the receptors and relax the blood vessels.

Calcium-channel blockers prevent calcium from entering the muscle cells of the heart and arteries, and have two categories: dihydropyridines and non-dihydropyridines. The former (CCB D) target the blood vessel walls, and don’t significantly affect heart rate. These would be the -pines, like amlodipine (Norvasc.) The latter (CCB ND) affect the blood vessels and the heart. They slow heart rate and reduce the force of contractions. Examples of this class would be diltiazem (Cardizem, very annoying to prescribe and fill), and verapamil (Calan.) CCB D drugs are better for blood pressure, while CCB ND drugs can also be used for chest pain or arrhythmia.

Ideally, hypertension would be managed by reduced salt intake and improved diet, but an antihypertensive or two would be good to have. I’d probably use a calcium-channel blocker or a beta blocker (we’ll get to that) for versatility.

Mental health is a massive, sticky topic here on Earth. In a high-stress, low-resource, isolated environment like a space station? I wouldn’t be surprised if everyone aboard needed a therapist. Antidepressants, antipsychotics, antianxiety meds… a lot of these do treat multiple conditions. For a personal example, I take two antidepressants and a beta blocker. Sertraline (SSRI, Zoloft), bupropion (atypical antidepressant, Wellbutrin), and propranolol (beta blocker, Inderal.) All of these have multiple indications. Sertraline is the heavyweight champ, the first line of defense, for depression. If a doctor diagnoses you with depression, at least here in the US, chances are they’re gonna try sertraline first. It’s well tolerated with a relatively small side effect profile, at least compared to its cohorts, and it’s been extensively studied. It’s reliable. Like most antidepressants, it takes a few weeks (4-6 weeks) to reach full effect. Not only does this treat my depression, but it also improves anxiety, and helps chill out the OCD. Bupropion is a supporter. Atypical antidepressants work on different reuptake receptors, with bupropion specifically affecting norepinephrine and dopamine. It’s used for major depressive disorder, but also for things like seasonal affective disorder and smoking cessation. It can even be combined with naltrexone for weight management.

Propranolol is a beta blocker, or a beta-adrenergic blocking agent, and these work by blocking the binding of neurotransmitters to stress hormones like adrenaline, epinephrine, and norepinephrine. They lower the heart rate, relax the blood vessels, and can calm physical affects of anxiety like shaking. I use it for migraine prevention, but it’s also used for HTN, angina (chest pain), heart failure, atrial fibrillation, and even helps protect the heart after a heart attack. Cardioselective beta blockers, like metoprolol, are specifically for blocking the B1 receptor. These affect the cardiovascular system more than nonselective beta blockers. With many uses and a VERY small side effect profile (generally just dizziness due to lower heart rate or blood pressure, dry mouth/eyes, and fatigue), they are extremely useful.

The most important category of meds, I’d say, would be the curative. An infection on a space station is an easy way to die. Antibiotics are wide and varied, with many types, indications, and side effects. But let’s start with the grandfather of them all: Alexander Fleming’s penicillin.

Penicillin was the first biologic antibiotic. We had experimented with antimicrobial agents before, like Dr. Paul Ehrlich’s Salvarsan (arsphenamine), which was created in 1909 to treat syphilis. Before that, American Civil War field physicians used sugar paste, regular table sugar, to treat wounds. And this worked! It killed bacteria and improved wound healing. Honey is known to be extremely shelf-stable and antibacterial, and we still use it to treat burns. Penicillin is the first time we’ve used a mold to kill a bacteria.

The story goes that after returning from vacation, Dr. Fleming began sorting through petri dishes containing colonies of Staphylococcus bacteria. Each dish was dotted with colonies, but one dish had something unusual: a different organism, with a ring of blank agar around it. This is known as the zone of inhibition, and the organism responsible was the mold Penicillium notatum.

Fleming found that this mold seemed to be killing off the Staph around it, and after testing, it was effective in killing a lot of the harmful bugs of the era: gonorrhea, streptococcus, meningococcus, and diphtheria. Howard Florey, Ernst Chain, and their colleagues at the Sir William Dunn School of Pathology at Oxford would later purify penicillin into the very first antibiotic, which was first administered to the police officer Albert Alexander in 1943. Since then, we’ve synthesized hundreds of antibiotics, and penicillin remains a widely used, widely prescribed drug.

Penicillin is a Gram-positive affective antibiotic, meaning it targets bacteria that give a positive result in the Gram stain test. This is one of the quickest ways to determine therapy for a bacterial infection. Penicillin contains a beta-lactam ring, which binds to enzymes that cross-link murein (a mesh-like molecule that makes up the cell walls of many types of bacteria) and essentially pops the bacterium open. If you’re only going to take one antibiotic with you, I’d make it a penicillin. I’d also take something for Gram-negative bacteria, or a newer antibiotic like cephalexin. Maybe not fluoroquinolones. Fluoroquinolones are a last-resort sort of antibiotic, the -oxacin class. They are rough on the body, and have a lot of side effects. I mean, they can rupture your tendons. Not ideal. Penicillin isn’t without side effects, and it is the most reported antibiotic allergy. However, anywhere from 95% to 99% of reported penicillin allergies aren’t actually true allergies. Patients will often experience gastrointestinal side effects like diarrhea or vomiting (common among all antibiotics) and interpret that as an allergy. So it’s unlikely anyone on the station is going to experience anaphylaxis while their infected hand is being treated. There is another enemy penicillin has, though, one that has haunted us for decades: Methicillin-resistant Staphylococcus aureus, or MRSA. Overprescription of penicillins and poor antibiotic stewardship caused a strain of staph to become resistant to cillins, and if it gets aboard a space station, it’s going to be nearly impossible to get rid of.

Antibiotics, antihypertensives, antidepressants/antipsychotics, and sanitation like alcohol would be some of my top priorities if I were packing a medkit for a station. But there is another category: supportive. This would be your analgesics, your pain relief.

Pain relief comes in several forms: APAP (acetaminophen/paracetamol/Tylenol, also an antipyretic/fever reducer), NSAIDs (non-steroidal anti-inflammatory drugs, like ibuprofen), and opioids. Acetaminophen is appropriate for use in children (though so is morphine, pediatric dosing is complicated), and doubles as an effective fever reducer. NSAIDs can also reduce fever, depending on the cause. They target inflammation to reduce pain. Opioids block the sensation of pain altogether. Ideally you’d want a mix of all three types, as well as steroids like dexamethasone (Decadron.) Steroids suppress the immune system, reducing inflammation as a result. In a PA survival situation, you could probably use morphine as a currency. I’d put it as one of the most important drugs you could have on a station. Nothing stops someone from working like pain.

So we’ve gone over some common maladies for astronauts, as well as drugs I’d choose and how they work/some of their drawbacks. But how would they get them up there in the first place?

This is where my research got especially interesting.

There are two sources of drugs: natural and synthetic. I guess that’s pretty much the two ways you get anything, but I digress. Penicillin was naturally derived, and we still use two natural forms of it (Pen G and Pen V.) Sertraline, conversely, is synthetic. There are two ways you can get something in space: bring it with you, or make it yourself. We’ve theorized for ages about how we might manufacture drugs in space. Using a 3D printer to just print pills, or storing the raw ingredients and compounding them as necessary. But an article by Megan Tatum of the Pharmaceutical Journal brought up an even more clever scheme: genetically altering plants to produce the therapeutic chemicals needed. This concept is currently being studied in lettuce, which I think is a perfect candidate. Lettuce is relatively easy to grow, and tends to grow pretty quickly. We’ve already grown three types of lettuce in the ISS’s garden (affectionately known as Veggie.) Right now, this is a purely theoretical method, but I think it shows real promise. Pick the most common drugs you need and engineer quick-growing plants that produce the necessary chemicals. After that, it’s a matter of extracting and purifying the compounds to ensure therapeutic efficacy. But we know how to do that already! So many of our drugs come directly from plants: aspirin from willow, opium from poppies, digoxin from foxglove, and more. It wouldn’t be out of the realm of possibility for a far-future society to synthesize drugs directly from genetically modified plants. I haven’t really addressed Eden, but they could have an advantage in this department, considering they are/were in possession of the only tree left in the universe.

We’ve gone over supportive and curative, with a brief nod to sanitation (you can get a lot done with plain water and alcohol), so now it’s time to talk about preventatives, particularly nutrition.

What kind of nutrition do you need on a space station?

It’s rather similar to what we need on Earth, but with increased protein, calcium, and vitamin D demands.

[Source: Astronaut Nutritional Needs]

Even on our current station, you want to keep intake ALARA: as low as reasonably achievable. You want to keep people alive and healthy, but you don’t want to run out of food! The COI’s definition of “healthy” may be a lower threshold than we’re used to, closer to “able to work.” Their priorities would likely focus more on macronutrients and the bare minimum to keep people going. This comes with some HEAVY risks: scurvy (vitamin C), beriberi (vitamin B1), rickets (vitamin D), pellagra (vitamin B3), and others. These four are probably the most well known, as well as the most preventable. A diet of simple carbs and protein will keep someone alive for a while, but once their scars disintegrate and teeth fall out (scurvy), their heart fails and nerves die (beriberi), their bones soften or break (rickets, osteoporosis), and they start to lose their mind (dementia caused by pellagra), the cost of vitamins may not seem so high. All of these are horrible ways to die.

I brought this up in my other miles long post, but the blood moons do present a possible source of fat-soluble vitamins and protein: bone marrow. Calcium could be synthesized from bones, and the bones could also be used to make activated charcoal for water filtration or poison control. Since traditional active charcoal is made from things like wood or coconut husks, bone char (charcoal made from bone) is a great alternative.

Other than GMO lettuce, keeping the raw components of common drugs would be a fairly efficient method of producing medicine. Bulk components would be a better use of space than a 1000ct bottle of ibuprofen, especially since certain binders could be used across different drugs. Storage is also an issue, since drugs and their components are sensitive to temperature and humidity. The USP outlines that drugs should be kept between 20 C and 25 C (68 F to 77 F) and 40-60% humidity. Space stations are pretty cold, and very dry. Good to know I’ve got some job security in the future, because to compound drugs, you need a few things: recipes for the drugs you need, and someone who knows how to read and follow them. Plus some binders, suspensions, mortars, pestles, spatulas…

Compounding may be more feasible for the COI, since it wouldn’t be impossible for a member of the medic team to multiclass in pharmacy. The sourcing of the raw materials would be more difficult, however. It’d be easy to write it off as “future technology.” But let’s think about it in the basic building blocks: for example, sertraline’s chemical formula is C17H17Cl2N, and its medical form is sertraline hydrochloride, so that’d be C17H17Cl2N*HCl. So that is carbon, hydrogen, chlorine, and nitrogen. These base compounds are easier to source: carbon is easy to find, especially if you happen to have a couple blood moons knocking around. Hydrogen makes up 75% of the universe, so even after the QR, we should be able to find it somewhere. Nitrogen is the majority of our atmosphere, and chlorine floats around the universe, both as free chlorine and as hydrogen chloride, HCl. Once you find the ingredients, it’d be a matter of ramming them together. I’m not a microbiologist or a physicist, so this is where my knowledge on the subject ends. But that’s how I think a space station with no resupply missions would best find the compounds they need: break it down into base components, and look for those. You could apply this logic to pretty much any synthetic compound, and all you’d need to know is the chemical formula to follow. In theory, you could isolate the needed compound in this way, then put that into the GMO Lettuce, and then you have a renewable source.

It doesn’t have to be lettuce, either. There is one canonical plant in the world of Iron Lung, and with the idea of making plants grow drugs, well, the COI now has a concrete incentive for confiscating pendants from Eden captives. If you can extract them safely from the resin and encourage them to grow, you’d just have to introduce the compound you want them to make. Getting a fresh body to mine asteroids or throw into the blood ocean is a bonus. Or you could eat them. Cannibalism comes with its own risks, like prion disease, and it’s not a perfect solution, but I can’t deny that a human body is a viable source of protein and vitamins. Just cook it thoroughly and maybe avoid eating the brain.

"Hey, Doc—whoa!" The last thing Marty expected to see walking into Doc's garage was him holding up a gun.

Doc snapped toward Marty's direction at his entrance, now pointing the gun directly at Marty. A bright red light crossed Marty's vision and he squinted as he instinctively raised his hands up.

"Marty?" Doc called, putting the gun down as fast as he had shifted targets.

"Doc?" Marty responded, raising a brow, hands still in the air. Doc rushed over to his unintentional captor and grabbed Marty by the shoulders.

"You're just in time, Marty! I was just about to test out my new Shrink Ray!"

Marty blinked, still trying to get the spots out of his vision. "Shrink Ray?"

Doc jostled Marty excitedly, forcing the boy to grab onto Doc's biceps to keep his balance. "Yes, yes! Come see!"

Doc wrapped his arm around Marty's shoulders and urged him to the center of the garage, where Marty now saw what Doc was originally aiming at: an empty soup can resting atop several miscellaneous stacked items.

"I thought it was getting a little tight in here, so what better way to make space than make everything smaller? Observe." Doc raised his "Shrink Ray" once more and aimed it at the can. This close to it, Marty could see that the gun in question was actually just some kids toy, looking more like a weapon seen on Star Trek than Miami Vice. The only stand out details being the various colored wires wrapped all around the thing.

Once the red laser settled on the can, Doc fired and Marty jumped at the red ray of light that sent the can flying from it's position, followed by the metallic sound of it bouncing around the garage. Doc rushed over to it excitedly and let out a laugh that could only come from a crazed scientist as he picked it up. Holding the can up as high as Doc could, Marty saw that it had, in fact, shrunk.

"Whoa, Doc! That's crazy!" Marty exclaimed, running over to Doc to check out the shrinkified can up close.

"Crazy genius, I know!" Doc said, some smugness in his tone. "Now go back, quickly. The test isn't over yet!"

Doc placed the can back on it's spot and they both rushed back to their position. Doc leveled the gun at the can once more and when the laser landed on it, he fired again. The can was once again sent flying and this time the both of them made it over to the can before it had finished it's bouncing. Doc picked it up yet again only to reveal that it was the same size it had been originally.

"Doc, Doc this is incredible!" Marty said, running his hands through his hair excitedly. Doc tossed the can to him and Marty just barely caught, eyeing it down like it was a brand new guitar.

"Thank you, Marty! I'm rather pleased myself." Doc started, proceeding to fiddle with the Shrink Ray in his hands. "It was an easy little contraption to make. Each wire contributes to the altering of atoms to feasibly make the item in question react appropriately to the sudden change in the density of its matter! I just flip this switch here," he gestured to tiny little lever on the side of the gun, "and everything is appropriately powered to cause the shrink! Now, to get to the real issue at hand, cleaning!"

Marty tossed the can back and forth between his hands as Doc moved to rearrage the stack of items that held up the can previously. On his way over, Doc tripped.

Everything seemed to move in slow motion as Doc fell to the floor. The Shrink Ray flying from his hands. Marty to tossing the can to the ground to rush over to Doc and make sure he's okay. The Shrink Ray hitting the ground and Marty being briefly blinded by a flash of red light before a beam fired from the Ray, shooting past Doc's head and landing straight into Marty's chest.

Doc hit the floor at the same as hit Marty was flung back, hitting the couch in the middle of the room and knocking it on it's back as he made his landing. Doc, ignoring his bruised elbows, quickly gathered himself upwards and ran in the direction his friend went flying.

"Marty!" He yelped. "Marty, are you alright?!"

Doc heard Marty groan before he reached the other side of the upturned couch. Once on the other side, Doc saw…

Marty. Normal sized.

Doc was briefly stunned at the sight before he came back to himself and reached down to help Marty up. "Are you hurt? How do you feel?"

Marty let Doc raise him to a sitting position and leaned back into the hand against his back when he was upright. "I don't think so. I'm definitely gonna be sore tomorrow but I don't think anything's broken."

Doc gently moved the hand on Marty's back to the top of his head and brought up his other head to stretch Marty's eyes wide open. Marty blinked rapidly at the intrusion when Doc was done and before he could ask, Doc stated, "Pupils look alright, so you probably didn't hit your head. You sure you're alright?"

"Yeah, Doc, I'm sure," Marty responded, teenage sass etching into his tone.

The attitude seemed to reassure Doc and he ruffled Marty's hair before bringing his hand up to cup his chin. "Interesting that the Shrink Ray seemed to have no effect on you."

"I wouldn't say no effect," Marty muttered as he slowly began to stand. Doc jumped up much quicker than him.

"It must be size! The Shrink Ray works by shrinking something of regular size and reverting it back to it's regular size if shot a second time. But if something is already too small, yes, if something is too small for it's usual size then it must not be able to shrink it! Fascinating!"

Marty dusted himself off during Doc's musings but came to a stop as he processed some of what he said. "'Too small'? Wait, Doc, what you do you mean 'too small'?"

"Hold that thought, Marty! Maybe I should run some more tests before I start using it too much…" Doc walked off to where the Shrink Ray laid on the ground, muttering to himself all the while. Marty still stood in the same spot.