The hazard landscapeApr 4, 2014
Once voyagers make landfall they face a new set of health and safety challenges.
Ellen Massey Leonard
Travel by sail is a relentless exercise in situational awareness and risk management. Once in port and the vessel is safely squared away, the sailor can finally fully disconnect from their constant focus and attention and enjoy a needed cognitive and emotional rest. Or perhaps not.
The potential hazards at sea are formidable, but in a way they are a finite quantity. In port you may be additionally exposed to a whole range of subjective and objective hazards.
The first step when creating health, safety and security strategies is to understand the who, what, where and when of your travels. Who is your crew? What are their pre-existing health conditions? Are there youngsters or oldsters on board? Where are you going? If you are stopping in low and middle-income countries (LMIC: World Bank designation), the hazards are greater and the mitigating resources are fewer.
What are you intending to do when you visit a port? When are you going? If it’s the rainy season, road travel may be more hazardous and there may be more mosquitoes around, which matters if you are stopping in places with endemic dengue fever, malaria, etc. If it is high-tourist season, it is probably also high-crime season.
According to State Department data, motor vehicle accidents are a leading cause of injuries to Americans abroad.
Once you’ve figured out your travel plan, you can start to define the hazard landscape. Most of us don’t want to spend much of our psychic energy on unpleasant possibilities, so it makes sense to distinguish between likely and unlikely hazards. Data on U.S. traveler fatalities may help to inform the overall strategy. The U.S. State Department has compiled a database called Death of U.S. Citizens Abroad by Non-Natural Causes: travel901d.his.com/law/family_issues/death/death_600.html.
In the aggregate, the data shows that motor vehicle accidents are by far the most frequent reason Americans die abroad from non-disease causes. This includes pedestrian fatalities. A great resource for road safety is the Association for Safe International Road Travel: www.asirt.org. Their country specific road travel reports (RTRs) not only provide data, they provide a very accurate description of the national driving culture, they identify the most hazardous roads and give a rundown on what you need to know about public transportation.
The second cause cited on the list is homicide. Besides keeping your wits about you, especially in bars and on the way home from bars, it also suggests that you attend to the security of where you are sleeping be it a dockside berth or a hotel. If your street smarts are under-developed or rusty, there is a great book by Gavin de Becker: The Gift of Fear. It spells out some of the ploys that human predators employ to turn people into prey. Also, you should know something about the local crime landscape. Local crime specifics are hard to come by, but to get a national perspective you can become a member of the Overseas Security Advisory Council: www.osac.gov or just Google the destination country, plus “crime and safety report.”
Suicide is the third leading cause and drowning is fourth. After that comes other modes of transportation, fires, falls, poisonings, etc.
Medical training, like this Wilderness Advanced First Aid Course simulation in the Turks and Caicos Islands, can help voyagers deal with health situations ashore.
If you go to the U.S. State Department website, you can dial up a destination country and specify the year(s) for which you’d like the data. There is significant variability across destinations and it may be helpful to you as you formulate your strategies for avoiding becoming a victim of trauma.
Once you’ve assessed the potential trauma hazards, you can decide how you want to behave. If you are not culturally competent in your destination and/or if you’ve grown up in an OSHA-certified country where there is no such thing as an accident and where everyone who has the potential to be on the wrong end of a lawsuit works really hard to prevent accidents, you may wish to cultivate an appreciation that you may not understand how things work.
In your particular destination, does it makes sense for you to get behind the wheel of a car or to drive after dark? Where is it safe and where isn’t it safe for you to be walking after dark? Is there any reason to believe that the person you just met, who is working really hard to become your new best friend, really finds you fascinating? Does it make sense to bring a portable smoke detector with you? Ask locals where it is safe to swim. And don’t sit on the third-floor balcony railing. It might break. Keep your wits about you and don’t drink yourself silly.
Pathways of disease
There are a host of environmental concerns both at sea and in port: seasickness, getting too hot or too cold, sun exposure, etc. Travel medicine data shows us that cardiovascular disease is the number one overall cause of traveler fatalities. These hazards don’t change that much between being at sea or in port. At sea, infectious diseases are limited to whatever originally came on board (which could include MRSA and norovirus). When you go ashore, your exposures may increase significantly.
Vector-borne diseases: Even before you touch land you are vulnerable to mosquito transmitted diseases and once there, you may also be exposed to a whole host of diseases carried by various vectors: ticks, sand flies, tsetse flies, triatomine bugs, body lice, deer flies, etc. Your exposure may be minimal depending upon destination, time of year, quality of accommodations, etc., but you should be familiar with the full repertoire of vaccination (e.g. yellow fever, Japanese encephalitis), chemoprophylaxis (malaria), and behavioral aspects of protection, i.e., using bug dope (25-35 percent DEET), sleeping under chemically-treated mosquito nets and avoiding bars and cafes at prime feeding hours of some mosquito species (dawn and dusk).
Unlike voyagers, local people, such as these preparing food in Vanuatu, have had generations to acclimate to local conditions.
Food and water: Perhaps the most frequent ailment for travelers is travelers’ diarrhea (TD). Most TD is caused by bacterial contamination of food. For the past 50-plus years, travelers have been told to observe a number of precautions summed up by the old adage “cook it, boil it, peel it or forget it.” Not coincidently, the odds of getting TD in many countries have not improved in more than 50 years. Most of us eat out most of the time when traveling. We don’t have a kitchen per se. Certainly following the “rules” makes sense if you are doing your own cooking, but the number one intervention you can make is doing a good job in wisely choosing where you eat.
Airborne: Many of the airborne diseases are those that we are protected against by childhood/routine vaccinations, i.e., measles, mumps, rubella, pertussis, etc. However, many people have not had those vaccines due to their parents’ perception that the vaccines may be risky. You can get away with that as long as you stay in countries where everyone is vaccinated because there is “herd immunity.” You are not likely to be exposed to those diseases. However, if you do venture to LMICs, those diseases may be widely present in the general population and potentially devastating for you. Also, tuberculosis has become a significantly greater concern as more and more drug resistance strains appear around the world. Wash your hands frequently, and move away from anyone coughing.
Sexually transmitted and blood borne: You should know all you need to know about this from health class but be aware that studies show that there is an association between risk taking and travel. Be smart, keep your wits about you and don’t let alcohol make you stupid. And, if you haven’t had the Hepatitis B vaccine, consider getting it.
Zoonoses: As David Quammen points out in his excellent book Spillover, many of the diseases that we grapple with were or are zoonoses, i.e., infectious diseases transmitted between species. The most interesting consideration for travelers may be rabies. Rabies may be found just about everywhere outside of Antarctica. Some Australians claim that there is no rabies in Australia, but there is lyssovirus carried by bats, which kills in the same manner and for which the same preventative treatment measures and post-exposure treatment measures are effective, i.e., rabies by another name.
The question is whether or not to get pre-exposure prophylaxis series of three shots before you go. These should cost somewhere between $700 to $1,100, not including consultation fees, etc. Should you have an exposure, the post-treatment will require two additional shots the cost of which will vary widely. However, if you have not had the pre-exposure chemoprophylaxis, the post exposure treatment will entail five shots including human rabies immunoglobulin (HRIG) that can run more than $2,000 by itself, plus four shots of rabies vaccine.
In many LMICs, the rabies vaccine will be much cheaper, but it may also have been developed using a mammal brain substrate as opposed to human diploid cells or purified chick embryo cells. The cheaper versions are known to have significantly more side effects. Perhaps the most important consideration is that you may find that HRIG is not available. If you decide to forego the pre-exposure prophylaxis, be sure to sleep somewhere secure from rodents and bats and, most important, refrain from petting puppies or jogging where dogs might give chase.
Water and soil associated: Avoid swimming, wading and washing in fresh water in sub-Saharan Africa, a good portion of South America, the Middle East and Asia where schistosomiasis might be found. You might consider wearing shoes above the tide line wherever you see stray dogs (or any other mammals) to avoid leptospirosis and cutaneous larva migrans. While you might see locals swimming in such water or going barefoot, understand that they may have generations’ worth of acquiring resistance and immunity, and they may also have a significant incidence of the diseases.
Disease prevention strategies: Prior to departure, assess what your potential disease exposures may be. In the U.S. the Centers for Disease Control and Prevention (CDC) is usually the authoritative source for information on both destination epidemiology as well as recommendations for preventative measures. A good travel clinic is the best route for cobbling together your health strategy. Also, understand that other countries have recommendations that may be different from the CDC’s.
Vaccines are a critical part of the prevention repertoire. They become all the more important when traveling to LMICs. Travel vaccines are also very effective at protecting us from Hepatitis A and B, typhoid, rabies, Japanese encephalitis, yellow fever, etc.
Chemoprophylaxis is another important tool for prevention primarily for malaria, but also potentially for altitude sickness and travelers’ diarrhea.
Becoming ill is oftentimes a matter of balance, i.e., when the disease load overcomes your immune system. Getting sleep, staying hydrated, minimizing hangovers, jet lag, etc., helps you stay healthy.
A lot of what you may be doing for medical strategy at sea may serve you well in port. Getting training for you and your crew is highly recommended. The best available training for providing emergency medical care in remote locales is from the “wilderness” medical training providers.
Also, using some manner of telemedicine in combination with advanced medical kits, either from a professional service or an advisory doctor will be helpful for medical opportunities acquired ashore. A travel assistance service provider such as International SOS, FrontierMEDEX, HTH, CISI, etc., may also provide security information, medical oversight and evacuation and repatriation services or insurance.
Assessment of local medical facilities is often challenging. Your telemedicine or travel assistance provider may be able to help. Otherwise, you should determine what the capabilities are so that you’ll know where to go. What is the level of expertise? Are there doctors there? General practitioners or specialists? Do they have a lab? Do they have scanning capabilities?
A significant number of medical incidents that occur on voyages have their causes in ports. Sailors should give the same attention to port safety that they do for being at sea.
Bill Frederick is founder and director of Lodestone Safety International providing training and consulting to educational and service organizations operating overseas. Prior to that he served as director of safety at the School for Field Studies and as an instructor and program director at Outward Bound.