David R. Shlim
Travel medicine is based on the concept of the reduction of risk. In the context of travel medicine, “risk” refers to the possibility of harm during the course of a planned trip. Some risks may be avoidable, and others may not. Vaccine-preventable diseases may be mostly avoidable depending on the risk of the disease and the protective efficacy of the vaccine. The risk of malaria depends on the combination of the degree of local risk, behavior, efficacy of the prophylactic medication, and compliance by the traveler in taking the medication. Some risks are common but not life-threatening, such as travelers’ diarrhea, or rare but severe, such as Japanese encephalitis. Nondisease risks, such as motor vehicle accidents or drowning, account for a much higher percentage of deaths among travelers than infectious diseases.
For most travelers, the perception of risk colors their choice of destinations, activities, and health concerns. Travel medicine practitioners may know statistics for a given risk, but whether the risk is considered high or low depends on the perception of the traveler. For example, the risk of dying while trekking in Nepal was shown to be 15 of every 100,000 trekkers. Although that was an accurate figure for the risk, there is no objective way to determine whether this is a high risk or a low risk. When the manuscript on trekking deaths was reviewed by two peer reviewers prior to acceptance by the journal, the first reviewer wrote, “You need to emphasize that these data show how dangerous trekking actually is.” The second reviewer wrote, “You should make a point of stating that these data show how safe trekking is.”
The subjective sense of risk is based on one’s perception of risk (“15 per 100,000 means it’s dangerous”), and one’s tolerance for risk (“it may be 15 per 100,000, but it’s worth it”). This subjective sense of risk suffuses the field of travel medicine, from the practitioner to the traveler, but it is rarely discussed. Some travelers canceled travel plans to Asia due to their fear of H5N1 avian influenza, even though the actual risk to travelers had been almost zero. Other travelers plan to ascend Mt. Everest, even though the risk of dying during an Everest climb is 1 in 40.
Regardless of the perception and tolerance of risk, the hazards associated with travel cannot be eliminated, just as the risks of staying home are not zero. Even the act of trying to prevent a risk—such as the risk of yellow fever—can lead to a fatal reaction to the vaccine. Therefore, the goal in travel and in travel medicine should be the skillful management of risk, rather than trying to eliminate risk. The pre-travel visit is an opportunity to discuss risks and develop plans that minimize the risks, based on evaluation of risks versus benefits. Each traveler may have individual concepts about the risks and benefits of vaccines, prophylaxis, and behavior modification. A traveler who is told that there is a low risk of typhoid fever at the destination may choose not to have the typhoid vaccine, while another traveler may say, “I’m the kind of person who doesn’t like to take any risks, so I’d like the vaccine.”
Travelers should consider the psychological and emotional aspects of foreign travel. Culture shock can occur on either end of a journey: on arrival when one encounters an entirely strange new world, and on return when one’s own world may temporarily appear unfamiliar. Travelers with underlying psychiatric conditions should be cautious when heading out to a new environment that may prove stressful, particularly if they are traveling alone.
All travelers should contemplate the concept of commitment, which is a term to describe the fact that certain parts of a journey cannot easily be reversed. A person trekking into a remote area may have to realize that rescue, if available at all, may be delayed for days. A person who has a myocardial infarction in a country with no advanced cardiac services may have a difficult time getting to definitive medical care. If the traveler has already contemplated these concerns and accepted them, it is easier to deal with them in the remote chance that they actually come to pass.
Finally, travelers should be encouraged to travel with compassion. It is all too easy to fall into a pattern of blaming the destination country for frustrating inefficiency, shortages, delays, and corruption, without stopping to think that most of the local population have to live with these problems their whole lives.
The goal of travel medicine, apart from helping advise people with regard to travel-related risks should also be to help people match their interests, abilities, fitness, and sense of adventure with the right destination. Evaluating underlying illness and helping to guide a traveler to the right type of trip is also a key part of travel medicine. Travel is one of the main activities that helps break down the barriers between cultures and human beings around the world and enriches the lives of travelers. Despite the risks of travel, we should never lose sight of the benefits.
