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Chapter 2The Pre-Travel Consultation

Perspectives: Risks Travelers Face

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. Non-disease risks, such as motor vehicle accidents or drowning, account for a much higher percentage of deaths among travelers than infectious diseases.

For many years, travel medicine practitioners have felt that if they knew the statistics for a given risk, they could objectively advise travelers about that risk. However, it has become clear that the perception and tolerance of risk are subjective factors that must be considered when addressing risks of travel. Travel health providers may know statistics for a given risk, but whether the risk is considered high or low depends on the perception of the traveler or the travel medicine provider. For example, the risk of dying while trekking in Nepal is 15 deaths per 100,000 trekkers, but there is no objective way to determine whether this risk is high or low. When the manuscript that reported this risk of dying while trekking was peer-reviewed, one reviewer wrote, “You need to emphasize that these data show how dangerous trekking actually is.” The other 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, but it is rarely discussed. Some travelers canceled travel plans to Asia because of their fear of H5N1 avian influenza, even though the actual risk to travelers was virtually zero. Other travelers plan to ascend Mount 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 yellow fever—can lead to a fatal reaction to the vaccine in very rare cases. Therefore, the goal in travel and in travel medicine should be skillfully managing risk, rather than trying to eliminate risk. The pre-travel consultation is an opportunity to discuss risks and develop plans that minimize these risks. Each traveler may have individual concepts about the risks and benefits of vaccines, prophylaxis, and behavior modification.

Travelers should also 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 stressful new environment, particularly if they are traveling alone.

Travel medicine providers should promote the understanding of the concept of commitment, the idea that certain parts of a journey cannot easily be reversed. A person trekking into a remote area may need to accept 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 will be easier to deal with them if they come to pass.

Travel medicine practitioners should explore their own perception and tolerance of risk, so that they can help travelers find their individual comfort level when making decisions about destinations, activities, and prophylactic measures.

 
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