I’ve seriously been meaning to write about this article for weeks. And I’ve wanted to discuss the topic actually since the Ebola outbreak started. Because who seriously doesn’t wonder about things like this.

[Oh wait, you don’t? Sorry, then, just me. Because I wonder about transmission risks of diseases on a daily (ok hourly) basis.]

So let’s cut to the chase: this is just my opinion of the article, as written. It’s may or may not reflect my personal or professional opinion on the actual, quantitative risk of Ebola transmission via commercial air travel. Why bother writing about it? Simply put, this is a good article in a high impact (read: well-respected) journal  that is worth a read by anyone interested.

On that note, did you know that most peer-reviewed articles are read by one or two people? And yes, that includes when you send an article to your parents so they can tell you that they are proud of your publication. Sometimes statistics are depressing. It’s also why you should always be encouraged when your articles are cited elsewhere.

And……I’m already off topic here. Moving on:

Why You Should Care

Planes are a great way for people to travel quickly from one continent to another. But they may also pose some level of risk for disease spread–as seen in the Ebola outbreak (which continues, though most of the world has stopped paying attention…Guinea, in particular, still has cases each week).

But How Risky Is Commercial Air?

The million dollar question, and one all policy makers wanted to know (like yesterday). To analyze the actual risk of transmission, the authors analyzed actual data of worldwide flight schedules, and travelers itineraries, to better understand how people move via commercial air travel from Guinea, Liberia, and Sierra Leone.

How Did they Assess Risk?

In order to better understand how likely commercial air flights are to transmit Ebola virus, the authors created a model with the data on travel itineraries, Ebola surveillance data, the efficiency of screening methods, and the impact of air travel restrictions that were implemented quickly when it became apparent the outbreak was out of control.

Important Limitations

The authors decided that all travelers originating from airports in these three countries, from any airport, could have Ebola (more specifically, exposure to Ebola); all other travelers were not to have any significant risk of exposure. Demographic data of air travelers were also not included in the study, nor was the purpose of the air travel including in the data sets. This information (e.g., traveling for business? visiting family?) could also impact these findings and recommendations.

Findings

Travel restrictions can have serious and detrimental effects on countries where they are imposed, both social and economic. As such, the authors suggest that exit screenings (upon leaving a country affected by Ebola) is the best way to both limit the risk of further transmission should an individual be infected but not yet detected, while also avoiding the more significant consequences of total or partial travel or flight bans to/from an affected country. They suggest that this method would be more effective than entry screening, particularly when entry screening is implemented at airports where there are no direct flights from affected countries.

Certainly this is easier said that done, as the authors do a good job of noting. Exit screening (and any screening or disease control measure, in reality) adds a “human” element. And while you can have quantitative or objective measures of things to look for (like temperature), people are a wild card. As history (and this Ebola outbreak) has demonstrated, people can make bad/uninformed/self-motivated/inadvertent decisions that have serious consequences for others when a disease is involved. Importantly, the authors carefully considered the number of travelers that would have to be screened to catch one infected person that remained asymptomatic at the time of the screening. But I think when you want something bad enough (e.g., to leave a country), if there is a will there usually is a way.

Conclusion

Overall, the authors stress the need for good information for policy makers, as well as a better understanding of the consequences of different policy choices: they argue that these pros and cons must be weighed by the international community collectively to respond to the outbreak in the most efficient way possible. But they also acknowledge that each country has exercised and will continue to exercise their own prerogative to make independent decisions on these issues.

Responding to Ebola is hard, and the answers aren’t so easy as “oh, the science tells you what to do.” If only they were.

Citation: Bogoch, I.I., Creatore, M.I., Cetron, M.S., Brownstein, J.S. et al. 2015. “Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 West African outbreak.” The Lancet. 385:29-35.

[Academia Meets Life is a TS’ series that presents useful/interesting articles published in peer-reviewed journals that are relevant to travel, in a easy-to-digest-quickly manner, in an effort to better connect academia/published articles to people who aren’t in that field of study .]

When we visited Uganda and Rwanda, I was a bit concerned about altitude sickness.

During gorilla treks, it is not unusual to start at around 6,000-7,000 feet and ascend to 9,000-10,000 feet (about 3,000 meters) before ascending back down. And it definitely had been a while since I had done anything strenuous at altitude. I grew up at about 6500 feet, but have been living at sea level or just above for nearly 15 years and can definitely tell the difference now. Fortunately all went fine, and my lack of problems in Uganda and Rwanda meant I was far less concerned when we headed to Bhutan, where passes can be that high or higher, and the Tiger’s Nest is at about 10,240 feet.

Sure, altitude sickness is a well known problem on high-altitude treks, like those in Nepal. But is it really that common in travelers visiting other higher altitude sights? While my doctor and I decided that preventative medication was not something I needed, how many people do take a prescription medication? [Disclaimer, as always, I am not a medical professional. Google is also not a licensed medical professional, much to all of our chagrin. Talk to your doctor for advice.]

So when I ran across this interesting article about acute mountain sickness (AMS) in Cusco, I was definitely interested and a bit surprised by what the authors found.

Is AMS really that common? The authors interviewed 991 travelers, of which nearly half (48.5%) reported AMS. That said, while they did use the common measure typically used to evaluate AMS, a lot of AMS symptoms are non-specific to AMS (i.e. headache, nausea, sleeping disturbances). I think all of us have experienced some of these symptoms while traveling! However, 17.1% of these travelers had severe AMS. This is a bit higher than I was expecting. About 20% of travelers with AMS did alter their travel plans.

So who was less at risk for AMS? Interestingly, people over 60 years old (I guess that’s one perk of aging!), and also those who came from other cities not at sea-level before going to Cusco. Unsurprisingly, those who had recent high altitude exposure also had fewer problems. So get older, spend more time at lower altitude cities, or at higher altitudes.

What about drugs? Only about a third of travelers talked to their physician about AMS, which seems about right considering how many travelers probably don’t see a physician who specializes in travel medicine these days. The authors report 16.6% used acetazolamide to prevent AMS (and travelers reported the acetazolamide did work). I’d be curious to know if those using the drug had previous problems and specifically requested a prescription…

And the myth of the coca leaf? Who hasn’t heard the tale that chewing on a coca leaf will make you feel better at altitude? I don’t know where this story came from, but I think it originally was something passed down from indigenous cultures…needless to say, the authors report that while nearly 63% of the travelers used coca leaf products, the use of coca leaf products was associated with increased AMS frequency.

Yes, you read that right, people that used coca leaf products had more AMS than those that didn’t. Now…let’s remember correlation does not equal causation. So coca leaf may or may not have caused those people to get AMS. It’s just a correlation. And in some ways, it makes a great deal of sense: those who feared getting AMS or had previously experienced AMS, tried coca leaf to alleviate their symptoms.

This article reminds us all to: talk to your doctor before heading to high elevations, especially if you have pre-existing conditions. If you don’t know how you will react to high altitude, give yourself some extra time at your location to find out and acclimate before climbing/hiking. AMS is extremely serious (and high altitude pulmonary edema is deadly), but there are mitigations and early treatment can help you get on your way and back to enjoying your travels.

Citation: Salazar, H., Swanson, J., Mozo, K., White, A.C., Cabada, M.M. 2012. “Acute Mountain Sickness Impact Among Travelers to Cusco, Peru.” Journal of Travel Medicine. 19(4): 220-225.

In this edition of Academia Meets Life, I cover an article which looks at the gaps in what we know about vaccine preventable diseases in travelers. While most–or maybe many–travelers go to their medical providers to receive appropriate vaccines before traveling, there are certainly those that either don’t or choose not to. But how to the providers decide what to recommend?

(In the United States, the Centers for Disease Control and Prevention [CDC] provide guidance based on similar criteria as those described here. This guidance is at the international level.]

This article specifically reviews how vaccine recommendations are made, and what gaps exist in the knowledge base used to make these recommendations. The authors focus on the absence of a current edition of the World Health’s Organization handbook for travel medicine, and what would be needed to create an evidence-based handbook in the future.

How recommendations are made: Randomized controlled trials, expert consensus, and estimates on disease (plus some guesswork, I think) are all involved in creating health guidelines for vaccines for travelers. Ideally, there is disease incidence information (rates of disease within a population) for both travelers and the native population.

What we don’t know: Unfortunately, there is rarely data between different types of travelers. I.e. those going for business, those visiting family, or those working or playing in high risk situations (i.e. health care environments). Because there are not data on these different groups, recommendations are typically far from individual.

What existing literature says: There are certainly studies focused on vaccine-preventable diseases in travelers. The authors focus on travelers from industrialized nations. However, the methods of data used to collect the information in travelers was incredibly varied–from voluntary reporting to anecdotal reporting. In other words, some of the methods of data collection, while better than nothing, are far from ideal. Moreover, the consistency within the literature on specific diseases is not so good. In other words, the existing evidence is spotty for most vaccine preventable diseases in travelers.

Part of the problem in tracking this type of information is travel, in and of itself.  Where you acquire a disease, where you get treated for that disease, and where you consider your location of permanent residence are often three different places. The systems to track this information often require voluntary reports–from you, from the treating provider. Reporting chains frequently are disconnected or break down.

What are the most common diseases in travelers? Well, this article claims travelers diarrhea, influenza, and Hepatitis A top the list (estimated at between 1-10 travelers per 10,000 in a month). But given that the data is pretty bad, I’m not totally certain how sure we should be about these rankings of disease risk, but nonetheless…. The next set of common diseases (estimated at between 1-10 travelers per 100,000 in a month) are Hep B, typhoid, rabies, tick-borne encephalitis, and tuberculosis. You’ll see “vaccine-preventable” is used loosely, as many of the diseases they discuss do not have licensed vaccines in the United States or have insufficient evidence regarding their efficacy.

For all you that have had the Yellow Fever vaccine, you’ll be interested to know this was in the very last category of risk (estimated <1 traveler per 100,000 in a month).

In sum: To no one’s surprise, the authors state that additional research is needed to better inform recommendations, including on traveler activities, seasonal impacts, and prevention of these diseases by non-vaccine measures.

My take: I think additional research is almost always needed on almost everything. The question is, how to get it done–in a reliable and valid way–that actually increases knowledge. And who pays for it. I’m guessing with disease rates this low, this is not a particularly high research priority, particularly given the myriad of other disease issues which deserve higher priority.  While it’s important to base recommendations on scientific evidence, sometimes you have to make recommendations on the best information available–not the information you wish was available. Hopefully a chat with a good travel medicine professional–coupled with a dose of common sense–can help us all make appropriate decisions about vaccines for travel.

ALSO hey give an example of “copious” washing of any bite with soap and water to prevent rabies…while this can help (the CDC agrees), I’d really suggest you follow the CDC guidelines for rabies rather than just relying on soap and water as the quick fix for a disease that is, for all intents and purposes, 100 percent fatal. Just saying.

Source: Steffen, R, Behrens RH, Hill DR, Greenaway C, & Leder, K. 2015. “Vaccine-Preventable Travel Health Risks: What Is the Evidence–What Are the Gaps?” Journal of Travel Medicine. 22(1): 1-12.

But even more than I love the color coordination, I loved going back through some of my favorite books and remembering how much I enjoyed them.  In light of heading to Kenya in a few months, I decided that I would highlight some of my favorite books about Africa, for anyone looking for a new read.

Beware, these aren’t all happy-go-lucky books. Not only is that not my style, but I don’t think listing only happy books about Africa is either accurate or appropriate. While all of the places I’ve visited in Africa are truly stunning, both in culture and landscape, the problems in many countries–whether corruption, politics, historical/colonial tensions, health issues, or other–deserve recognition.

1. Love, Life, and Elephants: An African Love Story by Dame Daphne Sheldrick. If you’ve ever wondered what it would be like to have have a pet dik-dik (and if you don’t know what it is, you need to google it, like NOW because they are ridiculously cute), this is a must read. It’s the life story of Dame Daphne Sheldrick, and it’s a fun–though at times heart-breaking–read.  She was the first person to successfully raise orphaned elephants. It’s a great story of the challenges of conservation in the bush (which continue) and life in east Africa.
2. When a Crocodile Eats the Sun by Peter Godwin. Peter Godwin has roots in Zimbabwe, and carefully traces Mugabe’s rise in coordination with his personal story after his father suffers a heart attack (and he ultimately returns to Africa). I think Peter tells the story of many of Zimbabwe’s white farmers during the Mugabe reign. Troubling and thought provoking, it’s a good read from an interesting perspective. Whether or not you agree with all of Peter’s sentiments regarding Zimbabwe and colonial history, there are certainly no winners (well…one winner…Mugabe) in Zimbabwe.
3. Dancing in the Glory of Monsters by Jason Stearns. There is absolutely nothing happy or go-lucky about this book. It details the Congo War, and not just the atrocities: Jason explains the nuances, personalities, and complex histories that shaped the war.  He also details the impact of the war on institutions, infrastructure, people, and culture in a manner that I found to be enthralling, though horrifying. If you are interested in the Congo, this book gives you past, present, and a look into the future from a remote village to the cities and high-level officials.
4. Blood River by Tim Butcher. What would this list be without a good story of adventure?! In 2004, Tim Butcher journeyed to the Congo to retrace the incredible 1874 journey of H.M. Stanley.  Forty days along the Congo river, Tim tells of allies, adversaries, corruption, war, atrocities–describing the Congo while also trying to work backwards to explain why it is the way it is today.
5. The Teeth May Smile But the Heart Does Not Forget by Andrew Rice. Most definitely one of my favorites, but yet another story of dictatorship, hardship, and death.  Andrew tells the story of Duncan Laki, who discovers new details about his father’s death (Eliphaz Laki). This ultimately leads him back to Idi Amin’s regime, at the highest levels. A detective story (who doesn’t love those), combined with Uganda’s history and the rise of Idi Amin, this story helps to shine light on the many that disappeared, and those they left behind.

Have any good suggestions for books about Africa? I’m always looking for new books!

If you’ve traveled, it’s likely you’ve seen children begging. Some beg for money, others for candy, toys, or whatever they are frequently given by travelers. For full disclosure, I typically choose not to give to people that beg, in my country or in others.

Some travel bloggers have written extensively about begging. I’m a fan of this piece on Uncornered Market,which I think is really thoughtful and thought provoking.  However, you’ll see by the comments that there are various opinions on the subject and lots of people who give to children (or adults for that matter) that beg.

The article that I’m reviewing caught my eye for a few reasons–as travelers, we frequently ask “what we should do”, but not as frequently at “what makes that child beg”. Sure, we assume they are poor, maybe orphans, could be forced to. I think often we are more focused on our reaction to the situation and not quite as focused on the specifics that they, the begging children are reacting to that put them in the situation.

Ballet et al. review the case of child begging in Madagascar. I was absolutely surprised to read, at least at the time of this article, that there were no statistics on child-begging and the topic is not really of interest in academic circles!

Specifically in Madagascar, many children were anecdotally noted to be begging for their parents–the authors wanted to find out if this was the case, and if so, why.  They interviewed 100 children; no begging child was older than 14. Of all the children, only 5 did not live with one or both parents. Each of these children were out of school to beg.

In terms of family, 93 children reported healthy parents, and only 23 mothers and 16 fathers were reported as “inactive”. Another 23 mothers were beggars (in comparison to only 2 fathers).

Here is where it gets interesting, though. In terms of begging activities, 58 children said they were forced to by their parents, another 42 percent said it was to eat. Seventeen children reported being beaten by their parents. The parents that take the money are usually the parents that force the children to beg, are often resorting to violence, and this typically happens to children younger than 8 years old. Alternatively, children 9-11 often beg to get money for food, and then use that money directly to eat.  The oldest children (11+), that typically earn the most, are usually those with at least one parent that is disabled or ill and they typically share the money with their family.

The authors conclude that “begging provides a means for poor households to exploit child labor”.  It is definitely clear that one size doesn’t fit all–there are distinct reasons why different ages of kids and family statuses are begging.  They (I think rightly) question the trajectory of child beggars, asking what happens to them, and how their begging behavior/family dynamics impact this path.

As with any research, there are limitations. I do think the authors may overstate their findings given their small and restricted study population that is also geographically isolated. However, given the dearth of the research on the issue, I can understand the wide generalization of their results and they do carefully acknowledge study limitations throughout the article. Additionally, research with  children is difficult–children often tell adults what they think they want to hear, which can skew research responses. Not saying that this happened here, but always a concern.

For travelers, I think this study reminds us–importantly–that we have no idea what’s going with most of these children. And we should never assume that we know; we should never assume we understand the problems. Some are truly exploited by their families, others are begging as a way to contribute to their family situation where a parent cannot. It’s certainly not something we can fix with the snap of our fingers. However, I do think begging is a really significant problem.  I strongly believe that if it wasn’t effective, it wouldn’t occur.

From an academic perspective, I wish there was more empirical research on the subject. It’s easy to say that we (travelers) should contribute to local non-profit organizations rather than an individual child, but fundamentally it is critical to understand why the child begs (and probably what this means for him/her later in life).  Yet it’s so hard to draw meaningful conclusions or identify cross-cutting themes with small samples in specific locations.

Citation: Ballet, J., Bhukuth, A., Rakotonirinjanahary, F., and Rakotonirinjanahary M. 2010. “Family Rationales behind Child Begging in Antananarivo.” Population. 65(4).

In this edition of Academia Meets Life, I’m reviewing an article about something that I think is in the back of every travelers mind. However, how we handle this information and knowledge varies dramatically from person to person and traveler to traveler.  I’m talking about perceived travel risks: what if something really bad happens when we are traveling?

This article assessed whether risk perceptions of traveling abroad impact decision-making. In particular, the authors were interested in assessing whether or not first-time and repeat travelers have different perceptions of risk, particularly after terrorist incidents and SARS.

Common sense would indicate that the answer to this question is “definitely”. Without a doubt, I think familiarity helps to reassure people and lower risk perceptions. As a species, we tend to gravitate to what we know. With travel, the first experience probably needs to be a good one: I’d hypothesize that if something bad happened to you–or you were inconvenienced by an event that occurred–that perceptions of risk will be higher.  Not to say that these individuals wouldn’t travel again to the same location, but they may change their behavior.

But we should never assume anything…so I think it’s appropriate the authors decide to do some actual, empirical research. Thailand is a good case, too, as it’s a very popular destination. They interviewed inbound tourists to Thailand and then also interviewed service providers in the hospitality industry. The first interviews were conducted during an outbreak of bird flu (more appropriately known as highly pathogenic avian influenza) and while terrorism was occurring in the southern provinces, but before the terrorism in Bangkok.

The authors–with qualitative and quantitative results–report that travelers cited SARS, bird flu, and terrorism as the top three reasons that they wouldn’t travel to Thailand. I think this is amusing, considering terrorism was ramping up in some regions of Thailand at the time and there was already bird flu there…and these travelers were already IN the country.  So clearly the travelers perceived these to be important risks–but they weren’t risks that changed their behavior. In large part, the authors suggest this is because they did not see the threat as relevant–it was in a different part of the country, infrequent, and they knew how to protect themselves from bird flu.

As expected, there were differences in how first-time travelers and repeat travelers perceived risks. In particular, first-time travelers perceived higher risks of disease than repeat travelers (i.e., they worry about getting sick way more than repeat travelers!). Repeat travelers perceived higher risks from increased costs or travel inconvenience (i.e. costs going up and/or being inconvenienced was a major concern for them and would be a reason they would avoid Thailand).  The two groups really didn’t view terrorism differently, which I thought was an interesting finding.

So how did this impact the tourism industry in Thailand? The authors used a qualitative approach and interviewed 15 tour operators/agencies. I wish they had done more quantitative analysis on this subject–as we all know that 15 tour operators/agencies are a drop in the ocean of those that exist in Thailand. Nonetheless, they do find that disease did have some impact–particularly on restaurants serving chicken, but terrorism did not have any impact until the bomb blasts in Bangkok.

From an academic perspective, I do think its important to discuss the generalizability of the article–in particular, the sample size of travelers (i.e. how many people were interviewed) was small, and most people were 20 to 39. I’m guessing this is pretty representative of the people that go to Thailand, but I would be careful about generalizing these results to “all” travelers or “all” destinations. And as mentioned, I thought the analysis on tour agencies/operators was incomplete: drawing conclusions from only 15 operators seems a bit premature, particularly barring any other quantitative analysis on occupancy rates, sales, and the like. I also worry that interviewees may have felt like they needed to say something worried them–i.e. terrorism or higher costs–in order to complete the survey, even if they didn’t actually feel that way.

Nonetheless, this research does confirm some of what I assumed: first time travelers and repeat travelers to a destination do not have the same perceptions of risk while traveling.  I’d be really interested to dig below the surface: what is the tipping point for experienced travelers? I.e. when are the risks (of higher costs, inconvenience, or disaster) too big to continue traveling to a destination? For inexperienced travelers, how do they gain information about risk, and what is the empirical evidence about how the source impacts the perception?

What do you think? How do risk perceptions factor into your travel decisions and destination selection?

Citation: Rittichainuwat BN & Chakraborty G. 2009. “Perceived travel risks regarding terrorism and disease: The case of Thailand.” Tourism Management. 30. 410-418.

So what is social tourism?
My understanding is that social tourism is a public policy to “facilitate access to tourism for groups who would otherwise be financially unable to participate in holidays”. Yup, that is straight from the article. Now I can imagine that many people are scratching their heads….Paying people who can’t afford to travel so they can go be a tourist somewhere? Whhaatttt?  This is institutionalized, government supported travel for those otherwise or typically excluded from travel opportunities.

Where does it exist?
Europe. Particularly, different programs (with varying levels of public and private participation, though they all have some level of public, government support) exist in France, Hungary, Spain, Portugal, and Belgium.

But it’s even more than that…
Many of these organizations not only help people take a holiday, they actually provide emotional support for “anxiety affecting the inexperienced tourists”. Yup. Not only is their financial uncertainty that worries the clients (because admittedly, most programs require some contribution from the individual as well), but also things like packing. Stop right there. Support organizations actually PACK for the travelers. Because, as one interviewee said, otherwise “they would forget to pack underwear” or “show[s] up with plastic bags”.

Who is the target population?
Interestingly, this article and research specifically discusses both the elderly and teenage mothers (who participated in travel between Belgium and the UK). The latter group has extremely high levels of uncertainty, which may cause them to refuse tourism participation even when money isn’t an issue.

Are there benefits?
Sure, for example, in Spain there is a program where senior citizens are subsidized to take domestic holidays to the coast on shoulder seasons. This means people in the coastal areas can continue working, benefiting hotels and other businesses. By subsidizing the elderly to take domestic holidays, the government is essentially injecting some money into a seasonal economy. This program is financed through beneficiary contributions (70%) and government (30%), but Spain estimates that the program helps to benefit or maintain about 80,000 jobs.

What do you think?
I’m sort of fascinated by this whole idea, since there is always lots of discussion over whether travel is a “luxury” good in the economy (using luxury in an economical-sense, here). The article states that such “social tourism” is not part of public policy in the United States, but has been undertaken by some private organizations.

The only thing that immediately comes to mind is potentially trips that veterans take to visit memorials (or even back to places like Vietnam), that may be subsidized by charitable organizations. There are also other programs for poor, suburban high school students to be able to take a first trip abroad, etc., which are mostly either done via fundraising or private charities.

But most definitely this is not institutionalized into government programs in the United States. Moreover, the uncertainty piece of this is very interesting…particularly for individuals in the United States. Would uncertainty and the unknowns of the “outside world” stop similar sub-populations in the United States from traveling abroad, even if they had the funding to do so? My strong contention would be YES.

What’s your opinion of institutionalized social tourism? Do you think that money is the only reason that non-travelers in the United States don’t travel?

Citation: Minnaert, L. 2014. “Social tourism participation: The role of tourism inexperience and uncertainty.” Tourism Management. 40: 282-289.