Urban Medicine: Threats to Health of Travelers
to Developing World Cities
Christopher Sanford
“. . . Lima, the strangest, saddest city thou can’st see.”
Herman Melville, Moby Dick, 1851
“[Cairo] is the metropolis of the universe, the
garden of the world.”
Ibn Khaldun, Arab historian, 1382
Historically, travel medicine providers have emphasized risks from infectious diseases. Most travel medicine
providers spend the bulk of their pretravel counseling
time discussing avoidance of vaccine-preventable diseases,
malaria, and travelers’ diarrhea. In a study of travel clinics around the world (57% of which were in the US, and
27% in Europe),whereas 99% of clinics usually gave advice
on malaria, 98% on insect avoidance, and 97% on travelers’ diarrhea, only 70% usually gave advice on “personal
safety”, and 70% regarding “environmental illness”.1 A
New Zealand study found that among 332 general practitioners, 100% addressed malaria and immunizations with
their pretravel patients, 97% addressed travelers’ diarrhea,
96% addressed insect avoidance, but only 47% addressed
“other areas”, which may or may not have included advice
on reducing risk from trauma, drowning, and cardiovascular causes.2
Although two studies have found that 2.4% to 3.6%
of deaths of international travelers are due to infectious
diseases,3,4 a larger study found that only 1% of deaths
of international travelers are due to this category of illness.5 A study looking at deaths of Americans who travel
to Mexico found that fewer than 1% of deaths were
due to infectious diseases.6 About half of all deaths of
international travelers were due to cardiovascular causes,
including myocardial infarction and cerebrovascular accidents; these occurred primarily in elderly travelers and
are only somewhat preventable by short-term intervention. The remainder of travelers’ deaths were due to causes
that mirror those found in developed countries: motor
vehicle crashes, drowning, falls from heights, and homicide.7 Steffen succinctly noted, “Excess mortality abroad
is mainly due to traffic and swimming accidents.”8
Each year, over 50 million travelers from industrialized nations visit the developing world.9 Whereas many
travelers and travel providers associate international travel
with rustic and sparsely peopled environments, an increasing proportion of travelers, including students and international business travelers (IBTs), spend most or all of their
time abroad in urban environments. Even tourists whose
final destinations are rural and remote must contend with
urban settings for at least portions of their trips. Tourists
who visit the game reserves of East Africa usually fly into
Nairobi, population 2.5 million; travelers to the beaches
of south Thailand usually transit through Bangkok, population 6 million; and trekkers to Machu Picchu, Peru,
usually fly into Lima, population 8 million. Travelers must
survive these urban environments if they are to reach their
more rustic final destinations.
During the 20th century the world population almost
quadrupled, from 1.7 billion in 1900 to 6 billion by 2000;
it is expected to increase by 3 billion more by 2050.10
Growth of urban centers is markedly more rapid than that
of rural areas; according to United Nations projections,
between 2000 and 2025 the world’s urban population is
expected to double, from 2.4 billion (in 1995) to 5 billion.11 The rate of urban growth in the developing world
almost strains credulity. In the six and a half decades
between 1931 and 1995, Lagos, Nigeria, grew from
126,000 to over 10 million inhabitants.12 This trend is
inevitable and irreversible;attempts to ruralize populations,
as with Mao Ze Dong’s China, and Pol Pot’s Cambodia,
have been at most temporary reversals.13
Currently, 97% of the world’s population growth is
in developing countries. Despite AIDS and widespread
malnutrition, the region of fastest growth is anticipated
Christopher Sanford, MD, DTM&H: Co-Director, Travel Clinic,
Hall Health Primary Care Center; Clinical Assistant Professor,
Department of Family Medicine, University of Washington,
Seattle.
This paper was presented at the 10th Update in Travel and
International Medicine, University of Washington, Seattle,
April 2003.
Christopher Sanford, MD, DTMH, Hall Health Primary Care
Center, University of Washington, Box 354410, Seattle, WA
98195-4410.
J Travel Med 2004; 11:313–327.
313
314
to be middle Africa, growing to 193% of its current size
by 2050. Among developed nations, only the US, which
has a relatively high birth rate for a developed country,
as well as steady immigration, shows robust growth.14
These trends—the overall increase in population,
almost all of which is occurring in the developing nations,
and the increasing urbanization—combine to yield
massive and rapid growth in cities. In almost all Latin
American countries, between one-quarter and one-third
of the population lives in a single city. Urban conglomerations with over 10 million inhabitants are termed megacities. In 1950, there was only one: New York. By 1995
there were 14, and in 2015 there will probably be 21; of
these, 16 will be in the developing world. Regarding this
proliferation of megacities, urbanists Peter Hall and Ulrich
Pfeiffer wrote, “Humanity has not been down this road
before. There are no precedents, no guideposts.”
This rapid growth has accentuated a number of
health problems of megacity inhabitants. Large peri-urban
slums—termed favelas in Brazil, bastis in India, pueblos
jovenes in Lima, and elsewhere slums and shantytowns—
ring megacities. Generally without basic services such as
water, electricity, and sewage, these neighborhoods are
ideal for the spread of most infectious diseases, including tuberculosis and those caused by intestinal parasites.
The inevitable ills of rapid urban developing world expansion, including poverty, crime, and pollution, could be
ameliorated to some extent by conscientious urban planning, but “many Third World countries lack such planning capacity altogether”.15
Despite the poverty of the shantytowns that make
up much of modern developing world metropolitan centers, the income of urban residents exceeds that of rural
residents.16 In Bangkok, for example, the average personal
income is about 2.5 times higher than that in the rest of
Thailand.17 Improved employment opportunity is the
most common motivation of those who move to urban
conglomerations. In a study performed in Nigeria, 94%
of respondents living in a high-density urban center said
that they moved from rural areas to the city in order to
find better jobs and increase their earnings.18 Marc Weiss,
chairman of the Prague Institute for Global Urban
Development, states: “Cities are the fundamental building blocks of prosperity, both for the nation and for
families.” However, this prosperity is very unevenly distributed. In the Philippines, the malnutrition rate is 3%;
in its capital city,Manila,it is three times this.19 Increasingly,
the middle class is moving to the suburbs, leaving only
the rich and the very poor in urban cores.
Travelers’ risks from specific threats are certainly
affected by the size of the towns in which they stay, but
the complex relationships between risk and level of urbanization are only beginning to be studied, described,
and elucidated. Western medicine has made impressive
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 11 , N u m b e r 5
progress in establishing links between particular infectious diseases, behaviors that place travelers at risk for those
diseases, and interventions during the pretravel encounter
to lower those risks. However, establishing the benefit of
interventions for noninfectious hazards, which comprise
the most significant threats to the urban traveler, remains
a virtually unexplored field.
The threats to the urban traveler are myriad; the eight
topics that will be addressed in this review are infectious
diseases, trauma, air pollution, heat illness, sexually transmitted diseases, crime, psychiatric illness, and recreational
drug use. Pretravel advice for travelers to developing world
cities is also presented.
Methods of Literature Review
Both PubMed and Google were used. The search
terms “developing world”, “developing nations”, “international” and “urban” were entered in combination with
each of the following terms and phrases: infectious disease, trauma, motor vehicle crashes, air pollution, heat illness, sex, sex tourism, prostitution, sexually transmitted
diseases, crime, psychiatric illness, and illicit drug use.
Infectious Disease
Morbidity is common in international travelers, with
up to 75% of travelers becoming ill during their time
abroad; these illnesses are most often self-limited episodes
of diarrhea or upper respiratory illness.20,21 Almost every
infectious disease for which travelers are at risk is transmitted in the urban setting. Indeed, it is easier to list infectious diseases that are not transmitted in cities than those
that are. Japanese encephalitis, bartonellosis, and Chagas’
disease are among those not commonly spread in cities;
however, these are not diseases frequently seen in travelers, regardless of destination.22 Yellow fever is not currently endemic in urban areas, but its urban vector, the
Aedes aegypti mosquito, is now present in urban areas of
the Americas, and there is concern that yellow fever could
“erupt in explosive outbreaks”.23
The vast majority of infectious diseases, including
all the more common ones that are transmitted to international travelers, including hepatitis A, tuberculosis (TB),
and travelers’ diarrhea, are vigorously transmitted in urban
regions. Urban malaria is widespread throughout Asia
and Africa.24 Many diseases, including meningococcal
meningitis, are particularly associated with crowded living
conditions. Zoonotic cutaneous leishmaniasis is expanding into many urban areas, including several cities in
Colombia and peri-urban foci in Venezuela.25 In the first
4 months of 2002, Brazil’s national health authorities
reported over 95,000 cases of dengue fever within the
Rio de Janeiro Municipality,including 571 cases of dengue
S a n f o r d , U r b a n M e d i c i n e : T h r e a t s t o Tr a v e l e r s t o D e v e l o p i n g Wo r l d C i t i e s
hemorrhagic fever, and 31 deaths.26 Dengue fever in
tourists is well documented.27,28
Threats from infectious diseases have been ably discussed in a number of publications.23,29 It should be noted
that the urban threats discussed below are not intended
to replace pretravel discussion regarding infectious diseases; rather, they are topics that should be discussed in
addition to traditional infectious disease-centered advice.
Trauma
Motor vehicle crashes are the most common cause
of death among young travelers. Travelers between the
ages of 15 and 44 years have a two- to-three-fold higher
rate of death in accidents as compared to the same age
group in developed nations.30 Males are more likely to
be involved in both fatal and nonfatal accidents.31 A study
of 309 Canadians who died abroad showed that 77 deaths
(24.9%) were due to accidents; motor vehicle crashes
formed the biggest subgroup within the accidental death
category.32 Accidental injury was by far the most common cause of illness and death reported for 801 visitors
to Jamaica’s northern coast during 1998–2000, causing
22.3% of illness and death; gastrointestinal disease (6.3%),
other disease (5.9%) and cardiovascular disease (4.4%) were
the next most frequent causes.33 Furthermore, tourists may
be more likely than indigenous populations to become
involved in motor vehicle crashes. In a study of tourists
to Bermuda, the rate of motorcycle injuries was found
to be 5.7-fold higher among tourists than among the local
population.34 A study at a regional hospital in Corfu,Greece
showed that among residents and Greek tourists, only 15%
of accidents were due to motor vehicle crashes, but among
foreign tourists, 40% of accidents were due to motor vehicle crashes.35
The amount of trauma attributable to driving on different sides of the road in different countries is not known,
but may be significant. In 1931, Winston Churchill visited New York City, looked right to check for traffic as
he stepped into a street, was struck by a taxi, and sustained
a scalp laceration down to the skull, and two fractured
ribs.36 In a study of nonfatal motor vehicle crashes in
Greece, travelers from left-side-driving countries were
more likely to be injured than those from right-sidedriving countries.37 In New Zealand, the failure to drive
on the left was found to be a significant factor in nonfatal motor vehicle crashes.38
Travel by motor vehicle is markedly more dangerous in the developing world.39,40 The rate of fatalities per
100 million vehicle kilometers in the US is 1.1; in Sri
Lanka and Turkey, the rates are 23 and 44, respectively.41
Deaths per 1 million vehicles during 1998 were 123
for Sweden, 125 for Britain, and 2,184 for Albania.42 Many
countries probably have higher rates still, but motor
315
vehicle crash-related mortality statistics are not collected
in much of the developing world. A study performed in
Ghana demonstrated that reports on fewer than 10% of
pedestrian injuries were collected and tallied.43 An estimated 1 million people die each year from traffic accidents, and 25 million are permanently disabled.44 Road
traffic injuries are predicted to rise by 2020 to become
the third most significant factor in the global burden of
disease.45 A recent article in the British Medical Journal
noted that the public policy response to this epidemic,
at both national and international levels,has been “muted”.46
The pattern of road traffic fatalities differs between
developed and developing countries. In the US, over 60%
of road crash fatalities occur among drivers; in the least
motorized countries, fewer than 10% of road crash fatalities occur among drivers.47,48 Most road traffic injuries
in developing countries occur in urban areas,where approximately 90% of road traffic fatalities occur among passengers, pedestrians and cyclists.49 Urban pedestrians alone
account for 55% to 70% of road traffic deaths. Among
children under the age of 4 years, and between 5 and 14
years, the rate of death from road traffic injuries in lowincome countries is six times that found in high-income
countries.44 Those who reside in these countries are often
aware of these risks. In Lagos, Nigeria, buses are known
as danfos, “flying coffins”, or molue, “moving morgues”.
A regular commuter on Lagos buses said, “Many of us
know most of the buses are death traps but since we can’t
afford the expensive taxi fares, we have no choice but to
use the buses.”50 The numbers of road traffic injuries and
fatalities are currently increasing in developing countries.51
In Vietnam, the numbers of motor vehicles, traffic injuries
and traffic fatalities increased between 2000 and 2001 by
14%, 16%, and 31%, respectively.52 In a recent review by
McInnes et al., none of the 24 studies investigating accidents in international travelers distinguished between
urban and rural levels of trauma.53
A study performed in Accra, the capital of Ghana,
investigated alcohol use among drivers.54 Of 722 drivers
who were selected randomly, 21% had a blood alcohol
concentration higher than 80 mg/dL, indicating impairment. This rate is significantly higher than the rates of
impaired drivers in the developed world, which range
from 0.4% in Denmark to 3.4% in France.55 Alarmingly,
3.7% of bus drivers and 8.0% of truck drivers in this Ghana
study had blood alcohol concentrations of 80 mg/dL or
greater.
Compounding this situation, there are no formal
emergency medical systems in most low-income countries. In Ghana, 70% of trauma patients travel to the hospital by taxi or bus, 22% travel by private vehicle, 5%
are brought by the police, and 3% travel by ambulance.
All the patients who arrived in ambulances were transfers from other hospitals, so no trauma patients were
316
brought to the hospital directly from the field by ambulance.56,57
Pretravel providers should counsel travelers to use
seat belts whenever possible, avoid riding in motor vehicles at night, and avoid renting mopeds or motorcycles.
If a traveler plans to rent a bicycle, moped, or motorcycle, they should pack appropriate helmets. Additionally,
wearing protective clothing while cycling or riding a
motorcycle is as wise while abroad as it is domestically.
A good rule of thumb is that if an activity is unwise
in the traveler’s native country (e.g., riding a motorcycle
without a helmet after a few drinks), it is, if anything,
more risky in the developing world.
Travelers do not see pretravel providers to hear about
seat belts and sobriety. Nonetheless, pretravel providers
should feel free to attempt to rearrange travelers’ priorities. When travelers state that their top priority is discussing a particular (often uncommon) infectious disease,
the pretravel provider can reply, “Good question, we’ll
get to that, first let’s discuss seat belts, helmets, and the
benefits of assigning a designated driver.” Additionally,
the benefits of obtaining medical and evacuation insurance prior to international travel should be discussed with
every traveler. The information that emergency medical
evacuation alone may cost $US 50,000–100,000 could
motivate travelers to obtain medical and evacuation insurance prior to travel.
Although many citizens of the developed nations
complain about lawyers, it is a fact that lawyers and their
not-infrequent litigation have led to a markedly safer environment within developed countries. Warning signs and
labels abound; restrictions are many. Indeed, many travelers to the developing world go there precisely because
there are fewer societal constraints. However, these less
structured and regulated settings—the unmarked precipice,
the unimpeded access to the roof of a bus—allow a rate
of trauma that far exceeds that found in developed nations.
Travelers need to remain cautious but not paranoid, optimistic yet realistic; they need to know that in many situations, such as crossing a busy city street as a pedestrian,
as Shlim said of high-altitude mountaineering,“A moment
of inattention could ruin your whole day.”58
Air Pollution
The first attempt to control air pollution occurred
in 1306, when England’s King Edward I banned the burning of coal in an effort to control the malodorous clouds
of coal smoke above London. The ban was not enforced,
and London became one of the first cities to suffer from
significant air pollution.59
It is not necessary to memorize which foreign cities
have significant air pollution; it is safe to state that virtually
all large cities in the developing world have significantly
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 11 , N u m b e r 5
polluted air. In 1992, Mexico City was deemed by the
World Health Organization to have the most polluted
air in the world. However, over recent years, through regulatory control, the air of Mexico City, while still heinous,
has significantly improved. Currently, China has the
unwelcome distinction of having nine of the 10 cities with
the worst air pollution in the world.
The developing world has no monopoly on polluted
air. In 1880, 2,200 Londoners were killed by a toxic smog
of coal smoke. The Meuse Valley Fog of 1930 killed over
60 people in Belgium.60 In 1948, 50 resident of Denora,
Pennsylvania were killed by a “killer fog”.61 In December
1952, the “Great Smog” of London brought the capital
to a standstill and caused an estimated 4,000 acute deaths;
an additional 8,600 excess deaths among Londoners
occurred during the first 3 months of 1953.62 The ongoing smog of Los Angeles is well known. However, the
air of urban centers in developed nations seems pristine and alpine when compared to that of large cities in
the developing world. For example, the levels of total suspended particulates in micrograms per cubic meter for
Stockholm, Mexico City and Lanzhou, China are 9, 279,
and 732, respectively. Levels of sulfur dioxide, which is
formed through the burning of fossil fuels such as oil
or gas, in micrograms per cubic meter, in Los Angeles,
California and Guiyang, China are 9 and 424, respectively.63 In Jakarta, Indonesia, due to most vehicles using
leaded gasoline, the level of lead in the atmosphere in 2000
was 1.3 g/m3; the World Health Organization’s recommended maximum is between 0.5 and 1.0 g/m3.64,65
In Bangkok, motorcycles are popular, as they can thread
through the ever-present traffic jams. Between 1993 and
2000,the number of registered motorcycles in the Bangkok
metropolitan region increased from 1.1 million to 2 million;66 future growth is projected to be 15%/year. Ninety
percent of these motorcycles have two-stroke engines,
which are the worst offenders with regard to suspended
particulate matter and hydrocarbon emissions.67 The numbers of vehicles in Asian urban areas have grown exponentially over the past two decades; in Delhi and Manila,
the number of vehicles has been doubling every 7 years.68
The United States Environmental Protection Agency
terms the six principal air pollutants “criteria pollutants”;
these are carbon monoxide, nitrogen dioxide, ground-level
ozone (not to be confused with “good ozone”, which
is in the stratosphere at 10 to 50 km above the earth),
particulate matter (airborne particles 10 m in diameter), sulfur dioxide, and lead. Some medical writers have
tried to compare the level of air pollution in a given city
with smoking a certain number of cigarettes per day, but
this is an inaccurate analogy; the pollutants and carcinogens are different.
Carbon monoxide is formed by the burning of fuels
such as gasoline, oil, and wood. Persons with pulmonary
S a n f o r d , U r b a n M e d i c i n e : T h r e a t s t o Tr a v e l e r s t o D e v e l o p i n g Wo r l d C i t i e s
and cardiac disease may develop dyspnea and angina at
carboxyhemoglobin (COHB) levels of 3% to 4%. Exercise
in a traffic tunnel will increase the COHB level to 5%
within 90 min.69 Elevated carbon monoxide levels have
been found to increase the rates of hospitalization of elderly patients with congestive heart failure.70
The effects of air pollution, specifically ozone and
particulate matter, on mortality and hospital admissions
due to respiratory and cardiopulmonary disease have been
found in both short-term studies, which have investigated
day-to-day variations of pollutants, and long-term studies, which have followed cohorts of urban residents over
some years. Effects have been found even at very low
levels of exposure; hence, it is unclear whether or not a
threshold value exists below which no effects on health
are noted.71
Air pollution does not have to be severe to impact
on children with asthma. In a French study, children with
mild-to-moderate asthma had measurable short-term
decrements in pulmonary function tests that correlated
with prevailing levels of photo-oxidant and particulate
pollution, even though the levels of these pollutants were
within those specified by international air standards.72
Air polluted with particulate matter causes increased
serum concentrations of fibrinogen and platelets, with
sequestration of red blood cells in the lungs.73 Particulate
matter also increases the risk of cardiac arrhythmias,74 but
the significance of these changes for cardiovascular events
remains unclear.75
Multiple studies have linked air pollution to increased
mortality.76 A restriction that reduced the sulfur content
of fuel oil utilized by power plants and road vehicles in
Hong Kong led to a substantial reduction in deaths from
all causes, from respiratory diseases, and from cardiovascular
diseases.77 Long-term exposure to fine particulate air
pollution causes increased cardiopulmonary morbidity,
including lung cancer.78 A study of the 1997 “haze disaster” in Indonesia found that over 90% of 543 people
interviewed had respiratory symptoms. The elderly, and
those with a history of asthma, had increased symptoms;
wearing a mask correlated with lessened symptoms.79
Ozone is produced by the effect of sunlight on volatile
organic compounds or oxides of nitrogen. In a study of
children who performed in outdoor team sports in 12
communities in southern California with varying levels
of pollution, ozone was the pollutant most strongly associated with the development of asthma.80 Ozone triggers inflammation, and animal studies suggest that it causes
increased susceptibility to bacterial infection. Great variability among individuals exists regarding the response
to ozone, with a minority demonstrating significant
responses at only moderate levels. An individual’s sensitivity to ozone appears to have a genetic basis.81 For
each 50 parts per billion increase in peak ozone levels,
317
hospitalization rates increase by 6% to 10% for asthma,
pneumonia, and chronic obstructive pulmonary disease
(COPD). Children living in Santiago, Chile were found
to have increases in lower respiratory tract illnesses in direct
proportion to the levels of particulate matter and ozone.82
For children 3 to 15 years of age, the increase in lower
respiratory tract symptoms is 3% to 9% for a 50 g/m3
change in particulate matter, and 5% for a 50 parts per
billion change in ozone.Intriguingly,the use of antioxidant
vitamin supplementation has been found to markedly
reduce the ozone-induced reduction in pulmonary function in young, healthy, nonsmoking adults.83
A study performed in India found that urban
children had a higher level of exercise-induced
bronchospasm than did children living in rural areas.84
A recent study performed in southern California, US,
found that associations between severity of air pollution
and asthma were stronger in asthmatic children not taking anti-inflammatories (inhaled cromolyn, nedocromil
sodium, or corticosteroids) than in children who were.85
A Denver (Colorado, US) study found strong
associations between rates of childhood cancers and
leukemia, and distance of residence from streets with a
high density of motor vehicles. In the highest traffic density category, that of close proximity to roads with more
than 20,000 vehicles/day, the odds ratio for all cancers
was 5.90, and that for leukemia was 8.28.86 In Amsterdam,
a much higher relative risk of death was found in individuals who lived on main roads,as compared to those who
lived away from main roads.87
Recent epidemiological research indicates that the
effects of air pollution on life-expectancy are not uniformly
distributed throughout populations, but are influenced
by factors including education level and antioxidant vitamin status.80,88,89 During an exacerbation of air pollution in Augsburg, Germany in 1985, increases were noted
in residents’ heart rate, plasma viscosity, and C-reactive
protein, all of which can contribute to an increased risk
of cardiovascular events.90–92
Given that air pollution has been found to affect residents’ health in both short-term and long-term studies,
there is no reason to think that travelers are not impacted
by it. However, the nature and extent of the risk are yet
to be determined.
What does this mean for the travel provider? Patients
with COPD should travel with a “rescue cocktail” of
three drugs for use during exacerbations: an additional
bronchodilator, an oral steroid, and an appropriate antibiotic. Patients with asthma, particularly those with a history of exacerbation in response to air pollution, should
carry an additional inhaler and an oral steroid. Antioxidant
vitamins may reduce the decrement in pulmonary function of travelers to cities with severe air pollution,82 but
controlled studies are lacking. Placing asthmatic children
318
on an anti-inflammatory medication, e.g., montelukast
sodium (Singulair), just prior to and during their stay in
a heavily polluted region would be reasonable and possibly of benefit. For elderly travelers, a pretravel physical
examination with stress treadmill and pulmonary function tests may be useful in screening for cardiovascular and
pulmonary disease.93 Certainly, travelers with cardiac or
pulmonary disease should have these conditions adequately
controlled prior to departure.
It is reasonable to assume that long-term visitors to
heavily polluted cities will develop many of the same
sequelae as do residents. The effects of air pollution on
the short-term traveler have not been studied; anecdotally, many develop eye and respiratory irritation. Travelers
with pulmonary or cardiac disease should be advised to
minimize their duration of stay in heavily polluted cities,
to avoid heavy exercise while residing therein, and to have
a low threshold for seeking medical care should they
become dyspneic or develop chest pain. The International
Association for Medical Aid to Travelers (IAMAT),founded
in 1960, is a Canadian-based nonprofit organization that
offers a list of IAMAT-affiliated physicians around the
world, all of whom speak English and have trained in
North America or Europe.94 Consideration should be
given to writing prescriptions for “rescue” medications
for patients with COPD or asthma, including an oral
steroid, an appropriate antibiotic and an additional
bronchodilator as standby medications for exacerbation.
Heat Illness
Like mountains, cities are capable of creating their
own weather. Asphalt and concrete absorb light and then
reradiate it as infrared radiation, raising the temperature
of the air; this is termed the “urban heat island effect”.
Often, huge domes of hot air sit above big cities, making them several degrees warmer than surrounding rural
areas.95 Many cities are 1°C to 6°C warmer than surrounding rural areas; this urban–rural temperature difference is greatest at night. Plants, particularly trees, give
out large amounts of water from their leaves, and the evaporation of this water absorbs significant heat; thus urban
heat is compounded both by the presence of asphalt and
concrete surfaces,and the absence of vegetation.For example, the population of the Phoenix valley (Arizona, US)
grew by over 10-fold, from 150,000 residents to 1.8 million, between 1944 and 1984; during this period, its average summertime lows rose by 4°C, from 22.8°C to almost
27°C.96
Every year there are approximately 400 deaths in
the US that are attributed to excessive heat.97 A heat wave
in July 1995 resulted in 485 heat-related deaths.98 Multiple
studies have shown that the elderly, particularly women,
and the mentally ill are at increased risk for serious
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 11 , N u m b e r 5
heat illness, including heat exhaustion, heat stroke, and
death.99,100 The heightened susceptibility of the elderly is due to dysfunctional thermoregulatory mechanisms,
chronic dehydration, medications, and diseases involving the systems that regulate body temperature.101 Additionally, some individuals may be genetically predisposed
to a higher risk of exertional heat illness and malignant
hyperthermia.102 Many drugs, including phenothiazines,
anticholinergics, diuretics, beta-blockers, and alcohol, can
impair thermoregulation.103 These work via different
mechanisms (e.g., anticholinergics by limiting the ability to sweat, alcohol by diuresis), but the net result is an
increased risk of heat illness.
While an individual is at rest in a neutral environment,
their temperature variation is minimal: about 0.3°C
diurnal change.This increases to 2.0°C in more extreme
temperatures with physical exercise. Sweating facilitates
the loss of body heat, with a loss of 670 W/L of sweat
evaporated. In humid conditions, when sweat drips from
the body but does not evaporate, this mechanism does
not lead to heat loss, but only to loss of fluid.104
Over 230 years ago, the Scottish physician James Lind
wrote that habituation to hot climates leads to a lessened
risk to health;105 this has been borne out by modern
research. In a hot climate, core body temperature and heart
rate become less elevated,and the ability to sweat increases.
The concentration of salt in sweat drops from 3 g/L in
those who are not heat acclimatized to 1 g/L in those
who are. These changes occur rapidly over the first 3 to
4 days of residence in a hot climate, and are almost complete by 9 to 10 days.106 Partial acclimatization can be
achieved by vigorous exercise in cool environments.107
Staying in airconditioned rooms prevents heat acclimatization and hence may increase the risk of heat illness
when the traveler goes outdoors.
A Spanish study that investigated heat waves in
Madrid between 1986 and 1997 found that mortality
increased by 28% for every degree Celsius by which the
temperature rose above 36.5°C; women above 75 years
of age were most heavily affected.108 Another Spanish
study investigated the effect of heat on mortality in Seville,
which is known for its hot summers. All-cause mortality increased by up to 51% above the average in those
over 75 years of age for each degree Celsius above 41°C.
This was more pronounced for cardiovascular diseases than
for pulmonary diseases, and, as with the Madrid study,
it affected women more than it did men.109
A study on heat-related deaths in London found that
mortality due to heat began at a relatively low temperature,and that there was a 3.4% increase in deaths for every
one degree Celsius over 21.5°C.110 In a case study of six
cases of classic heat stroke seen at a Taiwan emergency
department, the most frequent co-morbid conditions were
hypertension (4/6) and mental illness (3/6). All six patients
S a n f o r d , U r b a n M e d i c i n e : T h r e a t s t o Tr a v e l e r s t o D e v e l o p i n g Wo r l d C i t i e s
were middle-class, and were not socially isolated. Most
avoided cool air, and avoided staying in airconditioned
rooms.111
A study in California, US that investigated 2,650 participants in a long-distance cycling event found that
among the 117 patients who presented for medical care
with heat-related illness,a greater number of chronic medical illnesses correlated with developing heat illness, relative to controls.112
The combination of increasing urbanization, leading to higher temperatures, and the increasing age of
tourists, leading to increased susceptibility, will probably
make heat-related illness in urban travelers increasingly
common. Travelers should be warned that cities are
warmer than surrounding rural regions. Additionally, travelers should know that in humid regions, “sweat doesn’t
work”; it does not evaporate, and hence does not cause
cooling but only leads to fluid loss. Adequate hydration
and limiting exposure to the midday heat are thought to
be protective. Travelers need to be aware that thirst is not
always a reliable indicator of hydration status; they should
drink sufficient fluids such that urination occurs at normal
frequency, and urine is near-colorless. For the elderly or
those with chronic pulmonary or cardiac conditions, minimizing the duration of stay in particularly hot cities (e.g.,
airport transfer only) may be the wiser option.
Sex
Of the 42 million people living with HIV/AIDS
worldwide, 90% live in developing countries.113 However,
despite this dire statistic, “Sex and travel do not infrequently coincide.”114 A Spanish study of 1,008 travelers
who attended a tropical medicine clinic showed that 19%
of the travelers had sex with a new partner while traveling, and 46% of that group failed to use condoms.115
Alarmingly, a high percentage of travelers who did not
use condoms in this study—3.4%—acquired HIV infection. An Australian study indicated that only 34% of travelers had a definite intention not to have sex with a new
partner; 66% indicated that they were open to having sex
with a new partner while abroad.116 Thirty percent of
Swiss tourists have casual sexual contacts while abroad.
During 1989–1991, over one-quarter of cases of gonorrhea seen in Switzerland were imported from abroad.117
In most industrialized countries, the rates of classic sexually transmitted diseases (STDs), including syphilis, gonorrhea, and chancroid, have dropped dramatically over
recent years, but they remain hyperendemic in much of
the developing world.118
The likelihood of sex with a new partner increased
with increased duration of stay abroad. Among 1,242
Peace Corp volunteers, 60% had sex with another Peace
Corp volunteer; 39% reported sex with a host country
national. Of those volunteers who had a new partner
319
while abroad, only 32% used condoms consistently.119
Other factors identified in a study performed in Cuzco,
Peru as being associated with an increased probability of
having sex with a new partner, were being male, being
young (age 15 to 35 years), being unmarried, being from
a country other than the US,traveling alone or with friends
(but not the usual partner), homosexual or bisexual orientation, and having the expectation of having sex with
a new partner prior to travel.120 The typical “sex tourist”—
one who travels for the express purpose of hiring commercial sex workers (CSWs)—is male, with a mean age
of 38 years.121 The majority do not use condoms.122
According to an article in World AIDS, Sri Lanka
became a “gay paradise with the advent of tourism in
the late 1970s”. UNICEF estimates that as of 1993 there
were up to 15,000 boys in Sri Lanka who were engaged
in homosexual prostitution.123
The topic of regulation of CSWs is controversial. On
the one hand, the tight regulation of CSWs in Nevada,
US has resulted in an extremely low rate of STDs among
CSWs.124,125 On the other hand, this is dangerous and
degrading work, and many governments are understandably reluctant to legitimize it. The high percentage
of child CSWs in some nations (an estimated 36,000 of
Thailand’s 150,000 to 200,000 CSWs are children126) does
not simplify the ethics of this issue. Additionally, there are
no data suggesting that licensing CSWs in the developing world will lead to safer sex between CSWs and their
clients,as it has in the developed world.Proponents of regulating CSWs point out that making this practice illegal
has never eradicated it, and that regulated commercial sex
can be safer than commercial sex in its current illicit
form.127
The risk of acquiring HIV is markedly higher while
a traveler is abroad than in their native country. A Danish
study found that more frequent travelers had more sexual encounters involving a risk of HIV transmission than
did less frequent travelers.128 A study of UK citizens showed
that their risk of acquiring HIV was 300-fold higher while
abroad as compared to their at-home risk.129 However,
the “overwhelming proportion” of tourists do not consider the prevalence of HIV when choosing their holiday
destinations.130
The prevalence of HIV in CSWs often exceeds 50%.
In a study of brothel-based female CSWs in northern
Thailand, HIV-1 seroconversion in the first year of followup was 20.3%.131 British studies have also found positive
associations between international travel to developing
countries and being HIV-positive.132
The topic of pretravel counseling regarding safe sex
is complicated by the fact that travelers’ sexual behavior
has not been demonstrated to be influenced by educational
intervention. A study performed in a Zurich airport
on 3,100 Swiss travelers showed that, whereas travelers
320
appreciated receiving information on STDs such as HIV,
the counseling did not affect behavior; no difference was
found regarding planned condom use or sexual behavior between the group that received counseling and the
group that did not.133 There have been no randomized
controlled trials investigating whether or not pretravel
advice affects the rate of STD acquisition while travelers are abroad.134 Given that ethics committees might not
approve randomized controlled studies on this topic,
retrospective cohort studies could also be of benefit.
However, on a panoply of other topics, including the
cessation of tobacco use, the benefit of physicians’ advice
on patient behavior is well documented. Additionally, education regarding safe sex given outside the field of travel
medicine, as with educational projects regarding HIV
transmission in Uganda and elsewhere, has yielded dramatic reductions in high-risk behaviors. A frank and direct
sentence or two on this topic can only benefit the traveler (e.g., “Many travelers have sex with a new partner;
if this is a possibility for you, it would be a good idea to
take latex condoms with you”). All travelers, particularly
those who are young, male, and traveling without their
usual partner, should be advised to adopt a “no glove, no
love” policy. Additionally, pointing out the relationship
between alcohol use and poor judgment (“In vino stupidas”) may be of benefit.
There exists an excellent vaccine for one STD:
hepatitis B. This vaccine should be considered for virtually every traveler. However, this vaccine provides no
protection for other STDs; specifically, it does not offer
protection against HIV.
The proportion of casual sex among travelers in
urban, as opposed to rural, environments is unknown.
Concerning prostitution, the common belief among travelers and pretravel providers alike is that this is primarily an urban phenomenon.
Crime and Security
Personal safety is an often neglected area in pretravel
counseling, but is “one of the most important areas for
travel health advisors to cover when giving advice for travelers going to virtually any country”.135 A study that investigated the health problems of medical students at the
University of Tasmania, Australia during overseas rotations concluded that “assaults . . . and harassment are of
increasing concern, and students need pretravel counseling
on how to avoid getting into dangerous situations”.136
Travelers need to be reminded that when in the
developing world, they are, as Dorothy noted, no longer
in Kansas. The murder rate in Jamaica is five times that
in the US,137 which is itself significantly higher than that
found in western Europe. The homicide rate in Russia,
which increased markedly during the 1990s, is now about
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 11 , N u m b e r 5
20 times higher than in western Europe; this represents
one of the highest homicide rates of any country.138 Urban
homicide in Russia is increasing in frequency at a faster
rate than is rural homicide. In São Paulo in 1999, there
were 9,000 homicides, as opposed to fewer than 700 in
New York City, making death from homicide on a per
capita basis 12 times more likely in São Paulo than in New
York.139 A study by Hargarten et al. found that 9% of fatalities among American travelers overseas are due to homicide.140 A Canadian study found that a similar percentage
of deaths of Canadian travelers who died abroad, 8%, were
due to homicide.33
Street crime is common in large cities around the
world. Travelers from developed nations are viewed as
walking automated teller machines. Urban travelers should
be aware of the “mustard scam”, in which a substance is
squirted onto the clothes of a traveler; a seemingly helpful local then wipes off the substance while picking the
traveler’s pockets. The slash and grab technique is also
common in the urban centers of the developing world;
the thief slices a slit in the bottom of a traveler’s purse
or backpack, and then grabs whatever falls out. In a study
of travel claims made by travelers from Australia, theft and
assault combined to make up 12.0% of all claims, placing crime as the third most common reason for claims,
behind “general medical” and “loss”.141
Urban crime is multifactorial; overpopulation
and poverty are key factors. In China, which has an estimated 100 million surplus rural workers and 30 million surplus urban workers, approximately 30% of crimes
in Beijing, 70% of crimes in Shanghai and 80% of crimes
in Guangdong province are committed by migrant
workers.142
The US State Department maintains a regularly
updated listing of Consular Information Sheets, Travel
Warnings and Public Announcements for all foreign
countries at its Bureau of Consular Affairs.143 Travelers
should be encouraged to check this site on a regular basis,
both prior to and, if possible, during their travels. Travelers
should be reminded that war, major internal strife and
natural disasters are not spectator events; countries with
significant turmoil should be avoided. Street demonstrations in the developing world can turn violent with
little notice; travelers should be advised to not photograph
or join in protests.
Wearing clothes with a military appearance, e.g.,
camouflage-pattern fatigues, is unwise in the developing world. Many developing countries have a history of
unwelcome military intervention in their recent past, and
travelers dressed in garb that strikes residents as being reminiscent of armed forces may draw unwelcome attention.
Tourists should avoid photographing buildings or other
subjects with security implications (e.g., police barracks,
military maneuvers) in countries with recent or current
S a n f o r d , U r b a n M e d i c i n e : T h r e a t s t o Tr a v e l e r s t o D e v e l o p i n g Wo r l d C i t i e s
civil unrest. A good rule of thumb is that if uniformed
soldiers or policemen are in sight, the tourist should ask
permission prior to taking photographs. The soldier or
policeman will say yes, and the tourist can click away with
impunity, or no, in which case the traveler puts the camera away. Photographing sensitive subjects can lead to, at a
minimum, impoundment and destruction of film, if not
a several-hour session of answering questions as to why
the tourist was taking those particular photos.
Hotel safes are generally secure, and their use for
storage of all important documents and other belongings should be encouraged, although travelers should be
aware that there is usually a limit to a hotel’s liability
regarding theft. Particularly valuable items should be left
at home. Travelers should not carry more money in their
pockets than they are willing to lose to pickpocketing;
valuables can be kept under the clothes in a belt about
the traveler’s waist or neck. Should travelers note that
they have some substance on their clothing, they should
continue to walk and refuse offers of aid in cleaning off
their clothes. Some backpackers in cities with a high rate
of this manner of theft, e.g., Rio do Janeiro, take the
ungainly but often effective measure of wrapping their
backpacks with metal mesh wire to thwart slash and grab
thieves.
Kidnapping of international travelers has recently
increased; employees of international and nongovernmental organizations are at higher risk.144 The use
of licensed taxis is preferable to use of more informal ones.
During 1998–1999, at least six tourists were robbed and
murdered after taking unlicensed taxis from a Bangkok
airport.145 Hotels have a vested interest in their guests not
being the victims of crime; asking a hotel to call a taxi,
as opposed to hailing one randomly on the street, reduces
the risk of robbery and kidnapping. Tourists are not generally a target for terrorist attacks, the bombing of a tourist
bus in Luxor in November 1997 which killed 58 people being a notable exception.
Travelers should inform family and their local
embassy of their arrival and itinerary, and carry a mobile
phone if possible. Travelers should avoid wearing expensive jewelry or watches, and carry no more cash than they
need for the day. “Bum bags” (“fanny packs” in US parlance) are thought to be high risk, as these can represent
“one-stop shopping centers” for muggers. Travelers should
not accept food or drinks from strangers, as the drug-androb strategy is a not uncommon scam.146 If robbed, travelers should avoid resisting, and should report the theft
to the local authorities.
A key point to stress to travelers is that crime and
accidents are not random; risk can be reduced by cautious strategies. The need for travelers to be informed and
wary is increasing as fewer people are traveling in package tours, but are instead creating their own itineraries.147
321
Although some strategies employed by criminals, e.g.,
the mustard scam, or slash and grab robbery, are more associated with urban centers than rural areas, the incidence
of tourists who are victims of crime in urban areas as
opposed to rural regions is unknown.
Psychiatric Illness
It is a myth that travel abroad involves low stress.
Tourists may envisage relaxing in a hammock, but circadian disruption, alien diets, removal from support networks and unfamiliar surroundings all contribute to a level
of stress that may be significantly greater than that at home.
Big cities are not known for their propensity to extend
a welcoming hand to strangers. The impersonal, if not
frankly hostile, attitudes often encountered in cities, in
addition to ever-present noise and crowding, can overwhelm the recent arrival or long-term expatriate. Most
travelers have witnessed or experienced tourist flip-out,
in which previously calm tourists become frustrated to
the point of rage—they shout and make no more sense
than a 2-year-old having a tantrum. This unwelcome
regression can be induced in the most serene individuals
by sufficient heat, delay, and incomprehension.
A study that investigated 15 returning travelers with
psychological problems who were seen at an Israeli travel
clinic found that 11 had anxiety (with or without depression), three had psychosis, and one had pure depression.
None had prior psychopathology.148 This contrasts with
a French review which found that most returned international travelers with psychiatric pathology had a history of mental illness prior to leaving France.149
In a study of 152 international travelers at a mental health clinic in Jerusalem, Israel, a link was found
between psychopathology and crossing seven or more
time zones.150 Other researchers have proposed the possibility that psychosis and even schizophrenia can be
elicited by jet lag.151
Sixteen cases of psychosis in Japanese honeymooners in Hawaii were described in a 1997 study. The rate
of “honeymoon psychosis” was found to be higher than
the rate of psychosis seen in other Japanese tourists, or
in non-Japanese honeymooners. The authors speculate
that arranged marriages may play a role.152
There are even fewer studies of the health problems
of IBTs than there are for tourists,153 but high rates of
psychological treatment have been found in business travelers and their spouses.154
In a study of a medical assistance and evacuation company that evacuated 1,618 travelers in a year, psychiatric
emergencies, along with trauma and cardiovascular diseases, were the three most common reasons for air evacuation.155 A study of 380 international travelers who
contacted SOS International, Amsterdam with psychiatric
322
problems between 1985 and 1990 found that paranoid disorder was the most common diagnosis, comprising 21.2%
of all psychiatric diagnoses. The authors concluded that
travelers with schizophrenic disorders are less successful
in reaching their holiday destinations.156
An Israeli psychiatrist studied 470 tourists visiting
Jerusalem who were referred to Kfar Shaul Psychiatric
Hospital between 1979 and 1993. In what has come to
be known to psychiatrists as the Jerusalem syndrome, visiting tourists, many of whom have no psychiatric background, become “intoxicated” by their presence in this
holy city; they perform acts of purification, often using
hotel sheets as white robes, and identify with a figure from
the Bible. After 4 to 5 days of the “here and now” treatment favored by psychiatrists at Kfar Shaul, patients usually regain their grip on reality, and feel sheepish about
their dress, or having bellowed religious hymns in the middle of the night from the Old City ramparts.157,158
Similarly,Italian psychiatrists have identified a Florence
syndrome, in which tourists to Florence act in a bizarre
manner, seemingly brought on not by religious fervor but
in response to works of art and the beauty of the city
itself.159 This is also known as the “Stendhal syndrome”
after the reaction of the French novelist when he first
visited Florence. The Word Spy defines the Stendhal syndrome as follows: “Dizziness, panic, paranoia, or madness
caused by viewing certain artistic or historical artifacts
or by trying to see too many such artifacts in too short
a time.”160
Just as parents pack a favorite blanket or cuddly toy
for traveling children, so should adults consider packing
some small item capable of giving them comfort.Walkmans,
novels or diaries are lightweight items that can help to
smooth a perturbed psyche.
Also, not every pretravel provider is aware that
some antimalarials, most notably mefloquine, have the
potential to cause neuropsychiatric adverse events.161–163
Travelers should not be given mefloquine if they have a
history of anxiety, depression, or any other psychiatric
illness. Travelers with no psychiatric history should be
cautioned that if they experience nightmares or undue
anxiety while on mefloquine (or primaquine or chloroquine), they should, if possible, notify their health
care provider by E-mail or phone, or see a local provider,
to discuss changing to another medication for malaria
prophylaxis.
Just prior to or during international travel is a poor
time to stop or change psychotropic medications, including antidepressants.
Owing to the unknown denominator, conclusions
regarding the prevalence of mental health disorders in travelers cannot be drawn. There has been no research on
the topic of the relative prevalence of mental illness in
travelers to urban as opposed to rural regions.
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 11 , N u m b e r 5
Illicit Drug Use
The use of illicit psychotropic drugs by travelers is
common. Potasman et al. found that among 2,500 longterm young travelers to the tropics, 22.2% used recreational drugs.164 In the study of Beny et al.148 regarding
psychiatric problems in returned travelers seen at an Israeli
clinic, eight of 15 patients had used illicit drugs while
abroad.
Whereas the link between alcohol and tourist injuries
as a result of balcony falls and diving accidents has been
documented,165,166 there are no studies investigating the
impact of illicit drugs on tourist accidents. A study that
investigated psychiatric interventions for Japanese
nationals in New York City suggested that substance
abuse disorders were common in those who required
emergency psychiatric care.167
Westermeyer and Berger compared “world traveler”
American and European addicts in Laos with those in
Minneapolis, Minnesota. The “world traveler” addicts
were primarily in their twenties (80%), male (80%), and
single (70%).168 Most began their use of illicit narcotics
during their travels. Relative to addicts in Minnesota, the
American and European addicts in Laos were older, better educated, and more likely to be single. Significantly,
they tended to become addicted more rapidly.169 The
authors suggest that loneliness and sociocultural isolation
possibly accelerated the progression from casual use to
addiction in travelers.
Informing travelers of the draconian penalties for
possessing illegal drugs in many developing nations may
have some deterrence value. One-third of the 2,500 US
citizens who are arrested overseas each year are arrested
for drug offences. “A number of countries, including
the Bahamas, the Dominican Republic, Jamaica, Mexico
and the Philippines, have enacted more stringent drug
laws which impose mandatory jail sentences for individuals convicted of possessing even small amounts
of marijuana or cocaine for personal use.”170 Many European countries, including Austria, France, Greece,
Ireland, Luxembourg, and the UK, may impose a life
sentence for narcotic trafficking.171 The death penalty
remains an option in several countries (including Malaysia,
Pakistan and Turkey) for those convicted of smuggling
illicit drugs.
Limitations of the Present Paper, and Suggestions
for Further Research
There is no study showing that pretravel advice
concerning motor vehicle crashes and other trauma
leads to reduced morbidity and mortality in travelers.55
However, in other areas of risk reduction, such as smoking cessation, there is abundant evidence that physicians’
S a n f o r d , U r b a n M e d i c i n e : T h r e a t s t o Tr a v e l e r s t o D e v e l o p i n g Wo r l d C i t i e s
advice significantly impacts on patients’ behaviors;172,173
extrapolation from these studies may be reasonable until
definitive studies regarding travelers, trauma and counseling from pretravel providers are undertaken.
Studies on the effects of air pollution on travelers
are utterly lacking. All the data quoted above are from
studies of indigenous populations.
The travel medicine community is in need of studies that show the benefit or lack thereof of pretravel counseling regarding unsafe sex and STDs in travelers. The
feasibility and cost-effectiveness of screening post-travel
for STDs is a “virtually unexplored field”.174
Although mental illness in international travelers is
well documented, studies showing the relative rates of
mental illness of travelers to urban areas and rural environments have not been performed.
In a Scottish study, travel agents were the most frequently consulted source of travel health advice.175 Given
that travel providers feel they give superior advice to travelers, studies showing the superior health of travelers who
consulted with a travel provider, as opposed to a travel
agent, would be welcome.
Conclusions
It is not the intent of this paper to belittle the importance of infectious threats to travelers. These diseases, most
notably hepatitis A, malaria, and travelers’ diarrhea, are
significant and must be addressed with every traveler.
However, given that the raison d’être of the pretravel
encounter is risk reduction, pretravel providers must
attempt to address all major risks to health, not only those
from infectious disease. It should be stressed to travelers
that the morbidity and mortality among travelers is not
random, but is to a large extent within the traveler’s control (e.g., those travelers who choose not to walk near
bodies of water rarely drown, and STDs are not found
in the celibate).
Threats to the traveler to urban environments include
trauma (most significantly motor vehicle crashes), air pollution, heat illness, STDs, crime, psychiatric illness, and
illicit drug use. Appropriate pretravel advice may reduce
the risk from these threats.
With the exception of travelers with chronic pulmonary or cardiac conditions that might be adversely
impacted by severe air pollution, travelers should not be
dissuaded from urban travel. Cities contain the best and
the worst of humankind; they are fascinating in and of
themselves, and transiting through urban conglomerations
is necessary for visiting many of the remote and sublime
regions of the world. Appropriate pretravel advice can
increase the odds that travelers to cities will return home
with fond memories, enlightenment, and a desire for further urban travel.
323
Acknowledgment
The author is grateful to Dr Elaine Jong for her
encouragement, enthusiasm, and example.
Declaration of Interests
The author is on the speakers’ bureau for GSK.
References
1. Hill DR, Behrens RH. A survey of travel clinics throughout
the world. J Travel Med 1996; 3:46–51.
2. Leggat PA, Heydon JL, Menon A. Health advice given by general practitioners for travelers from New Zealand. NZ Med
J 1999; 112(1087):158–161.
3. Prociv P. Deaths of Australian travelers overseas. Med J Aust
1995; 163:27–30.
4. Paixao MLT, Dewar RD, Cossar JH, et al. What do Scots die
of when abroad? Scott Med J 1991; 36:114–116.
5. Hargarten SW, Baker TD, Guptill K. Overseas fatalities
of United States citizen travelers: an analysis of deaths
related to international travel. Ann Emerg Med 1991; 20(6):
622–626.
6. Guptill KS, Hargarten SW, Baker TD. American travel deaths
in Mexico: causes and prevention strategies. West J Med 1991;
154(2):169–171.
7. Baker TD, Hargarten SW, Guptill KS. The uncounted dead:
American civilians dying overseas. Public Health Rep 1992;
107(2):155–159.
8. Steffen R. Travel Medicine—prevention based on epidemiological data. Trans R Soc Trop Med Hyg 1991; 85(2):
156–162.
9. World Health Organization. The state of world health. In:
The world health report 1996—fighting disease, fostering
development. Geneva: WHO, 1997:1–62.
10. Chen V. Crisis of a crowded world. Audubon 1994; August:
51–52.
11. United Nations Centre for Human Settlements (UNCHS).
An urbanizing world: global report on human settlements.
New York/Oxford: Oxford University Press, 1996.
12. Hall P, Pfeiffer U. Urban future 21: a global agenda for twentyfirst century cities. London: E&FN Spon, 2000:5.
13. Friedmann J. The prospect of cities. Minneapolis: University
of Minnesota Press, 2002:2.
14. Haub C. World population data sheet. Washington, DC:
Population Reference Bureau, July 2003.
15. McKee DL. Problems resulting from the absorption of small
towns into urban areas in major Third World cities. Tiers
Monde 1985; 26(104):841–847. (Article in French.)
16. Belisle FJ. Building on people: in search of urban solutions
in Latin America. IDRC Rep 1984; 12(4):11–12.
17. Tuntawiroon N, Samootsakorn P. Bangkok—a city ready to
burst. Mazingira 1984; 8(2):20–26.
18. Johnnie PB. Rural–urban migration in Nigeria: consequences
on housing, health-care and employment. Migr World Mag
1988; 16(3):22–29.
324
19. Philippine Legislators’ Committee on Population and
Development Foundation. The future is urban. People Count
1992; 2(4):1–2.
20. Hill DR. Health problems in a large cohort of Americans traveling to endemic countries. J Travel Med 2000; 7(5):259–266.
21. Steffen R, van der Linde F, Meyer HE. Erkrankungsrisiken
bei 10,500 Tropen- und 1300 Nordamerika-touristen.
Schweiz Med Wochenschr 1978; 108:1485–1495.
22. Jong EC, McMullen R, eds. The travel and tropical medicine guide, 3rd edn. Philadelphia: Saunders, 2003.
23. Robertson SE, Hull BP, Tomori O, et al. Yellow fever: a decade of reemergence. JAMA 1996; 276(14):1157–1162.
24. Centers for Disease Control and Prevention. Health information for the international traveler 2001–2001. Atlanta: US
Department of Health and Human Services, Public Health
Service, 2001.
25. World Health Organization. Urbanization: an increasing
risk factor for leishmaniasis. Wkly Epidemiol Rec 2002; 77:
365–370.
26. World Health Organization. Website posting: Disease outbreaks reported, May 8, 2002. Dengue/dengue haemorrhagic
fever in Brazil—Update 2. WHO: Communicable Disease
Surveillance and Response. Available at: http://www.who.int/
disease-outbreak-news/n2002/may/8may2002.html (accessed
2 August 2003).
27. Jelinek T, Dobler G, Holscher M, et al. Prevalence of infection with dengue virus among international travelers. Arch
Intern Med 1997; 157(20):2367–2370.
28. Schwartz E, Mendelson E, Sidi Y. Dengue fever among travelers. Am J Med 1996; 101(5):516–520.
29. Sanford C, ed. Primary care clinics: travel medicine.
Philadelphia: Saunders/Elsevier, 2002.
30. Thompson DT, Ashley DV, Dockery-Brown CA, et al.
Incidence of health crises in tourists visiting Jamaica, West
Indies, 1998–2000. J Travel Med 2003; 10(2):79–86.
31. Hargarten SW, Bouc GT. Emergency air medical transport
of US citizen tourists: 1988–90. Air Med J 1993; 12:398–402.
32. MacPherson DW, Guerillot DL, Streinter K, et al. Death and
dying abroad: the Canadian experience. J Travel Med 2000;
7:227–233.
33. Van Herck K, Zuckerman J, Castelli F, et al. Travelers’ knowledge, attitudes, and practices on prevention of infectious diseases: results from a pilot study. J Travel Med 2003; 10:75–78.
34. Carey MJ, Aitken ME. Motorbike injuries in Bermuda: a risk
for tourists. Ann Emerg Med 1996; 28:424–429.
35. Petridou E, Dessypris N, Skalkidou A, et al. Are traffic injuries
disproportionally more common among tourists in Greece?
Struggling with incomplete data. Accid Anal Prev 1999;
31(6):611–615.
36. Manchester W. Last lion: Winston Spencer Churchill: alone,
1932–40. Boston, MA: Little, Brown & Co., 1978:878.
37. Petridou E,Askitopoulou H,Vourvahakis D,et al.Epidemiology
of road traffic accidents during pleasure traveling: the evidence from the Island of Crete. Accid Anal Prev 1997; 29:
687–693.
38. Page SJ, Meyer D. Tourist accidents. Ann Tourism Res 1996;
23:666–690.
39. Murray C, Lopez A. The global burden of disease. Cambridge,
MA: Harvard University Press, 1996.
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 11 , N u m b e r 5
40. Krug E, ed. Injury: a leading cause of the global burden of
disease. Geneva: WHO, 1999. Available at: www.who.int/violence_injury_prevention/index.html (accessed 28 July 2003).
41. ASIRT (Association for Safe International Road Travel). Web
posting. Available at: www.asirt.ort (accessed 14 August 2003).
42. Anonymous. Please slow down. The Economist 2002;
February 7:46.
43. Salifu M, Mock CN. Pedestrian injuries in Kumasi: results of
an epidemiological survey. Ghana Engineer 1998; 18:23–27.
44. Krug E, ed. Injury: a leading cause of the global burden of
disease. Geneva: World Health Organization, 1999.
45. Murray CJ, Lopez AD. Alternative projections of mortality
and disability by cause 1990–2020: global burden of disease
study. Lancet 1997; 349:1498–1504.
46. Nantulya VM, Reich MR. The neglected epidemic: road
traffic injuries in developing countries. BMJ 2002; 324:
1139–1141.
47. National Highway Traffic Safety Administration (NHTSA).
Traffic safety facts, 1999. Available at: www.nhtsa.dot.gov/
people/ncsa/pdf/TSFovr99.R.pdf (accessed 23 August 2003).
48. Nantulya VM, Muli-Musiime F. Kenya. Uncovering the social
determinants of road traffic accidents. In: Evans T, Whitehead
M, Diderichsen F, et al., eds. Challenging inequities: from ethics
to action. Oxford: Oxford University Press, 2001: 211–225.
49. Hijaar MC. Traffic injuries in Latin American and the
Caribbean countries. Global Forum for Health Research
1999. Available at: www.globalforumhealth.org/Non_compliant_pages/forum3/Forum3doc962.htm (accessed 2 August
2003).
50. British Broadcasting Corporation (BBC). On the buses
in Lagos, 2001. Available at: http://news.bbc.co.uk/hi/english/world/africa/newsid_1186000/1186572.stm (accessed
15 August 2003).
51. UNDP. Human development report. Oxford: Oxford
University Press, 1994.
52. Xinua News Agency. Traffic accidents in Vietnam rise. Hanoi,
5 November 2001. Vietnam News List. Available at: http://
coombs.anu.edu.au/~vern/vnews-list (accessed 23 August
2003).
53. McInnes RJ, Williamson LM, Morrison A. Unintentional
injury during foreign travel: a review. J Travel Med 2002;
9:297–307.
54. Mock CN, Asiamah G, Amegashie J. A random, roadside
breathalyzer survey of alcohol impaired driving in Ghana.
J Crash Prevent Injury Control 2001; 2(3):193–202
55. Ross HL. Prevalence of alcohol-impaired driving: an international comparison. Accid Anal Prev 1993; 25:777–779.
56. Forjuoh SN, Mock CN, Freidman DI, Quansah R. Transport
of the injured to hospitals in Ghana: the need to strengthen
the practice of trauma care. Pre-hosp Immediate Care 1999;
3:66–70.
57. Mock CN, Jurkovich GJ, nii-Amon-Kotei D. Trauma mortality patterns in three nations at different economic levels:
implications for global trauma system development. J Trauma
1998; 44:804–814.
58. Shlim D. Altitude illness. Lecture at International Society
of Travel Medicine Conference, Innsbruck, Austria, May 2001.
59. Freese B. Coal: a human history. Cambridge, MA: Perseus
Publishing, 2003:1.
S a n f o r d , U r b a n M e d i c i n e : T h r e a t s t o Tr a v e l e r s t o D e v e l o p i n g Wo r l d C i t i e s
60. Nemery B, Hoet PH, Nemmar A. The Meuse Valley fog
of 1930: an air pollution disaster. Lancet 2001; 357(9257):
704–708.
61. World Resources Institute. Rising energy use: health effects
of air pollution. Available at: http://www.wri.org/wri/wr98-99/airpoll.htm (accessed 14 August 2003).
62. Stone R. Counting the cost of London’s killer smog. Science
2002; 298:2106–2107.
63. World Development Indicators. Air pollution. World
Bank Group 2002; 3.13: 182–183. Available at: http://
www.worldbank.org/data/wdi2002/pdfs/table%203-13.pdf
(accessed 14 August 2003).
64. Dursin K. Jakarta is high on octane, low on IQ. Asia Times
[online] 20 April 2000. Available at: atimes.com (accessed 22
July 2003).
65. Gross R. Beyond food and nutrition: how can cities be made
healthy? Asia Pac J Clin Nutr 2002; 11(Suppl 9):S763–S766.
66. Asian Development Bank. Regional Workshop: Strengthening
Inspection and Maintenance. Chongqing, PRC, 7–9
November 2001. Available at: http://www.adb.org/
Documents/Events/2001/RETA5937/Chongqing/
documents/cq_21_thawanaphong.pdf (accessed 14 December
2003).
67. Koompalum S, Tongdhamachart C. International electric
vehicle conference: a new energy wave. Pollution Control
Department, Ministry of Science, Technology of Science,
Technology and Environment, Thailand. Available at: http://
www.entebbe.com/evcon/english/p_thailand.html (accessed
29 July 2003).
68. United Nations Economic and Social Commission for Asia
and the Pacific. Available at: http://www.unescap.org/enrd/
environment/activities/ES/SOE/CH06.PDF (accessed 14
August 2003).
69. Dickey JH. No room to breath: air pollution and primary care
medicine. A project of greater Boston PSR (Physicians for
Social Responsibility). Available at: http://www.psr.org/
breathe.htm (accessed 11 August 2003).
70. Burnett RT, Dales RE, Brook JR, et al. Association between
ambient carbon monoxide levels and hospitalizations for congestive heart failure in the elderly in 10 Canadian cities.
Epidemiology 1997; 8(2):162–167.
71. Brunekreef B, Holgate ST. Air pollution and health. Lancet
2002; 360(9341):1233–1242.
72. Just J, Segala C, Sahraoui F, et al. Short-term health effects of
particulate and photochemical air pollution in asthmatic children. Eur Respir J 2002; 20(4):899–906.
73. Seaton A, Soutar A, Crawford V, et al. Particulate air pollution and the blood. Thorax 1999; 54:1027–1032.
74. Donaldson K, Gilmour MI, MacNee W. Asthma and PM10.
Respir Res 2000; 1:12–15.
75. Gordon T, Reibman J. Cardiovascular toxicity of inhaled ambient particulate matter. Toxicol Sci 2000; 56:2–4.
76. Dockery DW, Pope CA, Xu X, et al. An association between
air pollution and mortality in six US cities. N Engl J Med
1993; 329(24):1807–1808.
77. Hedley AJ, Wong C-M, Thach TQ, et al. Cardiorespiratory
and all-cause mortality after restrictions on sulphur content
of fuel in Hong Kong: an intervention study. Lancet 2002;
360:1646–1652.
325
78. Pope CA, Burnett, RT, Thun MJ, et al. Lung cancer,
cardiopulmonary mortality, and long-term exposure to fine
particulate air pollution. JAMA 2002; 287(9):1132–1141.
79. Kunii O, Kanagawa S, Yajima I, et al. The 1997 haze disaster
in Indonesia; its air quality and health effects. Arch Environ
Health 2002; 57(1):16–22.
80. McConnell R, Berhane K, Gilliland F, et al. Asthma in exercising children exposed to ozone: a cohort study. Lancet 2002;
359:386–391.
81. Bergamaschi E, DE Palma G, Mozzoni P, et al. Polymorphism
of quinone-metabolizing enzymes and susceptibility to ozoneinduced acute effects. Am J Respir Crit Care Med 2001;
163:1426–1431.
82. Ostro BD, Eskeland GS, Sanchez JM, Feyzioglu T. Air
pollution and health effects: a study of medical visits among
children in Santiago, Chile. Environ Health Perspect 1999;
107(1):69–73.
83. Samet JM, Hatch GE, Horstman D, et al. Effect of antioxidant
supplementation on ozone-induced lung injury in human
subjects. Am J Respir Crit Care Med 2001; 164(5):819–825.
84. Sudhir P, Prasad CE. Prevalence of exercise-induced
bronchospasm in schoolchildren: an urban–rural comparison.
J Trop Pediatr 2003; 49(2):104–108.
85. Delfino RJ, Zeiger RS, Seltzer JM, et al. Associations of asthma
symptoms with peak particulate air pollution and effect modification by anti-inflammatory medication use. Environ Health
Perspect 2002; 110(10):A607–A617.
86. Pearson RL, Wachtel H, Ebi KL. Distance-weighted traffic
density in proximity to a home is a risk factor for leukemia
and other childhood cancers. J Air Waste Manage Assoc 2000;
50(2):175–180.
87. Roemer WH, van Wijnen JH. Daily mortality and air
pollution along busy streets in Amsterdam, 1987–1998.
Epidemiology 2001; 12:649-653.
88. Abbey DE, Nishino N, McDonnell WF, et al. Long-term
inhalable particles and other air pollutants related to mortality in nonsmokers. Am J Respir Crit Care Med 1999; 159:
373–382.
89. Brunekreef B. All but quiet on the particulate front. Am J
Respir Crit Care Med 1999; 159:354–356.
90. Peters A, Doring A, Wichmann HE, et al. Increased plasma
viscosity during an air pollution episode: a link to mortality? Lancet 1997; 349:1582–1587.
91. Peters A, Frolich M, Doring A, et al. Particulate air pollution
is associated with an acute phase response in men:results from the
MONICA-Augsburg study.Eur Heart J 2001; 22:1198–1204.
92. Peters A, Perz S, Doring A, et al. Increases in heart rate during an air pollution episode. Am J Epidemiol 1999; 150:
1094–1098.
93. Touze JE, Fourcade L, Heno P, et al. Cardiovascular risk for
the traveler.Med Trop (Mars) 1997;57(4 Bis):461–464.(Article
in French.)
94. IAMAT (International Association for Medical Aid to
Travelers). Home page. Available at: www.iamat.org (accessed
29 February 2004).
95. Islands in the (air) stream. Science @ NASA website. Posted
1 May 1998. Available at:http://science.msfc.nasa.gov/
newhome/ headlines/ess)1may98_1.htm (accessed 12
August 2003).
326
96. Yozwiak S. Island sizzle: growth may make valley an increasingly hot spot. Arizona Republic 25 September 1998.
97. Anon. Heat-related deaths—Chicago, Illinois, 1996–2001, and
United States, 1979–1999. MMWR 51(26):567–570.
98. Dematte JE, O’Mara K, Bueschler J, et al. Near-fatal heat stroke
during the 1995 heat wave in Chicago. Ann Intern Med 1998;
129: 173–181.
99. Rajpal RC, Weisskopf MG, Rumm PD, et al. Wisconsin, July
1999 heat wave: an epidemiologic assessment. Wilderness Med
J 2000; 99(5):41–44.
100. Kaiser R, Rubin CH, Henderson AK, et al. Heat-related death
and mental illness during the 1999 Cincinnati heat wave. Am
J Forensic Med Pathol 2001; 22(3):303–307.
101. Worfolk JB. Heat waves: their impact on the health of elders.
Geriatr Nurs 2000; 21(2):70–77.
102. Porter AM. Collapse from exertional illness: implications and
subsequent decisions. Mil Med 2003; 168(1):76–81.
103. The Medical Letter, 21 July 2003; 45:58–60.
104. Collins KJ. In: Cook GC, Zumula A, eds. Manson’s tropical
diseases, 21st edn. Saunders, 2003:545.
105. Lind J. An essay on diseases incidental to Europeans in hot
climates. London: T. Becket, 1768.
106. Leithead CS, Lind AR. Heat stress and heat disorders. London:
Cassell, 1964.
107. Clark RP, Edholm OG. Man and his thermal environment.
London: Edward Arnold, 1985.
108. Diaz J, Jordan A, Garcia R, et al. Heat waves in Madrid
1986–97: effects on the health of the elderly. Int Arch Occup
Environ Health 2002; 75(3):163–170.
109. Diaz J, Garcia R, Velazquez de Castro F, et al. Effects of
extremely hot days on people older than 65 in Seville (Spain)
from 1986–1997. Int J Biometeorol 2002; 46(3):145–149.
[Epub 25 April 2002.]
110. Hajat S, Kovats RS, Atkinson RW, et al. Impact of hot temperatures on death in London: a time series approach. J
Epidemiol Community Health 2002; 56(5):367–372.
111. How C, Chern CH, Wang LM, et al. Heat stroke in a subtropical country. Am J Emerg Med 2000; 18(4):474–477.
112. Krueger-Kalinski MA, Schriger DL, Friedman L, et al. Identification of risk factors for exertional heat-related illnesses in
long distance cyclists: experience from the California AIDS
ride. Wilderness Environ Med 2001; 12(2):81–85.
113. Buve A, Kalibala S, McIntyre J. Stronger health systems for
more effective HIV/AIDS prevention and care. Int J Health
Plann Manage 2003; 18(Suppl 1):S41–S51.
114. Hawkes S, Hart G. The sexual health of travelers. Infect Dis
Clin North Am 1998; 12(2):413–430.
115. Velasco M, Morote S, Aramburu C, et al. Sexual behavior risk
in Spanish international travelers. Med Clin (Barc) 2001;
116(16):612–613.
116. Mulhall BP, Hu M, Thompson M, et al. Planned sexual behavior of young Australian visitors to Thailand. Med J Aust 1993;
158(8):530–535.
117. Eichmann A. [Sexually transmissible diseases following travel
in tropical countries.] Schweiz Med Wochenschr 1993;
123(24): 1250–1255.
118. De Schryver A, Meheus A. International travel and sexually
transmitted diseases. World Health Stat Q 1989; 42(2):90–99.
119. Moore J, Beeker C, Harrison JS, et al. Risk behavior among
Peace Corp Volunteers. AIDS 1995; 9:795–799.
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 11 , N u m b e r 5
120. Cabada MM, Montoya M, Echevarria JI, et al. Sexual behavior in travelers visiting Cuzco. J Travel Med 2003;
10:214–218.
121. Halioua B, Prazuck T, Malkin JE. [Sexually transmitted
diseases and travel.] Med Trop (Mars) 1997;57(4 Bis):501–504.
122. Herold ES, Van Kerkwijk C. AIDS and sex tourism. AIDS
Soc 1992; 4(1):1–8.
123. West J. Selling cheap sex and seashells. World AIDS 1993; 26:9.
124. Albert AE, Warner DL, Hatcher RA, et al. Condom use
among female commercial sex workers in Nevada’s legal brothels. Am J Public Health 1995; 85(11):1485–1488.
125. Khabbaz RF, Darrow WW, Hartley TM, et al. Seroprevalence
and risk factors for HTLV-I/II infection among female prostitutes in the United States. JAMA 1990; 263(1):60–64.
126. Archavanitkul K. What is the number of child prostitutes in
Thailand? Warasan Prachakon Lae Sangkhom 1999; 7(2):
1–9.
127. Ditmore M, Saunders P. Sex work and sex trafficking. Sex
Health Exch 1998; 1:15.
128. Melbye M, Bigger RJ. A profile of migrant behaviours and
their potential influence on HIV spread in Greenland. Scand
J Soc Med 1994; 22(3):204–208.
129. Thomson MM, Najera R. Travel and the introduction of
human immunodeficiency virus type 1 non-B subtype genetic forms into Western countries. Clin Infect Dis 2001;
32:1732–1737.
130. Forsythe S, Hasbun J, Bulter de Lister M. Protecting paradise:
tourism and AIDS in the Dominican Republic. Health Policy
Plan 1998; 13(3):277–286.
131. Kilmarx PH, Limpakarnjanarat K, Mastro TD. HIV-1 seroconversion in a prospective study of female sex workers in
northern Thailand: continued high incidence among
brothel-based women. AIDS 1998; 12(14):1889–1898.
132. Hawkes SJ, Hart GJ. Travel, migration, and HIV. AIDS Care
1993; 5(2):207–214.
133. Gehring TM, Widmer J, Kleiber D, Steffen R. Are
preventative HIV interventions at airports effective? J Travel
Med 1998; 5(4):205–209.
134. Thomas RE. Preparing patients to travel abroad safely. Part
4: Reducing risk of accidents, diarrhea, and sexually transmitted diseases. Can Fam Physician 2000; 46:1634–1638.
135. Leggat PA, Klein M. Personal safety advice for travelers abroad.
J Travel Med 2001; 8:46–51.
136. Goldsmid JM, Bettiol SS, Sharples N. A preliminary study on
health issues of medical students undertaking electives. J Travel
Med 2003; 10:160–163.
137. Gary L. Travelers’ safety: crime takes no vacation in the busy
Caribbean. Seattle Times, 3 June 2001.
138. Cheryakov VV, Shkolnikov VM, Pridemore WA. The changing nature of murder in Russia. Soc Sci Med 2002; 55(10):
1713–1724.
139. Zwingle E. Global cities. National Geographic 2002; 202:
70–99.
140. Hargarten SW, Baker TD, Guptill K. Overseas fatalities of
United States citizen travelers: an analysis of deaths related
to international travel. Ann Emerg Med 1991; 20:622–626.
141. Leggat PA, Leggat FW. Travel insurance claims made by travelers from Australia. J Travel Med 2002; 9:59–65.
142. Jian X. Increasing pressure: impacts of migration on cities.
China Popul Today 1996; 13(5–6):21–22.
S a n f o r d , U r b a n M e d i c i n e : T h r e a t s t o Tr a v e l e r s t o D e v e l o p i n g Wo r l d C i t i e s
143. US State Department. Website. Available at: http://travel.
state.gov (accessed 14 September 2003).
144. Peytremann I, Baduraux M, O’Donovan S, et al. Medical
evacuations and fatalities of United Nations High Commissioner for Refugees field employees. J Travel Med 2001;
8:117–121.
145. Department of Foreign Affairs and Trade, Canberra, Australia.
Safe travel: Don Muang airport. Consular News 1999; 3:5.
146. Department of Foreign Affairs and Trade, Canberra, Australia.
Stories:Malawi,Africa—drugged and robbed.Consular News
1999; 1:3–4.
147. Behrens RH. Protecting the health of the international traveler. Trans R Soc Trop Med Hyg 1990; 84:611–612, 629.
148. Beny A, Paz A, Potasman I. Psychiatric problems in returning travelers: features and associations. J Travel Med 2001;
8:243–246.
149. Sauteraud A. Occurrence and management of psychiatric
pathology in travelers. Med Trop (Mars) 1997; 57(4 Bis):
457–460. (Article in French.)
150. Katz G, Knobler HY, Laibel Z, et al. Time zone change and
major psychiatric morbidity: the results of a 6-year study in
Jerusalem. Comp Psychiatry 2002; 43(1):37–40.
151. Katz G, Durst R, Zislin Y, et al. Psychiatric aspects of jet lag:
review and hypothesis. Med Hypotheses 2001; 56(1):20–23.
152. Langen D, Streltzer J, Kai M. “Honeymoon psychosis” in
Japanese tourists to Hawaii. Cult Divers Ment Health 1997;
3(3):171–174.
153. Rogers HL, Reilly SM. Health problems associated with international business travel: a critical review of the literature.
AAOHN J 2000; 48(8):376–384.
154. Dimberg LA, Striker J, Nordanlycke-Yoo C, et al. Mental
health insurance claims among spouses of frequent business
travelers. Occup Environ Med 2002; 59(3):175–181.
155. Lavernhe JP, Ivanoff S. Medical assistance to travelers: a new
concept in insurance—cooperation with an airline. Aviat Space
Environ Med 1985; 56(4):367–370.
156. Monden MA, Meester WJ. Mental decompensation during
vacation abroad. Ned Tijdschr Geneeskd 1994; 138(43): 2161.
(Article in Dutch.)
157. Bar-el Y, Durst R, Katz G, et al. Jerusalem syndrome. Br J
Psychiatry 2000; 176:86–90.
158. Fein J. Jerusalem syndrome. The Savvy Traveler. Available at:
http://www.savvytraveler.org/show/features/2000/20000603/
jerusalem.shtml (accessed 21 August 2003).
327
159. Abramowitz L. The Jerusalem syndrome. Jewish Online
Library; American Israeli Cooperative Enterprise. Available
at: http://www.us-israel.org/jsource/History/jersynd.html
(accessed 1 September 2003).
160. The Word Spy. Available at: http://www.wordspy.com/
words/Stendhalsyndrome.asp (accessed 13 August 2003).
161. Meier CR, Wilcock K, Jick SS. The risk of severe depression, psychosis, or panic attacks with prophylactic antimalarials.
Drug Saf 2004; 27(3):203–213.
162. Taylor WR, White NJ. Antimalarial drug toxicity: a review.
Drug Saf 2004; 27(1):25–61.
163. Fuller SJ, Naraqi S, Gilessi G. Paranoid psychosis related to
mefloquine antimalarial prophylaxis. PNG Med J 2002;
45(3–4):219–221.
164. Potasman I, Beny A, Seligmann H. Neuropsychiatric problems in 2,500 long-term young travelers to the tropics. J Travel
Med 2000; 7(5):225–226.
165. Grundy D, Penny P, Graham L. Diving into the unknown.
BMJ 1991; 302:670–671.
166. Delargy MA. Holiday balcony falls resulting in spinal cord
injury. Lancet 1987; 1:334.
167. Katsuta Y, Nishimatsu Y, Saito T, et al. Psychiatric intervention for Japanese nationals in New York. J Nippon Med Sch
2003; 70(2):141–150.
168. Westermeyer J, Berger LJ. “World traveler” addicts in Asia I:
demographic and clinical description. Am J Drug Alcohol
Abuse 1977; 4(4):479–493.
169. Berger LJ, Westermeyer J. “World traveler” addicts in Asia II:
Comparison with “stay at home” addicts. Am J Drug Alcohol
Abuse 1977; 4(4):495–503.
170. United States Department of State, Bureau of Consular Affairs,
February 2000. Available at: www.state.gov (accessed 29
February 2004).
171. Drug intelligence brief. The changing face of European drug
policy. April 2002. Available at: www.dea.gov (accessed 29
February 2004).
172. Marlow SP, Stoller JK. Smoking cessation. Respir Care 2003;
48(12):1254–1256.
173. Clavario P, Capurro E. Nicotine dependence therapy: medical counselling and other non-pharmacological interventions.
Monaldi Arch Chest Dis 2003; 60(1):85–91.
174. Matteelli A, Carosi G. Sexually transmitted diseases in
travelers. Clin Infect Dis 2001; 32(7): 1063–1067.
175. Cossar JH, Reid D, Fallon RJ, et al. A cumulative review of
studies on travelers, their experience of illness and the
implications of these findings. J Infect 1990; 21(1): 27–42.