May/June 2006

Newsletter of the International Society of Travel Medicine May/June 2006 The President’s Edinburgh “By Royal Appointment” he International Society of Travel Medicine is greatly pleased and Column honoured to be able to announce that Her Royal Highness, the Prin- write to you from a city that was until re- Tcess Royal (Princess Anne) will attend the 2nd Regional Conference I cently in the middle of political chaos, of the ISTM - the Northern European Conference in Travel Medicine in Kathmandu, Nepal. But travelers continue to June in Edinburgh. Her Royal Highness will be giving a plenary talk come despite the political troubles, recogniz- during the conference, detailing her fascinating work on behalf of volun- ing that no place on earth can be considered tary agencies overseas. The Princess Royal is the second child and only absolutely safe and trouble-free anymore. Al- daughter of Queen Elizabeth and The Duke of Edinburgh. though people around the world are closer to Save the Children Fund, of which the Princess has been President since each other than ever before thanks to instant 1970, was the first major charity with which she became closely associ- global communications, the world we live in is ated, and this association has given her great insight into the needs of becoming increasingly complicated. (Fortu- children worldwide. However, she also holds a very wide range of chari- nately, the situation here in Nepal has im- table appointments, to which she devotes a large part of her working life. In addition, the Princess proved now and life is slowly returning to carries out up to three overseas tours each year for the Foreign and Commonwealth Office in normal.) support of British interests overseas. The Princess Royal is a very accomplished public speaker and ISTM as a Society is moving on with speed. projects a great passion for her charitable work – certainly worth a listen. We have several new initiatives. To coincide Other highlights of the conference include four plenary sessions, the first focusing on how changes with the Northern European Conference on to the environment can affect international travel and human health, given by two United Kingdom Travel Medicine (NECTM) being held in experts, Dr James Willis and Dr Sari Kovats. Also, at this session, Dr Eric Noji from CDC will Edinburgh this June, ISTM will be holding a discuss how to prepare for natural disasters. European Summit meeting together with our friends in the European Societies to explore The plenary on Day Two focuses on the more mainstream topic of risks and benefits from vaccina- ways to further mutual understanding and tions, specifically the vaccines used to prevent gastro-intestinal infections (by Professor Robert collaboration. Steffen), rabies (by Dr Francois-Xavier Meslin, WHO) and respiratory tract infections (by Profes- sor David Hill). Keeping in mind repeated requests from membership to hold a preparatory course for the Day Three will have a distinctly European feel with sessions by Professor Victor Maleyev and Dr Certificate of Travel Health (CTH) examina- Øystein Søbstad on infection risks in Scandinavia, Russia and the Baltic states, and a presentation tion, such a course is being offered in North by Professor Karl Ekdahl from the European Centre for Disease Prevention and Control. America and in Europe in early 2007. It is The closing plenary finds our Scandinavian colleagues Dr Eilif Dahl and Professor Heikki Peltola hoped that at some point in the future, the presenting a fascinating insight into sea travel, past and present. course can be offered in other parts of the world as well. Persons wishing to take the To supplement the plenary talks there is a wide and varied programme of symposia. These include CTH examination may benefit from taking sessions on health risks related to mode of travel, malaria prevention, exploration and adventure travel, such a course. The ISTM CTH examination risk assessment, travellers with chronic diseases and underlying health problems, coping with difficult situations in the travel clinic, travel to extreme environments, animal- and tick-borne infections, and the Continued on page 2 very popular regional perspectives. There are also three scheduled sponsored symposia considering issues surrounding cholera/Japanese encephalitis, hepatitis, and clinical dilemmas. Workshops add a further dimension, and there are eight to choose from, tackling topics ranging from how to increase awareness of security and accidents, to the current situation regarding H5N1 influenza. There are also four free communication sessions, and a display of posters for delegates to browse. No conference would be complete (or truly memorable!) without a lively social programme, and in true Scottish style, a Welcome Get-Together is being held on the opening evening, Wednesday, June The President’s Column ...... 1 7th. Scottish hospitality that evening will include Edinburgh “By Royal Appt.” ...... 1 traditional pipes and drums, Scottish dancers and a Northern European sensational ceilidh band (dancing optional!). Other Letter to the Editors ...... 2 more light-hearted events over the three days in- Conference on Travel clude early morning talks on the history and culture Decompression Illness in Scuba of Scotland, a family and friends evening of music, Divers ...... 4 and a golf challenge. Don’t miss NECTM in Best Ethical Travel Destinations .. 8 Edinburgh! For full details on the Scientific and Social programme for Edinburgh, including registration Calendar ...... See ISTM Web Page details and hotel and travel options, please visit the conference website: www.nectm.com. Travel Medicine NewsShare 2006 May/June 2006 “The President’s Column,” cont. from p. 1 Letter to the Editors will be offered in Vancouver in 2007. Letter to the Editors Dear Editor, at the Columbia University School of Visual We are moving forward to collaborate with Arts in New York City. He felt that “this was the World Health Organization in a produc- The World Tourism Organization has estab- too good an idea not to pursue.” tive way. ISTM has been asked to coordinate lished a code of ethics to promote sustainable efforts to give suggestions for the WHO In- and respectful tourism. Promoting respectful Here are some thoughts to consider: ternational Travel and Health (ITH) book and behavior of travelers will help reduce the grow- • The winning production (and perhaps, even website update. ing resentment toward tourists in host coun- some of the runner-ups) can be used to pro- tries, preserve host countries’ cultures and en- mote responsible travel by ISTM and its The Journal of Travel Medicine is reaching vironments, and ensure a safer and more re- members and by the media. libraries across the world. I hope that you warding experience for all travelers. find the new cover refreshing and the content • We can have ISTM and CILECT members stimulating. Manuscript submission and re- The International Society of Travel Medicine submit films, videos and Internet produc- view is now so much simpler thanks to Manu- has already embarked on such an initiative tions that they have viewed and think would script Central’s shorter turnaround time for with our Responsible Traveler initiative and interest others, have media producers sub- manuscripts. This should encourage our mem- we are playing a key role by disseminating mit their productions, or both. bers to publish more with JTM. educational information on travel ethics. • We can start small and see what happens. Preparations are underway for CISTM 10 to However, it is time to take the next step. I The competition could be every two or three be held in May 2007 in Vancouver. The Scien- propose that ISTM and an organization years? such as The International Association of tific Program Committee met recently to chalk • Perhaps we could get sponsors and/or pub- Film and Television Schools (CILECT) out the details of the program, taking into ac- licity from the following groups: television [CILECT is a french acronym] count suggestions from Society members. The programs devoted to travel, companies that (www.cilect.org) sponsor a competition to scientific program for the conference is not sell airline tickets on the Internet, travel encourage film and video makers to produce one that you will want to miss. The local or- health information services, pharmaceuti- media that encourages responsible travel. ganizing committee too has many valuable cal companies, and private foundations, for These productions would be aimed at inexpe- ideas that will complement the excellent sci- example. entific program at the conference. rienced travelers going to developing countries. Films and videos would be submitted to ISTM • Subjects could include anything from pre- I look forward to seeing you all in Edinburgh and reviewed for quality and content that sup- venting malaria to how to use Asian toilet. this year and in Vancouver in 2007. If you port the principles of The Responsible have any ideas/suggestions to improve the Traveler. After preliminary evaluation the best Sincerely, Society, please send them along to me at: of these productions could be viewed and [email protected] or [email protected]. voted on by ISTM members at the ISTM bi- Michael Schwartz Manchester, NJ 08759 USA Thank you. annual meetings or over the Internet. Phone: (732) 657-8447 With best wishes, I have discussed this idea with Larry Engle [email protected] Prativa ([email protected]), a filmmaker and teacher Help Wanted. United Kingdom Medical Consultant/Lead in Travel Medicine, Health Protection Scotland, Glasgow, United Kingdom Advance notice of a unique job opportunity. Due to retirement of the current postholder, the Travel Medicine Section of Health Protection Scotland (HPS) will very soon be looking to appoint a Medical Consultant/Lead in Travel Medicine. It is expected that formal notice and advertisement of this post will be placed in the Lancet and British Medical Journal during May/June 2006. HPS is part of the National Health Service in Scotland (http://www.show.scot.nhs.uk/scieh) and is committed to work in partnership with others, to protect the Scottish public from being exposed to hazards which damage their health, and to limit any impact on health when such exposures occur. The Travel Medicine team of HPS aims to reduce the incidence and consequences of travel related infections and other health problems in Scotland. The Consultant in Travel Medicine will act as clinical lead for the multi-disciplinary Travel Medicine team, providing expert advice and consultancy to a wide variety of external bodies, and engaging in the strategic planning, development and implementation of a broad range of initiatives aimed at raising standards of practice and improving health protection activity in Travel Medicine. He/she will provide input into other HPS’s services especially where they overlap with travel medicine (e.g. immunisation, emerging infections) and will play a lead role in taking forward health protection services linked to travel (e.g. immigration and port health). Examples of major initiatives currently undertaken by the Travel Medicine Section include provision of Travax® (not to be confused with Shoreland’s Travax®) and the Diploma/Foundation courses in Travel Medicine (Glasgow). Due to the unique remit of this post, suitably qualified applicants from outwith the UK will be considered. For further information, contact Fiona Genasi, Travel Medicine Section Co-ordinator. ([email protected])

2 Newsletter of the International Society of Travel Medicine © 2006 ISTM Travel Medicine NewsShare 2006 May/June 2006 Accreditation of Scientific Travel Medicine Confer- ences by the International Society of Travel Medicine

any individuals – ISTM members mittee, the ISTM endorsement and logo can sources and industry sponsorship for the and others – ask the ISTM Board be applied to printed material of the organiza- activity and a statement of any involve- Mfor permission to use the ISTM tion in question. The application can be un- ment of sponsors in the program develop- name and logo for marketing travel medicine dertaken using an on-line form, available from ment or the selection of faculty. conferences with which the individuals are as- the ISTM website. The process of review will 6. A copy of the course evaluation form not sociated. probably require about four or more weeks. later than 1 month prior to the conference. As a result, the Board has considered how the Please include as an attachment the fol- 7. A copy of previous course assessments ISTM name and logo should be used while lowing: for previously held conferences in the same insuring the following: 1. Course aims and objectives as well as a series by the same organizing body. • Appropriateness and clarity of material used definition of the intended audience In a cover letter include: in marketing the conference, 2. Describe the intended Continuing Medical • A statement promising to apprise ISTM of • Realistic advertising of the event, and Education accreditation to be sought. In- any un-named funding sources procured at • A suitable faculty for the event advertised. clude the name and contact information of a date after any ISTM accreditation is the intended accrediting body(s). Proof of awarded. This process of accreditation requires the CME accreditation should be provided organiser of the conference to provide set cri- when obtained but not later than 1 month • A statement promising to apprise ISTM teria and information: sponsorship and/or prior to the conference. immediately of any substantive changes in funding, invited speakers and their affiliations, conference content, faculty, venue, or spon- CME accreditation, timetable of progress, the 3. List of key confirmed invited speakers with soring body. their professional affiliations programme for the conferences, and evidence • A statement promising to distribute ISTM of an evaluation process. 4. A timetable showing key deadlines for sub- brochures to delegates at the time of the mission and review of scientific materials The application will be reviewed by at least conference. to the conference and deadlines for partici- two members of boards or committees of the pant registration • A statement that the conference organizers ISTM. When accreditation is bestowed, and will in no way represent the activity as an with the permission of the Publication Com- 5. A list of current and prospective funding official ISTM organized or sponsored conference. Conflicts: Any conference that in the subjec- tive judgment of the ISTM has the potential to conflict with official ISTM organized ac- tivities will not be eligible for accreditation. APPLICATION FOR ACCREDITATION OF A SCIENTIFIC CONFER- Final Accreditation: Accreditation will be ENCE BY THE INTERNATIONAL SOCIETY OF TRAVEL MEDICINE provided by ISTM conditional upon with- Please allow up to 4 weeks for the review process to be completed. (aligned drawal if material circumstances surrounding text here) the conference change. In general, use of the ISTM logo will be restricted to display on the Name of Conference:______back of any brochures or bottom of any web pages and must be placed together with the Conference Organizer: ______statement “Accredited by the International So- Email:______ciety of Travel Medicine.” Any reference to ISTM in the text of promotional materials Dates of activity:______should be limited to the statement “Accred- Place of activity: ______ited by the International Society of Travel Medicine.” Each use and placement of the Primary Sponsor of Conference (i.e., University, Professional Society or ISTM logo or statements specifying ISTM Scientific Foundation): accreditation in any printed or electronic form is subject to specific approval by the ISTM [Note: Conferences where ISTM is the primary sponsor are initiated by Publications Committee. Application for such ISTM itself; in order for ISTM to accredit a non-ISTM conference there use should be made well before printing and should be an independent primary sponsor.] other deadlines. Electronic submission preferred to: [email protected]

© 2006 ISTM Newsletter of the International Society of Travel Medicine 3 Travel Medicine NewsShare 2006 May/June 2006 Decompression Illness in SCUBA Divers Decompression Illness in SCUBA Divers Gary Podolsky and Karl Neumann

Symptoms of DCS Joint pain and numbness or tingling are com- mon manifestations of DCS, followed by muscular weakness and inability to empty a full bladder. Severe DCS is easily diagnosed but most cases begin subtly, with minor joint aches or paresthesias in an extremity. Often the symptoms are ascribed to another cause such as overexertion, heavy lifting or a tight wetsuit. This delays seeking help and is why it is often said that the first symptom of DCS is denial. Even symptoms that remain mild and disap- pear spontaneously should be investigated promptly. Severe DCS may result in permanent problems such as bladder dysfunction, sexual dysfunction and muscular weakness. Rarely, damage to the spinal cord may decrease the likelihood of recovery from subse- quent bouts of DCS. Untreated joint pain that disappears may still cause small areas of bone damage (osteonecrosis). Future bouts of osteonecrosis may cause additional damages, making bones brittle and causing arthritis. Signs of DCS usually appear within 15 minutes to 12 hours after surfacing; but in severe cases, symptoms may appear before surfacing or immediately afterwards. Delayed oc- ravelers planning trips to exotic beach divers not at risk and who follow all the safety currence of symptoms is rare, but does occur, resorts should be asked about their in- guidelines are sometimes affected. especially if air travel follows diving. Symp- Ttentions of going scuba diving and if toms include: unusual fatigue; pruritis; pain in so, whether they understand the health issues Decompression Sickness joints/muscles of the arms, legs or torso; diz- involved and are aware of the subtle signs of DCS results from inadequate decompression ziness; vertigo; ringing in the ears; numbness, early decompression illness. Like any sport, following exposure to increased pressure. The tingling and paralysis; and shortness of breath. scuba diving involves the risk of injuries. There condition varies from mild with no immediate are between three and four illness/injuries re- threat to serious injury requiring prompt treat- Also associated with DCSR are the following: ported for every 10,000 dives, with the vast ment to ensure full recovery. e a blotchy rash on the skin, muscular weak- majority of them minor, with complete reso- ness and paralysis, difficulty urinating, con- lution and no impact on future diving activi- During a dive, the body tissues absorb nitro- fusion, personality changes and bizarre be- ties. Permanent sequelae are rare. gen from the breathing gas in proportion to havior, amnesia and tremors, staggering gait, the surrounding pressure. As long as the diver coughing up bloody and frothy sputum, and Decompression illness (DCI) includes two remains at pressure, the gas presents no prob- collapse or unconsciousness. conditions, decompression sickness (DCS) lem. If the pressure is reduced too quickly, (also known as the bends or caisson disease), nitrogen comes out of solution, forming Prevention and arterial gas embolism (AGE). DCS is be- bubbles in the tissues and bloodstream. This lieved to be due to bubbles forming in body Recreational divers should dive conservatively, commonly occurs as a result of violating or following guidelines set forth in dive tables or tissue, causing local damage. AGE results from approaching too closely to the diving table bubbles entering the bloodstream, usually in computers. This is highly recommended for limits, but can occur when accepted guide- all divers, especially when diving in cold wa- the lungs, traveling through arteries and caus- lines are followed. ing tissue damage at distant points by block- ter or when diving under strenuous conditions. ing blood flow in small vessels. Risk factors Bubbles forming in or near joints are the pre- There are also published guidelines for flying for both include deep/long dives, cold water, sumed cause of joint pain or “the bends.” after diving. Different sources advocate wait- vigorous exercise at depth or immediately af- Bubbles forming in the spinal cord and brain ing a minimum of 12 to 24 hours after an un- ter surfacing, and rapid ascents. Obesity, de- may cause paralysis and other neurological complicated dive before flying. hydration, and pulmonary disease may play symptoms. Bubbles entering the bloodstream roles. And there are unknown factors involved; can cause pulmonary and circulatory problems. Continued on page 5

“Decompression Illness in Scuba Divers,” cont. from p. 4

Arterial Gas Embolism (AGE) Treatment sion of 1 liter over 30 minutes to correct any This occurs when divers surface without ex- The treatment for DCI (DCS and AGE) is dehydration and reduce hemoconcentration. haling. Air trapped in the lungs expands with recompression. Although divers with severe Then reduce the rate of administration to 100- ascent and may rupture lung tissue (pulmo- symptoms require urgent recompression, it is 175 cc/hour maintenance rate. Additional flu- nary barotraumas) and release gas bubbles into essential that they be stabilized at the nearest ids may be required to further correct dehy- the arterial circulation. Since the brain receives medical facility before transportation to a re- dration and maintain blood pressure but only the highest proportion of blood flow, it recompression chamber. Oxygen may reduce after weighing complications of fluid overload ceives the most bubbles. The bubbles become symptoms substantially but should not change and discomfort from urinary retention. If lodged in the small arteries of the brain and the treatment plan. Symptoms often clear af- possible, insert a urinary catheter. damage brain tissue. Pulmonary disease may ter initial oxygen therapy, but may reappear Definitive treatment requires a facility with a be a predisposing factor. later. A dive physician should always be con- recompression chamber. The Divers Alert tacted even if the symptoms and signs appear AGE can occur even when ascents are appar- Network (DAN) can assist in locating one. to resolve. ently normal. The most dramatic presenta- And DAN medical experts can contact the tion of air embolism is the diver who surfaces receiving facility to assist in diagnosis and, if Care of the Diver with necessary, treatment. This should be done even unconscious and remains so, or the diver who Decompression Illness loses consciousness within 10 minutes of sur- if the diver appears to be improving on oxy- facing. Obviously, these are medical emergen- I. Determine the Urgency of the Injury gen. While awaiting evacuation, take as de- tailed a history as possible and try to evaluate cies. Rapid evacuation to a treatment facility Make an initial evaluation at the dive site. and record the diver’s neurological status. If is paramount. But usually air emboli merely Suspect DCI if signs occur within 24 hours of air evacuation is used, cabin pressure should cause tingling or numbness, weakness with- surfacing. The initial state of the affected diver be maintained near sea level and not exceed out obvious paralysis, or difficulty in think- will determine the order and urgency of the 800 feet/244 meters unless aircraft safety is ing without obvious confusion. Individuals are actions taken. The U.S. Navy uses a three- compromised. awake or easily aroused. In these cases, there part category system: is time for more thorough evaluations, prefer- Place the diver in the lateral recumbent posi- • Category A. Emergency ably by a diving medical specialist who can tion, also known as the recovery position. This rule out other causes of symptoms. • Category B. Urgent puts the person on one side (usually left) with As with DCS, ascribing mild symptoms to a • Category C. Timely head supported at a low angle and the upper non-dive cause delays or results in no treat- leg bent at the knee. If vomiting occurs in this ment, and symptoms resolve, though damage Category A - Emergency position, gravity will assist in keeping airway has occurred. This increases the risk of re- Symptoms are severe and appear rapidly, clear. sidual symptoms after a future bout of AGE, within an hour or so of surfacing. Uncon- even if the later bout is treated. sciousness may occur. Symptoms may be pro- Category B - Urgent Cases of gressing. The diver is obviously ill, may be DCI The signs and symptoms of AGE include diz- profoundly dizzy, have trouble breathing or Here, the only obvious symptom is severe ziness, blurring of vision, weakness and pa- altered consciousness and abnormal gait or continuous pain, no other signs of distress, ralysis, areas of decreased sensation, chest pain, weakness. and no obvious neurological signs, though a disorientation, bloody froth from the mouth careful history and physical may elicit some or nose, seizures and unconsciousness. If indicated, begin CPR and arrange for imme- findings. diate evacuation. Check for foreign bodies in The percent of diving problems due to AGE the airway. If ventilatory or cardiac resuscita- Give the injured diver 100 percent oxygen and has decreased substantially over the years, tion is required, the injured diver must be su- fluids by mouth. Do not treat pain with an- from 18% of reported cases of DCL in the late pine. Vomiting in this position, however, is algesics until advised to do so by experienced 1980s to less that 10% now, probably due to extremely dangerous; if it occurs, quickly turn medical personnel. Continue oxygen until ar- the advent of dive computers, which help chart the diver to the side until the airway is cleared rival at the medical treatment facility. Even if the rate of ascent, reminding divers to slow and resuscitation can resume in the supine symptoms improve, contact a medical facil- down. position. ity or DAN on what sort of transport is indicated. Emergency air transport may not be Caregivers should use supplemental oxygen if Preventing AGE necessary. As with category A patients, take a available during ventilatory support to the Breathing normally and relaxing during ascent history and evaluate and chart neurological injured diver. Even if CPR is successful and helps prevent AGE. Asthma, respiratory in- status. fections, obstructive lung disease and other the diver regains consciousness, 100 percent pulmonary pathology predispose divers to air oxygen should be provided and continued un- Category C - Timely Cases of embolism. Divers with these conditions til the diver arrives at a medical facility. Ad- DCI should be evaluated by a physician knowl- vanced divers are also encouraged to take oxy- Symptoms are vague, perhaps complaint of edgeable in diving medicine. gen provider course. some pain or abnormal sensations over a few If trained healthcare personnel are available, days. The diagnosis of DCI may be in ques- an IV with isotonic fluids without dextrose should be started. Give an initial rapid infu- Continued on page 6

“Decompression Illness in Scuba Divers,” cont. from p. 5

• Joint or other musculoskeletal pain includ- Advocating Safe Diving Learning to ing: location, intensity and changes with Many dive related injuries are also associated movement or weight-bearing; with poor technique and with “quickie instruc- screen • Distribution of rashes; and tions at resorts.” Proper certification by qualified dive shops can decrease this risk. • Traumatic injuries before, during or after candidates for the dive. Divers and Malaria Information regarding the injured diver’s neu- Mefloquine has been associated with a de- rological status will be useful to medical per- crease in fine motor reflexes and is listed as a diving can be sonnel in not only deciding the initial course contraindicated medication for divers (although of treatment but also in the effectiveness of some authors dispute this). It is best to use an very useful for treatment. alternative antimalarial in divers. Returned Travelers References: travel Although unlikely, with modern transport it 1) Dive and Marine Medicine (3rd Confer- is possible that travel medicine practitioners ence. March 2000, sponsored by The Under- will see a returned traveler with symptoms of sea and Hyperbaric Medical Society. medicine DCI. Such patients should receive oxygen immediately and be sent to an emergency fa- 2) Dive and Travel Medical Guide Ed cility for assessment for hyperbaric treatment. Thalmann, Editor, Revised 1999, published practitioners. by D.A.N. Finding a Dive Physician 3) Bore, Alfred A and Davis, Jefferson C. tion. Take a complete diving history and do a Dive physician may be available through local (1990) Pub W.B Saunders. Diving Medicine. neurological evaluation. Call the nearest medi- military hospitals. Many Navy and Air Force cal facility or DAN for advice, or go to the physicians are knowledgeable about the sub- 4) Edmonts (1978) Diving and Sub Aquatic nearest medical facility, if nearby, for evalua- ject and so are some occupational medicine, Medicine 2nd Edition. 6) Divers Alert Net- tion. emergency medicine and sports physicians. work. Report on Decompression Illness and Practitioners may vary in experience from Diving Fatalities 2000 Edition. In all cases of DCI try to document the 48 doing simple dive physical clearances to full hours preceding the injury: 5) Undersea and Hyperbaric Medical Society certification in hyperbaric medicine. Inc. (July 21, 1995) Published meeting. Are • Depths/times of dives, ascent rates, inter- Asthmatics Fit to Dive? vals between dives, breathing gases, prob- Becoming a Dive Physician lems or symptoms at any time before, dur- Learning to screen candidates for diving can 6) D.A.N Website link: http://www.divers ing or after dives; be very useful for travel medicine practitio- alertnetwork.org/ • Times of onset of symptoms and progres- ners. Guidelines for diving fitness are straight- sion after the diver surfaced from last dive; forward although there are some differences Gary lives in Winnipeg, Canada where he op- in the American, British and Australian defini- erates a travel clinic. Karl is the editor of this • First aid measures taken (times, method, tions of fitness and precluding conditions (see Newsletter. We thank DAN for allowing us to and percent of oxygen delivery) and their references). Introductory courses in Dive freely use their information and data. Gary effect on symptoms since the injury; Medicine are regularly scheduled through the adapted the material for travel medicine prac- • Results of on-site neurological examination; Divers Alert Network. titioners.

About Dan Divers Alert Network (DAN) is non-profit medical and research organization dedicated to the safety and health of recreational scuba divers and travelers. Associated with Duke University Medical Center (DUMC), DAN is supported by the largest association of recreational divers in the world. Founded in 1980, DAN has served as a lifeline for the recreational scuba industry by operating scuba diving’s only 24-hour emergency hotline, a lifesaving service for injured divers. DAN members have access to full-time travel assistance and emergency medical evacuation as well as help with legal, personal and travel information. Additionally, DAN operates a diving medical information line, conducts vital diving medical research, and develops and provides a number of educational programs for everyone from beginning divers to medical professionals. DAN also supports, through education and training, a network of recompression chambers worldwide for the treatment of injured divers. Divers Alert Network is supported by membership dues and donations. In return, members receive a number of important benefits including $100,000 emergency medical evacuation assistance, DAN educational publications, a subscription to Alert Diver magazine, and access to diving’s first and foremost accident insurance coverage.

6 Newsletter of the International Society of Travel Medicine © 2006 ISTM Travel Medicine NewsShare 2006 May/June 2006 Contact DAN • DAN America • DAN Europe • DAN Japan • DAN Southeast Asia-Pacific • DAN Southern Africa

DAN America (International DAN Europe DAN Southeast Asia-Pacific Headquarters) Geographical Europe, European Territories, (SEAP) United States and Canada, with regional IDAN and Protectorates, with regional IDAN re- Australia and New Zealand, with regional responsibility for Central and South America, sponsibility for the countries of the Mediter- IDAN responsibility for Papua New Guinea, the Caribbean, Polynesia, Micronesia and ranean Basin, the countries on the shores of Fiji, Indonesia, Malaysia, Vietnam, Singapore, Melanesia (except Fiji), and any other area the Red Sea, the Middle East including the Cambodia, Myanmar, Philippines, Vanuatu, not designated below. Persian Gulf, the countries on the shores of India, Solomon Islands, Brunei, Thailand, the Indian Ocean north of the Equator, as well Hong Kong, Korea, China and Taiwan. The Peter B Bennett Center as the related overseas territories, districts, 6 West Colony Place and protectorates. P.O. Box 384 Durham, NC 27705-5588 Ashburton, Victoria 3147 USA P.O. Box DAN AUSTRALIA 64026 Roseto (Te) 61-3-9886-9166 1-800-446-2671 Toll-Free ITALY 61-3-9886-9155 Fax 1-919-684-2948 General Inquiries 39-085-893-0333 1-919-490-6630 Fax 39-085-893-0050 fax Diving Emergencies 1-919-493-3040 Medical Fax Diving Emergencies DES Australia Diving Emergencies 1-800-088-200 (within Australia) DAN Europe 61-8-8212-9242 (outside Australia) DAN America 39-039-605-7858 1-919-684-8111 DAN / DES New Zealand 1-919-684-4326 (accepts collect calls) Non-Diving Emergencies and 0800-4DES111 DAN Latin America TravelAssist Services Singapore Naval Medicine & Hyperbaric Cen- 1-919-684-9111 (accepts collect calls) 39-039-605-7858 ter 67-58-1733 Non-Diving Emergencies & TravelAssist Services DAN SEAP - Philippines 02-632-1077 1-800-326-3822 (1-800-DAN-EVAC) DAN Japan 1-919-684-3483 (Call collect if outside the Japanese mainland and islands, with regional DAN SEAP - Malaysia USA, Canada, Puerto Rico, Bahamas, British IDAN responsibility for Northeast Asia-Pa- 05-930-4114 or U.S. Virgin Islands) cific. DAN SEAP - Korea Japan Marine Recreation Association 82-010-4500-9113 Kowa-Ota-Machi Bldg, 2F, 47 Ota-Machi 4- Chome DAN Southern Africa Nakaku, Yokohama City, Kagawa 231-0011 South Africa, Swaziland, Lesotho, Namibia, Japan Botswana, Zimbabwe, Mozambique, Angola, 81-45-228-3066 Zambia, Zaire, Malawi, Tanzania, Kenya, 81-45-228-3063 fax Madagascar, Comoros, Seychelles, and Mauritius. Diving Emergencies Private Bag X 197 DAN Japan Halfway House, 1685 81-3-3812-4999 SOUTHERN AFRICA 2711-254-1991 or 2711-254-1992 2711-254-1993 fax Diving Emergencies DAN Southern Africa 0800-020111 (within South Africa) 27-11-254-1112 (outside South Africa)

Best Ethical Travel Destinations Jeff Greenwald and Kiran Auerbach After compiling this data from the US De- partment of Commerce, Ethical Traveler took a look at the rest of the developing world, including two continents not on the list: Af- rica and Europe. (Europe, the most popular destination for American travelers, is not considered "developing," but several of the new Eastern European nations do fit that descrip- tion.) To determine "ethicalness," they investigated three categories: ecotourism practices, environmental standards, and social development indicators. Their research was conducted at Stanford University, using information from a variety of national and international sources. Ecotourism Over the past 20 years, the meaning of ecotourism has evolved. But even though many organizations have different definitions, key principles remain universal: conservation of the natural environment, low visitor impact, and benefit to the local population. Since ecotourism is such an attractive policy, many governments loudly profess their com- uring the past 20 years, the phrases the most environmentally and socially pro- mitment towards the industry. As a result, it's "ecotravel" and "ethical travel" have gressive places to actually spend our tourism often difficult to separate spin from reality. Dentered the globetrotter's lexicon. The dollars. The results were surprising - and in- Still, credible agencies like The International first term has been so co-opted and abused structive. Ecotourism Society (TIES) have singled out that it's practically stripped of meaning; even Ethical Traveler's goal was to formulate a list countries with strong commitments to pres- huge luxury hotels and cruise ships tout of the "Best Ethical Travel Destinations," ervation. Belize (for its Mayan sites), Brazil money-saving tactics like "gray water" reuse specifically geared to outbound American lei- (national parks), Ecuador (Galapagos Islands and energy-saving laundry practices as evi- sure travelers. The idea was not just to come and Amazonian rainforest), Kenya (wildlife dence of their commitment to ecotourism. up with a list of countries, but also to choose reserves), Nepal (mountain trekking), Peru Ethical travel is a more recent concept, and a places that Americans would actually want to (bird watching), and South Africa (game and much more demanding one. It fulfills both in- visit. nature reserves) all make the grade. dividual and collective ideals: a traveler expe- Here, alphabetically, are the most popular The best-known ecotourism destinations are riences environmental beauty and cultural im- developing-country destinations for American probably Costa Rica and Bhutan. With a vi- mersion while actually contributing to the eco- tourists: brant tourism industry that centers around its logical preservation and social development cloud forests, turtles, and volcanoes, Costa of their host country. This brand of travel com- Most Popular Developing World Rica has served as an inspiration for other bines ecotourism with broader environmental Destinations Latin American countries, such as Ecuador, and social issues. It can even be used as an Peru, and Honduras. Bhutan, though, is the economic carrot, to support and reward coun- Bahamas Brazil "poster child" for ecotourism. Their entire tries pursuing high standards in these areas. tourism industry is based on sustainability, It's also more demanding of service providers; China Costa Rica and an effort to attract "low volume, high qual- hotels and carriers can't simply tweak a few ity" visitors willing to pay a handsome fee for ecopolicies and award themselves gold stars. Dominican Republic India the privilege of visiting the pristine Himalayan For a country to be considered a good ethical kingdom. travel candidate, the government must dem- Jamaica onstrate a strong commitment not just to the Mexico Because of its direct link between the local environment, but to the well-being of its popu- Philippines environment and population, ecotourism was lation as well. South Korea the single most important factor Ethical Trav- Taiwan eler used in determining "ethicalness." But even Ethical Traveler recently conducted a study Thailand countries with strong ecotourism values are to learn where Americans tend to travel in the Trinidad and Tobago developing world, and how this compares with Continued on page 8

“Best Ethical Travel Destinations,” cont. from p. 7

for children under five actually increased between 1990 and 2003. In education, Barba- dos, South Korea, Slovenia, and Uruguay ex- cel, as does Argentina. Women's status is strong in Jamaica, Mexico, South Africa, Sri Lanka, and Uruguay. It's poorest in Egypt, India, and Nepal. The worst commitment to human and labor rights was measured in Thailand (which also has the highest government corruption index) - and, unexpectedly, Bhutan. The Kingdom of Bhutan has failed to ratify five human rights treaties, and has not approved a single international labor rights convention. Best Ethical Travel Destinations Argentina Barbados Belize Brazil Costa Rica Croatia Ecuador Kenya Peru sometimes careless of broader human rights Social Development Slovenia issues. That's why it's also crucial to examine While it's true that ecotourism benefits the Sri Lanka the environmental and social progress of a local population, it's usually a very local popu- South Africa country. lation. The inhabitants of a tract of rainforest Uruguay may thrive from the sale of creams made from The most provocative results of the social Environmental Protection their plant extracts, but this doesn't do much category, in fact are the abysmally low rankings Ethical Traveler's environmental evaluation for people in the urban centers - or even the of Bhutan, especially in light of its forward- took into account six factors: Carbon dioxide neighboring tribes. Thus, ethical travel has to looking ecotourism practices. On the other emissions, energy efficiency, percentage of include a country's overall social development, hand, high social development was a crown- protected land, percentage of mammals under to determine how committed the government ing achievement for Argentina, Barbados, threat, the environmental sustainability index, is to its entire citizenry. Costa Rica, Sri Lanka, and Uruguay. and the number of major international environmental treaties ratified. This was an at- Social development was the broadest of the Conclusion tempt to learn how serious, ecotourism in- three categories, with seven factors to consider. Ethical Traveler put income distribu- The final list of ethical destinations in the de- dustry aside, a country is in protecting its veloping world was compiled with care, and environment. tion, health, and education under the micro- scope, using reports from the UN and the should serve as a practical guide for American Seven countries earned very high environmen- WHO, among others. But they also took into tourists looking for vacations that are both tal ratings: Argentina, Bhutan, Brazil, Costa account crime, government corruption, and the self-rewarding and supportive of the people Rica, Peru, Sri Lanka, and Uruguay. All boast status of women. Finally, as a gnomon of on- and environments we visit. low CO2 emissions, steady progress in en- going progress, they looked at how many in- The most notable and unexpected result is that ergy efficiency, and a policy of signing trea- ternational human rights and international la- Latin America emerges as the leader in ethical ties designed to protect the Earth's ecosphere. bor rights treaties each country had ratified. travel. While certain recommended destina- Tourist favorites that came out on the nega- The results were sometimes counter-intuitive. tions are already popular (Brazil, Costa Rica, tive side included Kenya, with extremely poor They found that Sri Lanka, Nepal, Croatia, and Peru), other top countries (Argentina, energy efficiency, as well as Trinidad and To- and Slovenia all relatively low levels of in- Barbados, Belize, Ecuador, and Uruguay) also bago. Ironically, the five countries with the equality - while South Africa, Panama, and El have much to offer American tourists. Argen- highest percentage of threatened wildlife Salvador have high disparities. tina has a vast array of natural wonders: from (above 20%) also rank among the most popu- glaciers in the Andes to pre-Columbian vil- lar US travel destinations: The Dominican Healthwise, the Bahamas, Costa Rica, Barba- dos, Sri Lanka, and Uruguay took highest lages in the North. Belize hosts Mayan ruins, Republic, Jamaica, India, the Philippines, and as well as a lush rainforest. Uruguay, not as South Korea. rankings (though both India and China have made big improvements in this area). Kenya was again a disappointment; its mortality rate Continued on page 9

“Best Ethical Travel Destinations,” continued from p. 8 NewsShare well known, contains spectacular beaches as the Newsletter of the International Society of Travel Medicine well as trekking in the interior. ISTM EXECUTIVE BOARD Croatia's beautiful beaches make it a viable PRESIDENT: Prativa Pandey, M.D., Nepal alternative to Italy, France, or Greece. Slovenia is also a great destination, with impressive PRESIDENT ELECT: Frank von Sonnenburg, M.D., Germany underground caves, thermal springs, alpine PAST-PRESIDENT: Bradley A. Connor, M.D., USA skiing, and nature trails. COUNSELOR: Ron Behrens, M.D., UK COUNSELOR: Nancy Jenks, R.N., USA Sri Lanka, recovering from the Indian Ocean COUNSELOR: Kevin Kain, M.D., Canada tsunami, is outdoing India in both environ- COUNSELOR: Eli Schwartz, M.D., Israel mental and social development standards. And SECRETARY/TREASURER: David Freedman, M.D., USA though South Africa and Kenya lag a bit in both environmental and certain social measures, EX-OFFICIO MEMBERS good ecotourism values are their redemption. Ethical Traveler included these countries as a EDITOR, JOURNAL OF TRAVEL MEDICINE: Robert Steffen, M.D., Switzerland nod to their valiant strides in ecotourism, and NEWSSHARE EDITOR: Karl Neumann, M.D., USA in the hope that American travelers will help WEB EDITOR: Hans D. Nothdurft, M.D., Germany support a region that the international com- NECTM CHAIRPERSON: Fiona Genasi, R.N., UK munity habitually neglects. ISTM COMMITTEE CHAIRS Ethical travel to developing countries offers a positive, symbiotic exchange between travel- CERTIFICATE OF KNOWLEDGE EXAM: Phyllis Kozarsky, M.D., USA ers and their destination. By "voting with our DEVELOPMENT: Frank von Sonnenburg, M.D., Germany wings," tourists give their economic support HEALTH OF MIGRANTS AND REFUGEES: Brian D. Gushulak MD., Canada to such societies, raise the standard of living HOST COUNTRIES: Santanu Chatterjee, M.D., India for the population, and reinforce programs MEMBERSHIP: Bradley A. Connor, M.D., USA that protect the environment. The reward trav- PRACTICE AND NURSING ISSUES: Rebecca Acosta, R.N., USA elers receive is also worthwhile: a memorable PROFESSIONAL EDUCATION & TRAINING: Michelle Barry, M.D., USA vacation, and the realization that, although the PUBLICATIONS: Charles Ericsson, MD, USA world is getting smaller, some parts of it are RESEARCH: Anne McCarthy, M.D., Canada actually getting better. TRAVEL INDUSTRY & PUBLIC EDUCATION: Trish Batchelor, M.D., Australia About Ethical Traveler. Ethical Traveler is a grass-roots alliance uniting adventurers, tour- ISTM SECRETARIAT ists, travel agencies, and outfitters - everyone ADMINISTRATIVE DIRECTOR: Brenda Bagwell, USA who loves to travel, and sees travel as a posi- ADMINISTRATIVE ASSISTANT: Brooke Gouge, USA tive force in the world. Ethical Traveler feels P.O. BOX 871089 that all travelers are, in effect, freelance am- STONE MOUNTAIN, GA 30087-0028 USA bassadors. They also believe that we have the PHONE: 770-736-7060, FAX: 770-736-6732 ability to join our voices, and to use our economic power to strengthen human rights and EMAIL: [email protected] protect the environment. WEB: WWW.ISTM.ORG About the Authors. Researcher and co-author Kiran Auerbach received her B.A. in Interna- tional Relations from Stanford University in Ireland: Graham Fry 2005. She currently resides in Vienna, Aus- Indonesia: Hanny G. Moniaga tria, where she is studying violin and interning Japan: Yuka Ujita at the Ludwig Boltzman Institut für Editor: Karl Neumann, USA Peru: Eduardo Gotuzzo Menschenrechte (Institute for Human Rights) Assistant Editor: Eric Walker, UK Singapore: Helen M.L. Oh in Vienna. Assistant Editor: Peter Leggat, Australia Assistant Editor: Gary Podolsky Co-author Jeff Greenwald is a bestselling ISTM NewsShare travel and science writer with five books and Regional Editors: 108-48 70th Road hundreds of magazine, radio, and Internet fea- Australia: Jonathan Cohen Forest Hills, NY, USA 11375 tures to his credit. Mr. Greenwald is also a co- Austria: Martin Haditsch Tel: 718-263-2072 founder of Ethical Traveler, where he serves Hong Kong: Abu S. M. Abdullah Fax:718-575-0290 as Executive Director. India: Santanu Chaterjee E-mail: [email protected]