Sunday, 29 April 2012

The Amazing Race 20, Episode 10

Cochin, Kerala (India)

The two most recent episodes of The Amazing Race 20 in India have highlighted some of fairly typical medical hazards of travel in tropical Third and Fourth World countries.

Mark nearly collapsed from heat exhaustion after several hours of physical activity standing outdoors under full sun in the heat and humidity, barely finished the last leg of the race, and needed intravenous rehydration at the “pit stop” before he could go on.

Vanessa tripped and fell on the uneven surface of a roughly-paved lane, leaving her with “road rash” on her shoulder and worried that she might have aggravated an old ankle injury.

JJ cut his hand on the sharp-edged metal frame of a packing crate he was filling with dried ginger as one of the racers’ local tasks, and several of the racers cut their hands on the rope-making machinery they had to use for one of their tasks.

I’m not a doctor, and I won’t try to give you medical advice or try to second-guess the doctors who accompany the race as part of the TV production team. But I think there are still some health and safety lessons that can anyone can learn from watching the race.

Some of the tasks and challenges that are shown on The Amazing Race are things that you probably shouldn’t try on your own. When you think about doing something you’ve seen on a “reality” TV show, keep in mind that part of the “reality” is the presence, off-camera but always nearby, of a camera and sound crew accompanying each pair of racers, and an extensive on-call location support staff.

In the real world of your own independent travels, you won’t usually have an escort watching over you, or professional assistance (including a doctor) so close at hand.

You can call on any local people and/or fellow travellers who happen to be nearby for help if you get sick or hurt, and they will generally do whatever they can. But if you got to a village by foot, bicycle, or motorcycle taxi along a track that isn’t passable for cars, an ambulance to take you to a hospital may not be available for any amount of money.

Much of the population of the Fourth World (and of mountainous parts of the Third World) lives a considerable walk from any motorable road. The only way to get to a doctor may be to go back the way you came: on foot, on the pillion of a motorbike, or on some sort of beast of burden. That’s probably how those villagers who can afford medical care get to a doctor (unless they wait for a doctor or other medical practitioner who comes to the village, or to one a shorter walk or ride away, on weekly or monthly rounds).

In the Third World, at least in more accessible lowlands, there’s a good chance that even a village is reachable by some sort of road. But the road may be rough, rutted, muddy, and passable only by high-clearance vehicles. It may take time for any motor vehicle to arrive. And the only vehicles available may be trucks or rudimentary buses that provide a painfully jolting ride for someone injured or ill.

Before I do something that seems potentially risky while travelling, I try to evaluate not just, “How likely am I to get hurt?” but also, “What would I do in this place, in these conditions, if I did get hurt?” The consequences of a misstep may be much more serious than they would be at home, where you could take for granted that an ambulance, if needed, would be only a few minutes away.

You may be no more likely to twist your ankle on the road than at home. In practice, however, the same activities are often more likely to result in injuries while you are travelling, because:

  • You are in unfamiliar conditions where you don’t know which unfamiliar hazards to watch out for, and are distracted by sightseing and cultural disorientation. When everything around you seems strange, normal mental “alarms” — which are triggered by stimuli that don’t match familiar patterms, and normally serve to warn of hazards — sound constantly. This leads travellers either to panic (“culture shock”) or to tune out their mental alarms entirely, making them less likely to notice when something turns out to be not merely “strange” but also genuinely risky.

  • Safety is a luxury of the rich. It’s easy to misinterpret, “Local people are doing this without any safety equipment,” for “This must be perfectly safe.” It could be that everyone in a poor community does things a particular way because they can’t afford to do it any other way. It also could be that they’ve been practicing a particular skill all their lives, so that it really is safer for them to do it than it would be for you with no experience. Tasks that look simple — as the racers learned when they tried to spin “coir” (coconut fiber) rope — may require years of practice to do quickly, or to do without hurting oneself. Don’t underestimate the complexity and subtlety of “unskilled” labor just because it’s poorly paid or typically performed by people dressed in rags.

  • Travellers trying to see and do as much as possible in a limited time almost inevitably put themselves at elevated risk. Sleep deprivation, tiredness, overexertion, and hurrying are key safety factors on any job site. The same goes for travellers. One of many good reasons to travel more slowly, and get enough rest, is that it’s safer that way.

What’s noteworthy is that none of the racers’ ailments or injuries were “exotic” or peculiar to travel. That’s’ realistic: Most of the bad things that happen to travellers are things that could have happened at home. The difference is how likely they are while travelling (some bad things, such as violent crime, are significantly less likely in most of the rest of the world than in the USA) and how serious the consequences are likely to be.

You could get heat exhaustion if you exercised outside all afternoon on a humid summer day at home (perhaps without drinking enough if the local water isn’t safe to drink). But if you didn’t have travel plans you had to keep, you’d probably slow down, or take a day or two to rest and recover, rather than trying to continue your trip right away like the racers or many travellers on fixed itineraries. One reason not to commit yourself to a hard-to-change schedule in a place like India is that you can’t predict on which days of your visit to India you’ll have traveller’s diarrhea and not want to get on a bus, train, or plane.

You could trip and fall, and scrape or sprain yourself, anywhere. What’s different while travelling, especially outside the First World, is how easy or hard it will be to get treatment, and how much damage it may do if you don’t see a doctor soon enough.

My travelling companion had emergency surgery on a badly broken ankle in Ecuador after a fall, probably with no worse long-term consequences than if she had been in the USA. Four days in the best hospital in the country, including surgery by the chief of the trauma department, cost about US$2500. But there was no rapid-response ambulance to take her to the hospital (a friend took her in a car, which was adequately fast but more painful), and the outcome could have been very different if we had been hiking or in more remote towns and villages, as we had planned, rather than still in the capital.

In general, my impression from years of experience as a travel agent, and the stories told by clients who have had to cut short their trips, is that travellers tend to:

  1. Overestimate the exotic risks (tropical disases, terrorism, airplane crashes, etc.);
  2. Underestimate the routine risks (road accidents, slips and falls, infected cuts and scrapes, sexually transmitted disases); and
  3. Wait longer than they should before they seek professional medical attention, letting fear of foreign doctors and the logistical diffculty of finding a competent doctor trump the possibility of adverse long-term health consequences.

Far more often than necessary, people who have let an injury or serious illness fester for too long before seeking medical attention come home needing long-term follow-up treatment and/or having done permanent damage to their bodies by postponing treatment.

Ignoring any significant orthopedic injury, or relying on painkillers and/or anti-inflammatories to get through your trip, can result in lifelong joint pain or loss of range of movement.

The smallest infected, untreated wound can suddenly become life-threatening. The combination of heat, humidity, and poor sanitation, which creates favorable conditions for infections, means that in the tropics of the Third and Fourth Worlds, minor cuts and scrapes are much more likely to require at least careful first aid for several days if they are to heal, and prompt professional medical attention if they show any signs of spreading or persistent infection.

Good, often excellent, medical care is available in almost any country, although often only in big cities. In places where it’s available at all, it’s typically easier to find than most travellers from the USA expect — we have an exceptionally complicated medical “system” — and almost always cheaper than similar medical services would cost a foreigner paying out of pocket for walk-in medical care in the USA. (Insurance for catastrophic medical costs is essential for foreign visitors to the USA, who may find treatment in the USA for even minor injuries, much less a “routine” car crash or other emergency, shockingly expensive.) Most hospitals anywhere have at least some doctors who can communicate on medical subjects in basic English.

Medical care in remote and/or poor communities may be poor or nonexistent, but there’s no reason to be afraid to consult a big-city doctor recommended by local expatriates, local people who can afford good medical care for themselves, or in a pinch (and probably more expensively) one recommended by your country’s local embassy or consulate.

Far from home, fear of strange doctors and the inertia of a planned itinerary are often reinforced by the sense that, “This is a once-and-lifetime trip, and if I don’t do this now I’ll never get another chance.” Seeing a doctor might mean paying to change your plans, and/or taking a long bus ride to a big city where there are enough people wealthy enough to support adequate medical facilities and competent doctors. I’ve heard from many travellers, though, who would rather have cancelled or cut short a planned trek or tour, even at some expense, than have had to cope with long-term medical consequences from trying to stick to their itinerary. Travel isn’t war, and there are no “Purple Hearts” for travellers who “soldier on” despite injury or illness.

Link | Posted by Edward on Sunday, 29 April 2012, 23:59 (11:59 PM)

It's not that there was no ambulance available when I broke my ankle. There might have been. I just didn't know how to summon an ambulance, and, because of shock and fear, didn't have the language skills to find out.

Posted by: Edward's traveling companion, 3 May 2012, 15:58 ( 3:58 PM)

I knew I was tired and grouchy when we arrived in Burma from Bangladesh. We put off seeking medical care until we arrived at Inle Lake where we spotted a pharmacy near where we stayed. We were struggling to explain my symptoms when a man in a lab coat walked up and put a stethoscope to my chest. "Bronchitis" he said and prescribed several medicines. I spent the next day resting in our room and felt considerably better by nightfall when my wife returned. She, who had never been outside the US before this trip except to England and Cancun, smiled broadly as she told me of her adventures during the day. She had walked through the town, played with some local kids and gave some appreciative teenaged boys a lesson in English. We both thoroughly enjoyed the remainder of our Burma journey except the ordeal getting from Kyengtung to the Tachilek/Maesai border in the "golden triangle". We were in a cab with a honeymooning Burmese couple and were stopped 6 times for security checks along the 100 mile roadway.

Posted by: Jerry Jackman, 3 May 2012, 18:13 ( 6:13 PM)

Good commentary, I have had occasion to criticise some of your commentary on 'third world' issues but this is good practical advice.

It remains to ask why the Amazing Race indulges in such stupid tasks when the risks are so obvious??

Posted by: Barry, 4 May 2012, 00:54 (12:54 AM)

Wonderful post. Thank you.

We are 10 months into our 12 month trip. Even though I am a doctor, we've visited doctors along the way. All with good success. Of course, it was hard to watch as my son got stitches in Bali. I did intervene at one point there.

What I liked in your blog was your statement about the dangers of violent crime in the world. We have felt so safe on this trip except for maybe the driving in India, and Kenya, and Vietnam. The day before we left a man in Walnut Creek, when told about our trip, said, "That sounds dangerous." Maybe that's why he lives in Walnut Creek and I live in Oakland.

Thanks again for all your posts. We were in Kerala. It was wonderful.

Posted by: Annie Mohler, MD, 4 May 2012, 14:50 ( 2:50 PM)
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