Dr. Rose Recommends for Healthy & Safe Travel
Health Guide Chapter 19
Business Travel and Health
Corporations have the responsibility to ensure that employee travel is as safe and secure as possible.
This responsibility also extends to an employee's family when they accompany the employee abroad.
Trip preparation must take into account the stress factors not usually encountered by the traveling tourist.
Business travelers should have 24-hour access to an assistance center that can provide emergency medical evacuation or deal with any security/safety issues that may arise.
Business travel is increasingly international in scope, and more companies are taking steps to protect the health and safety of their employees who are traveling or living abroad. The reason? Business travelers may be at significant risks for travel-related health and safety problems.
Business travel is different from tourism. In addition to the multitude of tropical and infectious diseases that the business or corporate traveler may be exposed to, these travelers are often under higher stress because of job performance requirements, tight schedules, sudden departures, separation from home and family—plus the increased fear of kidnapping or a terrorist incident. If you are on a long-term assignment overseas, not only you but also your spouse must deal with culture shock and must adapt to living abroad.
As a corporate or business traveler, you need to maintain a high degree of personal health at home, know your medical history, and have access to your medical records. Maintain a close relationship with your corporate medical department. If your company does not have a medical department, contact a travelers' clinic for advice, shots, and medications.
Routine Immunizations These immunizations should be kept up to date and include the following:
Trip-Specific Immunizations More and more business trips occur at short notice, so many travelers barely have time to book their tickets and pack their suitcases, let alone time to arrange a visit to their travel clinic. Also, many travelers are unaware that certain immunizations (such as hepatitis B) require up to three injections spanning 6 months.
Many travel-health professionals now practice “proactive” vaccination management so that the traveler is “ready to travel” at any time. The traveler is given the appropriate vaccinations for the most likely destinations and these are kept up to date. These vaccinations may include: hepatitis A, hepatitis B, typhoid, cholera, meningococcal vaccine, rabies, Japanese encephalitis, and/or yellow fever. A baseline PPD/Mantoux skin test for tuberculosis may also be appropriate.
Yellow fever vaccine can be administered only in certified clinics, or at a health department. The vaccination is recorded in the WHO “International Certificate of Vaccination” booklet (often called the “yellow booklet” because of its color) and this must be produced when entering a country that requires proof of yellow fever vaccination. Note that the certificate is not valid until 10 days after receiving the vaccination. Not having a valid vaccination certificate could mean being quarantined, denied entry to a country, or, even worse, being vaccinated on the spot, possibly with a non-sterile needle/syringe.
Hepatitis A Hepatitis A is the most common vaccine-preventable disease in the world and is very common in all developing and even some developed countries. The first dose of the two-shot series gives good protection, even if administered just before departure. The second dose, usually given 6 to 18 months later, essentially gives you lifelong immunity to this disease. The hepatitis A vaccine is now considered practically routine for foreign travel.
Hepatitis B Certain travel-health professionals recommend hepatitis B vaccination for all international travelers. However, vaccination is certainly recommended for all health-care workers and expatriates and frequent visitors to developing countries. It is important if there is a possibility of receiving medical or dental injections abroad or the possibility of new sexual partner(s) during the stay. Counseling on body fluid and blood precautions—as well as safe sex—is strongly recommended before departure.
Sexually acquired hepatitis B may be a significant threat to the health of corporate travelers. A study in the British Medical Journal reported a 50% exposure to the hepatitis B virus over a 5-year period in expatriate male company employees in Southeast Asia. Sexual contact with the local populace was the apparent mode of transmission. Males, especially those traveling to Asia or sub-Saharan Africa, where there is a high incidence of hepatitis B, and who want maximum protection against hepatitis B, should be immunized.
Medication—Talk to your travel-health advisor about the need for medication for the prevention or treatment of travel-related problems such as motion sickness, travelers' diarrhea, jet lag (short-acting sleeping pill?), altitude sickness, and malaria.
Start medication—If you're going to a country where there is the risk of falciparum malaria and your doctor has prescribed the prophylactic drug mefloquine, start this medication 2 weeks before departure. This time period will ensure protective blood levels of the drug and alert you to possible side effects.
Under special circumstances, your health-care provider may start you on a short-term course (2 weeks maximum) of prophylactic antibiotics to prevent travelers' diarrhea. This may be justified if your project demands your complete availability and physical well-being and you will be at high risk for illness.
Other Medications Carry enough of any medication that you might regularly use for the treatment of any chronic medical condition, such as for high blood pressure or diabetes.
Medical Kit/Travel Supplies Obtain a travel kit that contains basic first-aid supplies, plus analgesics, antacids, a quinolone antibiotic for treating travelers' diarrhea, loperamide (Imodium), antimalarial drugs (if needed), and perhaps a short-acting sleeping pill for jet lag. Mosquito repellents and permethrin clothing spray are very important when traveling to a country where there is the risk of malaria or other insect-transmitted diseases. A permethrin-treated mosquito net is often useful. (See checklist in Chapter 2)
Avoid Unsafe Sex and Unsafe Injections It's virtually impossible to get infected with HIV or hepatitis B if you avoid casual sexual relations (or at least practice safe sex), and avoid unsafe injections and unscreened blood transfusions. Although getting an unsafe injection overseas is unlikely, it can occur when travelers receive emergency medical or dental treatment in hospitals or clinics in developing countries. Some health-care facilities abroad can't afford disposable needles and syringes, so these items are sometimes recycled, usually without sterilization. Because of this situation, some travelers now carry kits stocked with sterile needles and syringes, suture supplies, and, in some cases, in case they need injections, wound repair, or intravenous fluids.
HIV Testing See if this applies to you. Test results are required by about 50 countries for long-stay travelers as a condition for granting certain types of visas. Country-specific testing requirements are available online (http://travel.state.gov) but you should contact that country's embassy or consulate before departure to verify the requirement.
Medical Care Abroad Your company may have a contract with a medical assistance or insurance company to look after its international travelers. Know who to call and how to access this system. If no such arrangement exists, make sure that you know how to find, or arrange for, medical care (and medications) abroad (see Chapter 16).
Travel Insurance If your company does not have a program, you should purchase travel health insurance to (1) pay your hospital bills on the spot or (2) evacuate you in event of serious illness or injury. The best travel policies also provide telephone access to an emergency assistance center through a 24-hour hotline. At the assistance center, medically trained multi-lingual personnel refer you to appropriate medical care, monitor your condition and, if necessary, arrange emergency evacuation if the standard of care in the local hospital is inadequate to treat your medical condition. In Chapter 17, you'll find a list of other companies that offer travel health insurance.
Medical Assistance An alternative method of protecting a traveling employee is for a company to purchase travel assistance directly. Your firm sets up a credit account with an assistance company. The assistance company will monitor your medical care, provide direct payments to overseas doctors and hospitals, and arrange evacuation, if necessary. Contact International SOS (215 942 8000), Medex Assistance Corporation (410-453-6300), or AXA Assistance (800-756-5900).
KIDNAPPING AND TERRORISM
Not only should you be concerned about your health, but you should also consider your physical safety. What are the risks of being kidnapped, hijacked, or taken hostage? What's the best way to reduce these risks? How should you react in a terrorist incident? When traveling to a hostile or unstable country, what rules should you follow to maintain a low profile? These and many other questions increasingly concern today's business traveler, especially after 9/11 and the escalating conflicts in the Middle East. Multi-national corporations and their employees are often the targets of insurgent or dissident groups who are trying to make a political statement, take hostages, or extort money.
Preparing for a Safe Trip
A large industry has developed in the field of corporate travel safety and security. If your company has a corporate security division, contact that office for a briefing. You also need to start some essential background reading. Suggested titles include The Safe Travel Book—A Guide for the International Traveler by Peter Savage (Lexington Books: 800-462-6420) and The Security Minute: How to Be Safe in the Streets, at Home, and Abroad So You Can Save Your Life! by Robert L. Siciliano (Safety Zone Press: 800-438-6223).
Safe Travel Tips
Dress like a high-profile business person
Carry expensive luggage
Display tickets from U.S. airlines
Wear shirts or hats with logos of U.S. corporations
Carry English-language publications in plain view
Take a nonstop flight
Send sensitive documents separately
Leave a detailed itinerary at the office
Carry medical evacuation insurance
Check Department of State travel warnings and advisories
Risk management firms, usually run by former employees of the State Department or CIA, have sprung up to meet the security needs of multi-national corporations and certain high-risk travelers. These firms do more than just arrange kidnap insurance. They can do the following:
Train employees to reduce their risk of being taken hostage
Conduct counter-terrorism-training seminars
Provide personal security training
Prepare a crisis management plan
Negotiate hostage release
Provide anti-kidnapping equipment (for example, armored vehicles)
Alert you to which airlines are under increased terrorist threat (and advise appropriate travel alternatives)
Provide detailed security advisory before travel to a high-risk country
Some well-known firms are listed below. Kidnap insurance is arranged through their affiliated underwriter:
The Ackerman Group, Inc.
1666 Kennedy Causeway
Miami Beach, FL 33141
Control Risks Group, LLC
1600 K Street, NW
Washington, DC 20006
iJET Travel Risk Management
910F Bestgate Road
Annapolis, MD 21401
Parvus International/Armor Group
1401 K Street, NW, 10th floor
Washington, DC 20005
International SOS Assistance, Inc.
3600 Horizon Boulevard, Suite 300
Trevose, PA USA 19053
215-942 8000 or 1-800-523-8930
BUSINESS TRAVEL AND STRESS
Your Health May Be at Risk
Business travel can be stimulating and rewarding, but it also can be stressful to the point of jeopardizing your health. In fact, a study by the Hyatt Hotels Corporation found that business travel lasting more than 5.2 days interfered significantly with a traveler's personal life.
The problem is more than just chronic jet lag. Frequent departures on short notice, high-pressure work schedules, job-performance anxiety, living in hotels and motels, traveling alone and feeling isolated, eating calorie-dense restaurant and airline foods, and not exercising all take their tolls. Add to this being separated from your home, your family, and your usual routines. No wonder you feel depressed and lonely—even disoriented at times. You may start to smoke and drink too much or overeat. You need a sleeping pill at night and then a tranquilizer in the morning. Fatigue mounts and performance suffers. Things spiral downward. The possible outcome? Burnout or worse. You need a plan.
Start with physical fitness. A regular exercise program promotes physical and mental health. Exercising also helps control your weight and combats insomnia. Not being fit can lower your self-esteem. What's the best exercise? It's the one you like doing, but experts often recommend either walking or jogging. You can do them almost anywhere, without charge, and they build aerobic stamina.
Plan the exercise activities you want to pursue during your trip and pack the necessary equipment: footwear, gym gear, bathing suit, tennis racquet, etc. Take into account the climate (how hot?) and the geography (seashore? mountains?) at your destination.
Stay in hotels that cater to travelers interested in fitness. Ask about the facilities when you make your reservation. Most major hotels and resorts now have fitness rooms and health clubs. Is there also a swimming pool? Tennis courts? The Hyatt, Hilton, and Marriott hotels even provide guests with information on dealing with all types of stress.
Use a guidebook to plan walking tours of local tourist attractions, museums, scenic areas, etc. If possible, walk to your business appointments. Wear walking shoes made by companies such as Rockport; many models are also formal enough for business dress.
Emotional needs of travelers—In addition to exercise and diet, you need to care for your emotional and psychological needs.
Keep in close touch with your office and family. Carry some photos of your spouse and children, or close friend. Write postcards and letters. Keep a diary. Take pictures. Buy gifts and souvenirs to bring home.
Carry playing cards, a board game, a walkman with your favorite cassettes (or foreign language tapes), and a short-wave radio to listen to music and news on the Voice of America or the BBC. The Grundig short-wave radio from Magellan's (800-962-4943) is a good choice.
If you are a recovering alcoholic, find out if there is a local AA chapter or other self-help group in the area. For a directory of AA chapters overseas, contact: AA World Services, P.O. Box 459, Grand Central Station, New York, NY 10163; or call 212-686-1100.
Research your destination. Find out as much as possible about the country you're in, its history, and its culture. Make it a project to learn something specific about some aspect of the culture. If you can speak some of the language, do this as much as possible.
Turn your trip into a psychic adventure. Stripped of your ordinary surroundings, your friends and family, and your usual routine, you may be forced into a more direct experience with your new surroundings and yourself. This can be painful, but don't retreat. View your new surroundings not only in terms of work but also as an opportunity to learn and grow.
Long-Term Assignments and Stress
If you are being assigned to an overseas post, and will be living abroad for many months, or even years, you and your family will encounter additional stresses. If your spouse and children are traveling with you, how will they adjust? Studies show that spouses (usually the wife of a busy executive) bear the greatest burden adapting to overseas living. Today, most companies anticipate these stresses and provide appropriate counseling. Pre-departure orientation and counseling can have dramatic effects on your psychological well-being and the success of your trip.
To better prepare for your trip also consider the following:
Survival Kit for Overseas Living: For Americans Planning to Live and Work Abroad by L. Robert Kohls. Widely used guide for adapting to living abroad. Paperback $16.95. Discounted pricing from Amazon.com.
Culture Shock! Country Guides. These individual guides explore the psychological consequences of exposure to unfamiliar environments. They claim to “take you beyond the stereotypes and misinformation that often precede a visit to a foreign country.” Available from Amazon.com and other online booksellers.
For further resources, contact the Intercultural Press, Inc., P.O. Box 700, Yarmouth, ME 04096 for their catalog or to order directly, 207-846-5168.
Stages of Adjustment What happens when you are uprooted and sent overseas to live and work? Research has delved into the lives of people stationed abroad to analyze their psychological reactions to their new environment. These studies show that adaptation will typically occur in three phases.
Phase 1. You experience an initial period of excitement and well being, usually lasting about a month. You then start to “come down” as the reality of life in a foreign country sets in.
Phase 2. This is a period of disillusionment, usually lasting several months. The disillusionment may be with your host country, your work, or both. Instead of acknowledging your feelings, you may instead experience physical symptoms such as fatigue, headaches, and stomach problems and pass these off as simple stress. You, or your spouse, may even become overtly depressed. In this case, you should seek psychological counseling. (Some employees, or their spouses, don't get over this phase. They can't adapt to their new environment and consequently reconsider their decision to remain abroad.)
Phase 3. After about six months, you will have adjusted to your new life in a foreign country. You will also have picked up some of the language, your children will have adjusted to school, your home will be established, and social connections will have been made.
Overview of Stress Factors and Business Travel
The number of international business travelers continues to increase rapidly, perhaps doubling every decade or so, an increase that is likely to continue.
One study reports that the bank's employees who travel frequently see physicians and other health-care professionals about three times as often as a matched group of employees who do not travel. Traveling males are 80% more likely to see a health-care professional than matched nontraveling males; whereas for women, those who travel are 18% more likely to see a health-care professional than matched females who don't travel. Although many of the complaints deal with known travel-related health hazards (e.g., infectious diseases), there is a striking number of psychological complaints. The number of psychological complaints increases as the number of trips per year increases, and the increase is steeper for female travelers than for male travelers.
Employees on business trips tend to feel a strong sense of social and emotional concern for their families and a sense of isolation. These traveling employees believe that there is a strong association between such stresses and their physical and emotional health, making frequent international business travel an important, previously overlooked occupational medical concern. Moreover, it is reasonable to assume that the countless business travelers who work for small companies, or who are self-employed, experience similar stress-related problems. Previous studies, performed among both travelers and nontravelers, have shown that an accumulation of work-related psychological stress is associated with physical illness, including a general perception of poor health, cardiovascular disease, and mental health problems.
Many factors are not important determinants of stress, including geographic areas of the world visited, number of time zones crossed, having children at home under the age of 18, satisfaction with work, days off overseas, and length of the mission.
In spite of the frequent complaints raised by business travelers, few missions end in total failure, meaning that it is very rare for a business traveler to return home prematurely because of stress-related problems. But stress does seem to cause many hard-to-quantify, less-than-optimum work performances. Failures are far more common among employees posted overseas (i.e., away for more than 6 months), and in most cases such failures are because of coping problems experienced overseas by accompanying dependents, rather than employees. In financial terms, each such failure costs employers tens of thousands of dollars in actual costs (less employee training and relocation expenses), and additional lost revenue from disruption of business.
Causes of Stress
International business travelers experience the following stressors:
The routine discomforts and annoyances that all long-distance travelers encounter, such as planning the trip, hassles of getting to and through airports, altered eating and sleeping patterns, changes in climate, safety concerns
Challenges unique to frequent, long-distance business travelers. These fall into three general categories (two already discussed):
Concerns about the effects of frequent and extended travel on one's physical and psychological well being, the effects of jetlag, loneliness, and fear of dangerous ground transportation in many developing countries;
The effects on one's family of repeatedly being away from home, which is by far the most frequently cited cause of travel-related stress in self-assessment questionnaires, with the number of missions per year an important determinant;
The workload that business travelers are expected to accomplish on each mission and the amount of work awaiting them on their return to the office—workloads frequently perceived as “unreasonable.” During the mission, stressful activities may include having to make decisions away from the office without the usual office support system, communicating in foreign languages, operating in an unfamiliar business culture, and spending long hours in negotiations.
The spouse at home often feels abandoned, worries about the traveler's safety, and is sometimes concerned about infidelity. Spouses without children tend to experience stress either before or after the mission; spouses with children primarily experience stress during the mission.
Strategies for Dealing with Stress
Here are some realistic strategies recommended by symposium participants for alleviating stresses when traveling overseas on business.
Better Selection of Employees for Travel Because about one third of business travelers do not complain of travel-related stress, there are clearly differences in people regarding this issue, but little is known about these differences. Perhaps psychological tests could be developed to better screen job applicants for positions that involve extensive travel.
Employers should be more candid with job applicants about how much travel a position requires, which is not always the case today. Job descriptions sometimes change and nontravel positions can suddenly become travel intensive. Promotions within an organization can also change travel requirements. Job applicants should be apprised of the fact that in many organizations experience gained in missions is an important consideration in a promotion. Moreover, overseas travel is often appealing to young (perhaps, unmarried) job seekers, but it becomes tedious and stressful after time.
Flexible scheduling of travel to allow more time at home—Corporate travel budgets are often “penny wise and pound foolish.” Cost considerations sometimes force travelers to be away on a Saturday night or to use an airline with limited scheduling flexibility. Ideally, business travelers should be able to return home before weekends and leave home after weekends. When possible, employees should be consulted about the timing of their missions. There should also be realistic limits to the amount of time an employee can spend away from home per year. In fact, many organizations have such limits, but they are rarely followed. In many organizations, immediate supervisors look down on the official policy of reduced travel assignments.
Travel schedules and work assignments reviewed by senior staff members who have “been there, done that”—Realistic scheduling from a human resource point of view may require days off from work before a mission and again on return to take care of both family chores and office matters. Family chores may involve seemingly mundane tasks such as paying bills, servicing the car, and other tasks that, ideally, should not be left for the stay-at-home spouse. Female business travelers seem to have a tougher time preparing for their absences than do males, perhaps because females are generally more involved with arranging for child care and carpools, for example.
Office workload tends to increase just before a mission—Doing routine work plus preparing for the mission—and immediately on return. Optimal office scheduling may dictate that several days be devoted exclusively to the mission before departure, with no other work assignments, a day or two of “debriefing” on return, and another day or so to be spent handling desk work and computer work that has piled up.
Minimize trip cancellations and date changing—It is extremely disruptive to frequent business travelers' personal lives to experience repeated changes in travel schedules, which happens quite frequently, albeit often unavoidably. Having to reschedule missions often requires rescheduling family obligations that have already been changed. Employees should be given the option to decline missions if this happens frequently.
Counselors to help with the “nuts and bolts” of overseas travel—Experts can help travelers cope with many of the basic travel issues (e.g., health and safety concerns). In fact, many corporations already have in-house medical departments, sometimes even travel clinics, and some organizations even maintain extensive websites to help business travelers better plan trips; however, many travelers do not use these available resources.
Preparing to Leave
The effects of a parent's frequent absence from home on children are not well understood, but presumably they have a negative impact on children; sometimes children show anger, especially when a parent is away for an important event. (However, according to one boy who was interviewed, “My father being away on a trip makes little difference. When he is home he spends so much time at the office that he is never home anyway.”) The impact can, perhaps, be minimized by scheduling special family events before departure (e.g., a day in the park, a day trip, or a visit to a favorite restaurant). It may also be beneficial to have young children accompany the departing parent to the airport, discuss the itinerary and look at maps, and be provided with books and videotapes about the countries the parent will be visiting.
Coping Overseas and Staying in Touch with Home
Travelers should stay in close touch with spouses and children back home, using regular mail, the telephone, and e-mail, even if the traveler has to bear the costs, which may be high. Some organizations cover the costs of daily e-mail and telephone; those organizations that do not cover such costs should be encouraged to do so. Children like to receive regular mail, even though the parents may call or e-mail daily. E-mail appears to be a very effective way for a parent to stay in touch with a child old enough to use a computer. Sending audiocassettes and videos from overseas may help smaller children. According to some experts, adolescents are the most difficult age group with which to maintain a long distance relationship. Some can be interested in the purpose of the mission and kept informed of day-to-day developments, but most adolescents don't care about that either.
Children and Spouses at Home Children appear to require more personal attention while one parent is away traveling. They appear more comfortable with familiar routines rather than additional changes (e.g., staying at home rather than being shuttled off to a grandparent). Some children seem to find comfort in marking off the days on a calendar until the parent returns home. Support groups with other families of business travelers working for the same organization and living in one neighborhood appear to be very helpful for spouses at home.
Nearly 100% of spouses describe their returning mates as being irritable and withdrawn when they return home, probably the effects of fatigue and stress. Awareness of such behavior helps families deal with it. It's best to postpone any coming-home celebrations for a few days. Travelers should try to return home before a weekend, if possible.
Taking children on work trips is no longer the sole prerogative of Hollywood stars with a legion of nannies, or the last recourse of desperate single parents. Surprisingly, it is a commonplace choice around the world and is often encouraged or at least tolerated by the employer; some of them are even willing to foot the bill. In the United States last year, more than 23 million trips were made with one or more children in tow, about 11% of all business trips. Parents who take children along say it is educational and entertaining and helps build family togetherness. Most parents interviewed believe travel is worth missing a few days of school. Frequent flyer miles often help pay the bill if the company won't.
There are no figures for how frequently children accompany parents on international business trips, but the percentage is probably far smaller than it is for domestic travel. The obvious reason is the cost. Trips are generally longer and may interfere excessively with children's school and spouses' work schedules, and most destinations are not exactly to London, Hawaii, or Hong Kong, but rather to dull, uncomfortable, and, occasionally, dangerous locations.