International Health and Wellness Considerations

Prepared by Rachel Hansen, MD

NOTE: This document is intended to serve as general advice compiled from multiple sources and veteran physicians in overseas areas.  It in no way can replace the individual consultation with a personal physician regarding specific health problems or travel needs.  It is not intended to serve diagnostic or therapeutic purposes without physician guidance. 

A Word to the Reader
The design of this brief handout is not to help you avoid all disease and keep you from dying.  The fact that you have come to this event necessarily implies that you are learning to value Jesus over your own comfort, health, and even your own life.  Rather, the goal is to teach you how you might avoid unnecessary risks and maximize your effectiveness in difficult places of the world by minimizing distracting health issues.  Many well-intentioned missionaries have been forced to return home due to potentially avoidable health issues.

Travel Insurance/Evacuation Insurance

Many expats fail to consider the financial ramifications of sickness and medical evacuation while they are overseas, especially if the trip is a short term trip.  Medical evacuation from many countries can easily cost a minimum of $10,000.  So begin by strongly considering your international medical and evacuation coverage whenever traveling internationally. 
Evacuation insurance:
www.globalhealthinsurance.com
www.insuremytrip.com
www.hthworldwide.com
www.travelguard.com

Vaccinations

MUST:
1) General childhood and adult vaccines MUST be up to date -- all the bad diseases that these vaccines protect you against are often not seen in the US, so they might appear to be unnecessary.  But those diseases are often common and even rampant in international locations. So if your parents refused childhood vaccines for you, you must get these as an adult.  If you received the normal childhood vaccine schedule, the most important issue in this category is making sure your tetanus vaccine is up to date--you should have received one within the last 5 years.

2) Check with the CDC website (http://wwwnc.cdc.gov/travel/destinations/list.htm) and a local travel clinic to get specific vaccine recommendations for the region you are traveling to:  Hepatitis A and typhoid are two common vaccines in this category.

MAYBE:
1) Malaria:  Malaria prophylaxis is strongly recommended for short term trips to certain regions.  Check the CDC website for details on whether your country / region qualifies for this.  But also ask local veterans about what is needed (i.e., if you are living and working at high altitudes, you may not need prophylaxis even if you are in a region where it is recommended.). Malaria prophylaxis will require you to take pills daily or weekly while traveling, and in some cases for a period of time before traveling and after returning home.  Check with your doctor a minimum of 6 weeks in advance, so that you can start on the appropriate medication. Your doctor or health clinic will decide which medication is best for you based on your area--this requires a prescription.  Although these medications are helpful, they are not perfect.  The best prevention is to avoid getting bitten by mosquitoes in the first place--DEET insect repellant and permethrin spray on clothing can be helpful in this regard.

For long term workers in malaria areas, prophylaxis is generally not recommended simply because it’s impractical unless you are in a documented high-risk area.  In high-risk areas, some physicians would recommend a daily dose of Doxycycline--but this becomes an issue of personal choice and discretion, as long-term antibiotic use comes with its own set of risks.  Again, discuss this with local veterans and your doctor.

Malaria diagnosis: if you receive a diagnosis of malaria abroad, make sure to have it confirmed again at a reliable hospital.  Many hospitals in developing nations will diagnose anyone with fever and a certain array of symptoms with malaria, without adequate testing to prove the validity of the diagnosis.

2) Rabies: Avoid exposure. In the US, rabies is often associated with bat exposure or bites; but worldwide dogs are the most common source of transmission. So think twice before compassionately caring for stray animals internationally (i.e., There are documented cases of Peace Corp workers who have adopted puppies; later the puppy died; then workers developed symptoms and died as well).  Also keep in mind that a rabid animal may be classic (animal that is wet down its chest, acting unusual and erratic) or apparently tame and calm.

The key issue in a potential rabies exposure is getting rapid treatment. After an individual begins to show symptoms of rabies, it is too late to treat them—death is certain and painful.  So a potential rabies exposure cannot be taken lightly or ignored for a few days.  It requires immediate action.  In developed countries there are nice clear protocols for this: the animal is quarantined and if they get sick they are sacrificed and checked for rabies.  Overseas this is nearly impossible.  This means that if you get bitten by an at-risk animal while traveling, you MUST get multiple post-exposure vaccines plus immunoglobulin ASAP.  BUT, internationally, you may not have access to these medications, and even if you do, you often don't know the quality of what you're being given or whether it has been refrigerated correctly at a random clinic.

Consider pre-vaccination. In many international settings, it is strongly recommended that long-term workers be vaccinated in advance against rabies.  If you are bitten after receiving this vaccine, you will still need some treatment, but the urgency and risk levels are much lower.  So if you cannot receive the shots fast enough or if they are low quality, your chances of survival are much higher.  The big issue with the rabies vaccines is the cost--in the US it is around $900.  Because it is significantly cheaper to buy this overseas, many expats choose to wait and get this at a trusted hospital internationally.

Seeking Medical Care Internationally

Quality of care in hospitals in developing countries can vary dramatically.  In the case of a serious disease, problem, or injury, you need to have a plan for how to get to reliable care quickly, and ideally without requiring evacuation to your home country immediately.  Criteria to help you evaluate the quality of care at a hospital you are considering include:  physicians trained to western standards (board certified in a developed country or completed training in a developed country), hospital accredited by the Joint Commission International (an arm of the organization that oversees US hospitals), or credentialed through the International Society for Quality in Health Care (www.isqua.org). Remember that these hospitals do not have US federal oversight, insurance coverage may vary, and there are limited options in event of a bad outcome.

Suggested Medications When Traveling or Moving Abroad
Prescription meds—even the ones you only use once a year.  Do not assume that you can buy your medications in the country you are living in—counterfeit medications and antibiotics are a big problem in many countries.  So if the quality of the medication is at all important, you need to bring it with you.

Consider asking your physician to prescribe a few antibiotics with clear directions and parameters for when and where to use them.  AGAIN, counterfeit medications and antibiotics are a big problem in many countries. Cipro, Amoxicillin, and Azithromycin are three prescriptions you could discuss with your physician based on your potential needs.
Prophylaxis meds (if needed): for Malaria
Pain meds: Tylenol, Motrin, etc.
Stomach meds: Imodium, laxative, anti-nausea, Pepto-Bismol, motion sickness meds, etc.
Sleep meds: some travelers will request prescription medications to help with sleep when making short term trips.

Melatonin or Benadryl can also be helpful short term.
Dehydration solutions: Oral rehydration salts, Pedialyte powders for children
Other: Steroid cream (hydrocortisone), anti-fungal cream (Clotrimazole), antibiotic ointment, band aids, cough/cold/sinus medicine

Other Issues to Consider

  • Insects: Use Permethrin spray and/or at least 20% DEET insect repellent if in a malaria or dengue fever area.
  • Food: The basic mantra for travelers has always been “Cook it, peel it, boil it or forget it....” That is good advice for short-term workers. But long term, that type of diet restriction is nearly impossible.  Again, talk to other veterans—many use diluted bleach, vinegar, or just lots of scrubbing with soap and water—depending on the situation. If you are going to avoid a few foods for health reasons, raw meat, shellfish, and especially lettuce are the most likely places to pick up parasites.

So—safety aside—should you eat like the locals? Yes and no.  Short-term trips—yes. When together with locals, it's often important to eat similar foods. But in your own home, you really need to think through what you're eating if you want to last long term. Many developing nations have diets that are actually quite unhealthy—deep-fried, fatty foods, high sugars, highly processed ingredients, unknown additives—think about small modifications you can make to the typical diet in order to maintain your health and effectiveness for the long haul (i.e., cooking with less oil, eating more fresh fruits and vegetables and fewer processed foods).

  • Water: In most developing countries, it is a given that you will need to ingest only bottled or filtered water. However, if you continue to get sick even with these precautions, consider where you might be contacting contaminated water—brushing your teeth, residual water on plates, fruits, vegetables after washing, swimming pools, etc.  If water is obviously dirty, filter it FIRST before boiling it.
  • Jet Lag: Exercise and sunshine have the best proven effectiveness for quick recovery. 
  • Swimming: Limit your swimming to chlorinated pools.  Fresh water swimming and even ocean water is often a hazard with various parasites, chemical contamination of water, or waste contamination.
  • Travel Hazards: Motor vehicle collisions are the highest cause of death for expats other than war. Wear a seatbelt. Wear a helmet. Avoid riding in overfilled buses, trucks, or other vehicles.
  • Entertainment: Don't assume western regulations of equipment (think hard before bungee jumping, etc.). The difference between a hilariously-fun-Facebook-picture-posting-story and a tragedy is often just the outcome.
  • Don't Get Sued: If you lead a short-term team, consider a waiver for team members to include: Voluntary consent, hold harmless, assumption of risk, waiver of liability, etc., including but not limited to accidents, illness, injury, political unrest, violence, terrorism, weather, government restrictions and regulations.

Research Before You Leave:

Safety Issues
Emergencies and Crises
Travel Warnings

Conclusion: So in conclusion, you MUST take risks. You MUST take risks for the Kingdom. You MUST take risks to get the Gospel to people.  But as you go and serve and risk for the sake of love, try to prepare yourself adequately to limit foolish or unnecessary health problems and maximize your effectiveness with the things that really matter.