by Valerie Gregg he first time Bruce Knauft went to the remote rain forests of Papua New Guinea, he had a critical brush with drug-resistant malaria. When he went again last year, he had prepared for the trip meticulously but nevertheless had a potentially fatal run-in with something slithering down a dark path one night. "We were walking back to the government compound, single file, through the brush," says Knauft, who is an Emory professor of anthropology. "Because I was the only one who had a flashlight, I was in the front of the line. I had worn my open-toed mountain sandals because the weather was so hot. I stepped right on a death adder, and it bit me on the foot. Despite all my preventive measures, there was very little I could do in such a remote area except try to relax and hope I wouldn't die. Ironic, isn't it?" He kicked the snake off before it could really dig in, so he didn't suffer the slow, agonizing, deadly paralysis that usually results from a death adder bite. It did keep him hobbling for a week, however. "My toe felt like someone had taken a sledgehammer to it," he said. "I was very lucky." Knauft learned an important lesson the hard way: You can never be too prepared when you travel overseas. And simple solutions that minimize risks are often the best. After his brush with death, Knauft always wore closed-toed boots when walking the trails at night.

TravelWell founder and director Phyllis Kozarsky serves on the editorial board of The Journal of Travel Medicine and co-edits the CDC publication, Health Information for the International Traveler. She also confers with President Clinton's physician to discuss international disease surveillance and how to keep American travelers healthy.

s the saying goes, you never see the bullet that gets you. In foreign ports, bacteria, viruses, and parasites are invisible, but very real threats. Accidents, most often car related, are the number one cause of preventable deaths for Americans outside the United States. And cultural differences can be so psychologically overwhelming that they can render travelers unable to cope. Knowing the risks and preparing for them is the key to staying healthy overseas, says tropical disease specialist Phyllis Kozarsky. For the past 10 years, her TravelWell clinics have filled a crucial need for a growing number of international travelers -- many from Emory's schools of medicine, public health, and nursing. TravelWell is the best equipped clinic in the Southeast to serve patients before, during, and after international travel. There are only a handful of such clinics in the nation. TravelWell started as a small, out-of-the-way office at Crawford Long in 1988 and in the past few years has added sites at The Emory Clinic Perimeter and Emory Hospital on Clifton Road. Kozarsky's patient load at TravelWell has grown from less than 50 in 1988 to more than 3,000 last year. And there are no signs that the demand will lessen. More than 600 million people worldwide including 30 million Americans - as well as 10% of Emory employees - travel by air to other countries each year. Twenty percent head for developing nations. Half of all international travelers become ill, most commonly with diarrhea, and one in every 100,000 travelers will die. TravelWell serves a diverse clientele that reaches far beyond the Emory community: international companies like Delta Airlines, CNN, and Coke; humanitarian groups like the Carter Center, missionaries, and Habitat for Humanity; as well as sports teams and tourists. It coordinates a network of almost 30 affiliated clinics around the world for patient referral and disease surveillance. Through Kozarsky's contacts at the Centers for Disease Control and Prevention and physicians around the world, TravelWell maintains up-to-the-minute information about health risks and emerging diseases. Kozarsky realized the need for something like TravelWell in 1988, when she returned from India with acute pneumonia and gastrointestinal illness. "I was very sick and hospitalized for days," she says. "When I look back now, I can see that I was completely unprepared for my trip. I got my shots but did nothing else to avoid medical problems while I was in India. Even though I was a physician, I wasn't a very smart traveler." The timing of her realization coincided with a new awakening in the field of public health. For the past several decades, the medical community had predicted an end to the scourge of infectious disease around the world. But suddenly, the AIDS crisis loomed large and out of control. Drug-resistant viruses and bacteria were turning up everywhere, and travelers were carrying these germs from one country to another. Emerging knowledge of genetics, microbial evolution, and the human immune system were changing the rules of the game. It was the end of an era. And Kozarsky knew it.

"Having a great time, wish you were here!" During pretravel consultations, TravelWell staff advise travelers on how to make sure what they eat or drink in other countries doesn't make them sick.

ozarsky knows what happens when migrant mosquitoes, mutant viruses, and oblivious travelers cross paths. "Last year, we had a perplexing situation in the Dominican Republic," says Kozarsky. "German tourists there were returning home from a supposedly malaria-free zone with the disease -- something we had never seen there before. We were mystified." TravelWell's affiliate clinic in Munich helped put the pieces of the puzzle together. "Apparently, hurricanes and heavy rains had increased the mosquito population in that area," Kozarsky says, "and migrant workers from malarious areas may have brought the strain over when they came to rebuild after the hurricane." According to Kozarsky, malaria is the most worrisome problem for travelers. Malaria-prevention drugs are not foolproof, and fever within several months of a traveler's return should always be considered a medical emergency. Malaria can kill a patient within 24 hours if not treated promptly with the right drugs. If physicians can't predict which strain of malaria someone has, they can't be sure which drug to use. "That's why surveillance is so important," says Kozarsky. "The infectious disease situation around the world is constantly changing. It's fluid because people are traveling internationally more than ever -- business people, vacationers, migrant workers, and refugees. Malaria affects 300 million people worldwide. But we don't pay attention to it until it comes back in western countries. "That's why we have to keep watch. We have to know what's going on elsewhere, because it will eventually affect us." Traditionally, international surveillance of health risks has been uncoordinated and sporadic. Because there is no international public health system, diseases and deaths have been hard to track worldwide. The CDC and the World Health Organization are working to change that. Emory and TravelWell are on the front lines. Kozarsky helps coordinate a worldwide network of 30 clinics called GeoSentinel that tracks illness in returning travelers, immigrants, refugees, and foreign visitors. This data, which is continuously analyzed, is used to develop health recommendations for travelers. In 1991, Emory hosted its first continuing medical education conference on travel medicine. It was the largest continuing education conference ever held at Emory, with 850 people from 52 countries attending. Kozarsky also helped found the International Society of Travel Medicine in 1991, which may soon create a "certificate of knowledge in travel medicine" for doctors and nurses. The day for a new medical specialty of travel medicine has arrived. "We need to monitor emerging diseases all over the globe," she says. "We can't hide our heads in the sand anymore. No matter where in the world an emerging illness may be, it will eventually find its way here. The entire medical profession has to face that. We are truly a global village now." Payers must also think more globally, says Kozarsky, who is working to educate the insurance industry about the changing needs of its customers. Unfortunately, most insurance companies won't pay for pretravel consultations at TravelWell. That needs to change, she stresses, noting that Emory is "making every effort to cover travel services for employees." "Prevention is unbelievably important," she adds. "Studies show it is cost-effective to pay for preventive pretravel education rather than thousands of dollars in hospital bills when a traveler returns home ill. The companies we work with, like Delta and Coke, recognize this."

owhere was the global village more evident than in Atlanta during 1996, when a million people from around the world converged for the Olympic Games. Emory, the CDC, and Coca-Cola collaborated to study what illnesses these travelers suffered. "The study found that the ailments were basically the same as for people traveling to developing countries -- diarrhea, respiratory illness, skin problems, and psychological trauma," Kozarsky says. "The results of the study will help us prepare for similar international events in the future." Some employees for international companies like Delta Airlines and CNN must adapt to new environs several times a week. During the Persian Gulf War, Kozarsky helped CNN employees prepare for the possibility of biological weapons exposure. She now consults regularly with Delta on preventing illness overseas. Being informed keeps employees healthy and saves the company the vast amounts of money it takes to replace sick crew members overseas. "Our flight crews travel all over the world," says physician Tom Faulkner, Delta Airlines regional medical director for Air Crew Health Services. "We can't have pilots coming down with food poisoning or anything else. We take prevention very seriously." Kozarsky sees Delta employees both before and after they travel and holds workshops on both medical and cultural issues. She once went to India herself to personally check out a flight crew's accommodations. "We had pilots telling us they weren't going to fly there any more because they didn't feel confident about the sanitation," Faulkner says. "Everyone felt a lot better once she gave the place a clean bill of health." International volunteer organizations also consult with TravelWell. "One night I was called into the emergency room to meet a Habitat for Humanity volunteer who had been working in rural Mexico," says Kozarsky. "A cab driver had picked him up at Hartsfield Airport and literally carried him into the hospital. The man was so ill he didn't know where he was." He had dengue fever, a relatively common disease spread by mosquitoes. There is no vaccine or effective drug treatment for it. Although usually not fatal, it is extremely unpleasant -- a week of high fever, severe headache, joint and muscle pain, rash, nausea, and vomiting. On occasion, the virus attacks the circulatory system, causing a life-threatening condition called dengue hemorraghic fever. Blood plasma and intravenous fluids may be needed. But in a hospital in an impoverished part of the world, such simple measures might be unavailable or may carry the risk of infection, HIV, and hepatitis. "Sitting alone in a hotel, in a foreign city, when you're not feeling well, can be a pretty scary feeling," says Kozarsky. "You don't speak the language, you don't know where there is a reputable doctor, and the thought of being admitted to a hospital with standards different from ours is pretty scary." That's why TravelWell takes phone calls and e-mails from patients in the field. Sometimes the best medical advice Kozarsky can give is "Consider coming home." The Habitat volunteer had done just that.

nterestingly, dengue fever would not have been as high a risk in Mexico just 10 years ago. "It had virtually disappeared from the Western Hemisphere," says Kozarsky. "But this year we even had some indigenous cases in Texas. Now it's spread throughout Central and South America." Here's why: The world has experienced high population growth during the past 50 years, mostly in developing tropical countries. The result: crowded, sprawling cities with unsanitary housing, water, and sewage systems -- the perfect breeding ground for mosquitoes. Airplane travel then moves diseases, via both humans and mosquitoes, from one urban center to another. All it takes is the bite of a local mosquito to start the cycle again in a new city. New strains of malaria, HIV, influenza, and tuberculosis and infections like west Nile virus have been found in the United States -- possibly the result of international travel. "West Nile virus had never been seen out of the African subcontinent before -- and here it popped up last year in New York!" Kozarsky says.

n our increasingly complex, rapidly changing world, the medical community must be more vigilant than ever. The rules of the game in international health are constantly changing, and disease surveillance must become a more thorough, continuous, and comprehensive process, says Kozarsky. Physicians and travelers must be aware that health threats can strike suddenly and unexpectedly. Anthropologist Knauft has certainly learned that lesson. He is an expert on Papua New Guinea. What he didn't know was the impact on the reptile population when trees were cut down near the goverment station. The more open environment had boosted the snake population. Disruption of the delicate rain forest ecology had added yet another health risk to his list -- one that even TravelWell didn't anticipate. The field of travel medicine faces the same challenge as Knauft and other travelers. "Preparation is the key, whether it's bioterrorism in the Persian Gulf or bubonic plague exposure in India," says Kozarsky. "Anything can happen, but if you're alert and informed, odds are you'll not only survive your trip but will want to go to even more remote and exotic places in the future." Valerie Gregg is an Atlanta freelance writer.

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ravelWell's GeoSentinel quarterly report cites these most frequent diagnoses (not including injuries) for Atlantans returning home from their travels in the last three months of 1999: diarrhea, anxiety and fatigue, rashes, respiratory infections, cystitis, malaria, and viruses. The bottom line? Know what you're getting into, especially if you plan to spend significant time overseas. Many business travelers return with a diagnosis of stress and anxiety. "Sometimes people are just blown away by differences in everything," TravelWell Director Phyllis Kozarsky says. "They come back physically sick because they are so emotionally overwhelmed. Among missionaries and volunteer workers, 20% to 30% are early returns. So educating people as much as possible about what they will encounter is essential. The fact is, the vast majority of the world lives 180 degrees differently from the way we do."

In pretravel consultations, she discusses cultural differences travelers should be aware of, including communication barriers and cultural sensitivities. For women traveling abroad, cultural issues are important, especially in Arab countries and Latin America. The way a woman dresses or makes eye contact is interpreted differently in these cultures. The risk of terrorism against Americans is also covered. While infectious disease and parasites are a danger in many places, accidents rank as the number one cause of preventable mortality for American travelers. Kozarsky encourages travelers to learn about traffic laws in the countries they visit. In many developing countries, there are literally no rules of the road. "Travelers often engage in all kinds of risky behavior when they visit other countries that they would never do at home -- such as having unprotected sex or driving drunk without a helmet on a moped on a country road full of potholes at night," Kozarsky says. "People need to know that a risk is a risk, no matter where you do it."

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