Health Care for Tourists

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HEALTH CARE FOR TOURISTS

HEALTH CARE FOR TOURISTS By the new millennium, there was a substantial increase in travel to India. Further growth is anticipated as the country opens up its economy and develops more tourist facilities. In addition, trips to South Asia by the Indian diaspora are expected to rise. For travel to India, all foreigners, including those from Commonwealth countries, are required to have a valid passport and an appropriate (entry, transit, or tourist) visa obtained abroad from an Indian mission. Tourist visas are generally valid for 120 days from the date of issue. Though directed toward U.S. citizens, a useful precaution prior to departure is to check the travel warnings posted on the U.S. State Department's web site, <www.travel.state.gov/travel_warnings.html>. The International Society of Travel Medicine's web site, <www.istm.org>, is also useful.

Precautions before Travel

Medical insurance

Most medical insurances do not cover health-related expenses incurred abroad or the cost of medical evacuation from overseas, unless such specific coverage is purchased before travel. This is particularly true of U.S. Medicare and Medicaid. However, most travel agencies and health insurance companies offer plans for medical coverage during foreign trips.

Vaccinations

Four to six weeks should be allowed for certain vaccinations to take full effect. The following vaccinations should be obtained before leaving for India:

Hepatitis A, or immune globulin (IG).
Hepatitis B, if exposure to blood (for example, health-care workers), sexual contact with the local population, or a stay longer than six months is anticipated. Hepatitis B vaccine is now recommended for all infants and for children who did not receive it as infants.
Japanese encephalitis, only if visits to certain rural areas for four weeks or more are planned.
Rabies, if exposure to wild or domestic animals through work or recreation is anticipated.
Typhoid vaccination is important because S. typhi strains in the region are resistant to multiple antibiotics.
As needed, booster doses for tetanus, diphtheria, and measles, and a one-time dose of polio for adults. In 1998, 75 percent of all polio cases in the world occurred in India. The incidence has dropped dramatically following the massive vaccination programs carried out in the country since then.

There is no risk for yellow fever in the Indian sub-continent. A certificate of yellow fever vaccination is required for entry into India if the visitor is coming from certain countries in South America or sub-Saharan Africa, where yellow fever is endemic.

Dental care

Dental appointments should be scheduled early enough to allow time for the completion of necessary or outstanding dental work before departure. Decayed teeth and broken fillings should be tended to and teeth cleaned. Consideration should be given to the removal of partially exposed lower wisdom teeth, especially if a long trip is envisaged. The fleshy covering over such teeth creates a food cap that can cause pericoronitis, a potentially serious infection. Similarly, all root canal treatment should be completed before travel. On the other hand, most Indian cities have well-trained, well-equipped dentists in private practice. The fees are much smaller than in the West.

Medications

All medications should be properly labeled. Copies of prescriptions, especially narcotics, with a letter from the prescribing doctor identifying such medications, could prove helpful should security or customs officials raise questions about them.

First-aid kits

First-aid kits for travelers are commercially available in most developed countries. The cost varies from U.S.$10.00 to ten times as much, as does weight and size. The kit should contain antacids, analgesics, antibacterial ointments, antidiarrheals (as tablets), antihistamines, antiseptics (including towelettes), calamine lotion, bandages (adhesive, butterfly, and elastic), corticosteroid creams (low-dose emollients are most cost effective), cotton-tipped applicators, hypodermic needles (nonluer lock are more versatile), insect repellants, moleskin (for blisters), waterproof adhesive tapes, oral rehydration salts, single-edged razor blades, sharp scissors, sterile small syringes (nonluer lock, 1 and 3 ml), thermometer (digitals are less fragile, but have limitations), tick-remover forceps, and tweezers. Kits should be packed in the checked-in baggage as most contain sharp metallic objects like razor blades and will not be cleared by airport security. An emergency smoke hood can be carried into the cabin.

Air travel and its medical effects

Air travel is the most common means of transportation to India. Deep vein thrombosis (DVT), jet lag, and motion sickness are the most common medical conditions resulting from long-distance jet travel. DVT, "coach class syndrome," is increasingly common and affects all ages. Most airlines therefore provide instructions on in-seat ankle exercises to minimize the risk. Immobility, cramped seating and dehydration further contribute to DVT. Hence, compression stockings, avoidance of alcohol, consumption of plenty of fluids, and regular walks around the cabin are useful in preventing DVT. An alternative to water is a fluid expander like CeraLyte, which prevents jet lag as well.

Jet lag is caused by the alteration in the endogenous rhythms of the body vis-à-vis environmental changes, especially time. Hence a six-hour journey in the same meridian—for instance, travel from North to South America—is much less likely to cause jet lag than the six-hour trip across five time zones. Travel from west to east appears to worsen jet lag more than a trip in the opposite direction. Reduced output of the regulatory hormone, melatonin, is considered an important underlying factor. Other factors, like the dehydrated cabin air, older age, night flights, and consumption of alcoholic and caffeinated beverages, also contribute to jet lag. The most common symptoms are increased fatigue and irritability, disturbed sleep patterns, and loss of concentration. The incidence and severity of jet lag is reduced by taking melatonin (3–5 mg), a high-fiber diet, and liberal intake of fruit juices and drinks that contain electrolytes, like Gatorade and CeraLyte. Melatonin is available without prescription at pharmacies and health-food stores.

Pacemaker malfunction does not occur in modern pressurized and insulated airplanes. Most long-range aircraft carry defibrillators for resuscitating the stopped heart resulting from acute myocardial infarction (heart attack). Motion sickness is caused by irritation of the middle or inner ear, and/or the brain stem. It is treated by prescription medicines and may be alleviated by getting a seat in the center of the cabin. Avoiding unnecessary head and eye movements (as when watching television or reading) and abstinence from alcohol and caffeinated drinks further reduces its severity and incidence.

The International Commission on Radiation Protection calculated that air crews, after twenty-five years of regular flying, have a risk of radiation-related malignancies of 25.5–26 percent, as compared with a 25 percent risk in the rest of the population. Hence, radiation is a very small hazard. There is also the unlikely possibility of picking up infections, ranging from the common cold to tuberculosis.

At landing, aircraft are usually disinfected using 2.9 percent d-phenothrin spray. Passengers wearing contact lens should keep their eyes closed during disinfection.

Common illnesses

The most common concern is travelers' diarrhea ("Delhi belly"). About 50 percent of travelers are stricken with this illness. It is caused by a variety of different viruses, bacteria, toxins, and parasites. The most frequent etiology is certain strains of the bacteria E. coli. The onset is usually within the first week of arrival in India. The diarrhea is often associated with nausea, vomiting, abdominal cramps, bloating, low-grade fever, urgency, and malaise. Most cases resolve in a few days without treatment. The most commonly prescribed antibiotics are Quinolones, Trimethoprim-Sulfamethoxazole (Bactrim), and Azithromycin (Zithromax). Antidiarrheals, such as Diphenoxylate (Lomotil) and Loperamide (Imodium), may be judiciously used to reduce the frequency of stools and to prevent dehydration. The safe and simple compound Pepto Bismol, a binding agent that neutralizes toxins and solidifies stools, is recommended for both prevention and cure of symptoms. If the diarrhea is bloody, severe, or accompanied by chills and high fever, medical attention should be immediately sought.

To prevent travelers' diarrhea, it is advisable to avoid consuming foods or beverages from street vendors and other places where unhygienic conditions may be present. In addition, raw or undercooked meat, seafood, and raw fruits and vegetables, unless they can be peeled or thoroughly washed, should be avoided. Furthermore, tap water, ice, unpasteurized milk and dairy products increase the risk of travelers' diarrhea. Safe liquids include bottled beverages, hot tea and coffee, beer, wine, and sealed bottled water.

Other common illnesses are respiratory tract infection or inflammation, and dengue, a flulike illness occasionally complicated by bleeding. Much rarer are exotic infections like filariasis, Japanese encephalititis, leishmaniasis, leptospirosis, and the plague. All these diseases are transmitted by insects. Accordingly, protection against the relevant insect bites is an important precaution while traveling in India.

If visits to the Himalayas are planned, then gradual ascent above 10,000 feet is desirable to allow the body to adjust to high altitudes. At higher elevations the early symptoms of illness are insomnia, headaches, and nausea. Later, high-altitude sickness characterized by shortness of breath and accumulation of fluid in the lungs can develop. In addition, it is prudent to use sunblock rated at least 15 SPF, because the risk of sunburn is greater at high altitudes.

Health maintenance

In addition to washing hands with soap and running water after meals and morning ablutions, the visitor should take the following precautions:

Drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, the water can be purified by filtering it through an "absolute 1-micron or less" filter and adding iodine tablets to the filtered water. Both filters and iodine tablets are available from camping supply stores.
Consume thoroughly cooked food or fruits and vegetables that can be thoroughly washed or peeled. A useful axiom: boil it, cook it, peel it, wash it thoroughly, or forget it. An exception: sealed "comfort foods" brought into the country by the visitor.
Malaria prophylaxis should be undertaken throughout the year, regardless of official guidelines and recommendations. Medications should be taken before, during, and after travel. The commonly prescribed medicine, Chloroquine, is not effective in the Indian subcontinent. Instead, mefloquine (Lariam), atovaquone/proguanil (Malarone), or doxycycline is recommended. Malarone is used most often as a once daily dose, starting two days before arrival, and continuing through the trip and for seven days after departure from India.
Take protection from mosquito and insect bites by:
- Paying special attention to mosquito protection between dusk and dawn, the period when the type of mosquito-bearing malaria is most active.
- Wearing long-sleeved shirts, long pants, and hats.
- Using insect repellents that contain DEET (diethylmethyltoluamide). For adults, a 25 to 35 percent preparation is available. For children, a 10 percent compound is adequate. DEET should not be used for children under two years of age because of the risk of neurological toxicity.
- Applying insect repellent to exposed skin but not putting it on wounds or broken skin.
- Not breathing, swallowing, or getting repellents into the eyes (DEET is toxic if swallowed). If using a spray, apply DEET to the face by spraying it on hands and rubbing the product over the face, avoiding eyes and mouth.
- Unless housing is air-conditioned or well-screened, using a bed net with a mesh size of less than 1.5 millimeters. The net should be impregnated with the insecticide permethrin or deltamethrin. Spray the bed net with one of these insecticides if pretreated nets are not obtainable.
- Protecting infants by using a carrier draped with mosquito netting with an elastic edge for a tight fit.
- Children under ten years old should not apply insect repellent themselves.
- Using tweezers or forceps for grasping and removing the head of ticks from humans. Most tick-borne illnesses can be prevented by prompt removal of the head of the insect.
To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot.
Always use latex condoms to reduce the risk of the human immunodeficiency virus (HIV) and other sexually transmitted diseases.
Avoid swimming in freshwater lakes and rivers. Saltwater is usually safer.

Medical facilities

Adequate to excellent medical care is available in major population centers, but services are usually limited in rural areas. Pharmacies are present even in small towns and most larger villages. The Indian pharmaceutical industry is the fourth largest in the world, and most of the latest medications are easily obtainable. The cost of a visiting doctor is low (about $2.00) in the countryside. On the other hand, traffic safety and road conditions, especially in the countryside, are a major health hazard as regulations regarding safety of public transportation are lax; maintenance of roads is poor, and availability of roadside assistance, negligible. Consequently, the capital, New Delhi, despite its slow-moving traffic, experiences more than two thousand road deaths annually.

Terrorism and crime

Petty crime, especially theft of personal property, is not uncommon. But violent crime, including rape, is rare. Areas of instability and terrorism, particularly in Jammu and Kashmir and in the northeast of the country, may expose the visitor to unexpected and sporadic violence, civil disturbances, and kidnapping. In any case, most of these regions are restricted for foreign travelers.

Medical tourism

India reportedly attracts approximately 100,000 patients from abroad every year, as certain hospitals provide international standards of care at affordable prices. The Apollo group pioneered the establishment of state-of-the-art medical facilities in India's four largest metropolitan cities and other big towns like Pune, Kochi, and Ahmedabad. The group, India's largest, operates 38 hospitals and has opened information centers in key foreign countries to attract medical tourists. Other well-known hospitals that attract medical tourists include the All India Institute of Medical Sciences in Delhi; Escorts Heart Institute, also in Delhi; the Madras Institute of Orthopedics and Traumatology in Chennai; the Rabindranath Tagore International Institute of Cardiac Sciences in Kolkata; and the Hinduja Hospital, Mumbai. In general, these hospitals have created connections with good hotels and shopping centers to cater to the needs and comforts of the families of patients. In 2003 the Confederation of Indian Industry, sensing commercial opportunities offered by medical tourism, sent a delegation, led by a prominent heart surgeon, to negotiate with Britain's National Health Service to provide low cost and expeditious health care to British patients. The figures for using India as a destination for health care are compelling. For instance, heart surgery costs U.S.$8,000 in India as compared to $30,000 in the United States; liver transplantation is $45,000 in India, in contrast to $300,000 in the United States; similarly, orthopedic surgery is generally available for a tenth to a third of the price. The expense of certain operations is remarkably cheaper; for instance, cataract surgery, at $1,500 in the United States, is performed for $12 in India. The growth of similar facilities in smaller cities is likely, if small hospitals (100 beds and under) are given the same tax exemptions enjoyed by the larger ones. Traditional Indian strengths in ā yurveda, yoga, naturopathy, and other alternative medicines continue to attract an increasing following as well.

Rajesh Kadian