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1.2: Prefixes and Suffixes

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• Page ID 65807

• Andrea Nelson and Katherine Greene
• University of West Florida

Learning Objectives

• Understand the difference between a prefix and a suffix.
• Differentiate prefixes that deal with body parts, color, and direction.
• Distinguish suffixes that deal with procedures.

Prefixes are located at the beginning of a medical term. The prefix alters the meaning of the medical term. It is important to spell and pronounce prefixes correctly.

Many prefixes that you find in medical terms are common to English language prefixes. A good technique to help with memorization is the following:

• Start by reviewing the most common prefixes.
• Consider common English language words that begin with the same prefixes.
• Compare them to the examples of use in medical terms.

Common Prefixes

Body part prefixes, color prefixes, physical property and shape prefixes, direction and position prefixes, quantity prefixes, concept check.

• Do you know the difference between the prefixes inter- , infra- , and intra- ?
• What color is an erythrocyte? A leukocyte?
• around something else?
• within something else?
• below something else?

Suffixes are word parts that are located at the end of words. Suffixes can alter the meaning of medical terms. It is important to spell and pronounce suffixes correctly.

Suffixes in medical terms are common to English language suffixes. Suffixes are not always explicitly stated in the definition of a word. It is common that suffixes will not be explicitly stated when defining a medical term in the workplace. However, when transcribing or reading medical reports the suffix is always clearly written. In order to properly spell and pronounce medical terms, it is helpful to learn the suffixes.

Common Suffixes

Procedure suffixes.

• Do you know the difference between the suffixes -gram , -graph , and -graphy?
• Which suffixes denote a condition or disease?

Word parts and definitions from “Appendix A: Word Parts and What They Mean” by MedlinePlus and is under public domain.

Definitions of medical term examples from:

• Anatomy and Physiology (on OpenStax ), by Betts et al. and is used under a CC BY 4.0 international license . Download and access this book for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction
• Concepts of Biology (on OpenStax ), by Fowler et al. and is used under a CC BY 4.0 international license . Download and access this book for free at https://openstax.org/books/concepts-biology/pages/1-introduction
• NCI Dictionary of Cancer Terms by the National Cancer Institute and is used under public domain.

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Why Patients Are Turning to Medical Tourism

Statistics, Benefits, and Risks

Planning Ahead

Frequently asked questions.

Medical tourism is a term that refers to traveling to another country to get a medical or dental procedure. In some instances, medical tourists travel abroad seeking alternative treatments that are not approved in the United States.

Medical tourism is successful for millions of people each year, and it is on the rise for a variety of reasons, including increasing healthcare costs in the United States, lack of health insurance, specialist-driven procedures, high-quality facilities, and the opportunity to travel before or after a medical procedure.

According to a New York Times article from January 2021, pent-up demand for nonessential surgeries, as well as the fact that many Americans lost their health insurance during the coronavirus pandemic led to a surge in medical tourism once other countries re-opened.

However, there are specific risks that come with traveling overseas for surgery. If you're thinking of pursuing a medical procedure in another country, here's what to know about the benefits and the risks.

Medical Tourism Benefits

The most common procedures Americans go abroad for include dental care, cosmetic procedures , fertility treatments, organ transplants , and cancer treatment.

This is not to be confused with having an unplanned procedure in a foreign country due to an unexpected illness or injury.

Among the reasons a person might choose to go abroad for a medical procedure are:

Lower Costs

Medical tourists can save anywhere from 25% to 90% in medical bills, depending on the procedure they get and the country they travel to. There are several factors that play into this:

• The cost of diagnostic testing and medications is particularly expensive in the United States.
• The cost of pre- and post-procedure labor is often dramatically lower overseas. This includes labor costs for nurses , aides, surgeons , pharmacists, physical therapists , and more.
• High cost of malpractice insurance—the insurance that protects medical professionals against lawsuits—in the United States.
• Hospital stays cost far less in many overseas countries compared to the United States. In other words, quality care, hospital meals, and rehabilitation are far more affordable abroad for many people.

For someone who doesn't have insurance , or someone having a procedure that is not covered by insurance , the difference can be enormous.

Popular Countries for Medical Tourism

Dominican Republic

South Korea

Culture and Language

Many immigrants prefer to have treatments and procedures done in their country of origin—a sensible decision, considering just how much language barriers alone can affect the quality of their care.

Furthermore, at least 25% of immigrants and noncitizen residents in the United States are uninsured, compared to 9% of American citizens. Children with at least one noncitizen parent are also more likely to be uninsured.

Practicalities aside, many people choose to have their procedure done in their country of origin simply because it allows them to be close to family, friends, and caretakers who can assist them through their recovery .

Insurance Incentives

Some insurance companies have started promoting medical tourism. The reason behind this is simple: savings for the insured means savings for the insurance provider and vice versa.

Several insurance providers, including Aetna have programs specifically geared at promoting safe medical tourism. Some insurance providers even offer financial incentives for medical tourism, like discounts on medical bills .

That said, many insurance companies will not pay for surgery performed outside of the country unless it is an emergency.

Luxury and Privacy

Medical tourism is a lucrative business for many countries, and much of the money brought in by medical tourists is reinvested into the local economy and health infrastructure.

The effect of this is apparent in the spa-like luxury that some foreign hospitals offer, providing medical tourists the opportunity to be pampered during their stay for a fraction of the cost they would pay at home.

Some facilities offer hospital rooms that are more like a hotel suite than a traditional hospital room. Other hospitals offer one-on-one private nursing care, which is far more generous and attentive than the staffing ratios that most hospitals allow.

Medical tourists who seek that added layer of privacy can find it abroad. Many can return home from their "vacation" without anyone knowing they had a procedure at all.

Vacation in a Foreign Country

Medical tourists often take advantage of their stay in a foreign country to travel for pleasure by scheduling a vacation before or after their procedure.

This is an especially inexpensive way to travel to a foreign country, especially if their insurance provider is paying for the flight and the cost of staying is low. 

While it seems logical to recover on a beach or in a chalet by the mountains, keep in mind that it's important not to jeopardize your recovery.

Swimming isn't recommended until your incisions are completely closed. You may not feel up to doing much more than napping in the days following your procedure, either.

Don't let your vacation disrupt your recovery. Any time you have a procedure done, especially a surgery, it's important to listen to your body, take your medications as directed, and follow your doctor's recommendations closely.

Bypassing Rules and Regulations

Some travelers seek surgery abroad to bypass rules that are set in place by their own government, insurance company , or hospital. These rules are typically in place to protect the patient from harm, so getting around them isn't always the best idea.

For example, a patient may be told that their weight is too low to qualify for weight loss surgery . A surgeon in a foreign country may have a different standard for who qualifies for weight loss surgery, so the patient may qualify overseas for the procedure they want.

Talented Surgeons

Surgeons in certain countries are known for their talent in a specific area of surgery. For example, Brazilian surgeons are often touted for their strong plastic surgery skills .

Whereas in the United States, insurance companies might only cover cosmetic procedures if it is medically necessary, cosmetic surgery is often free or low-cost in Brazil's public hospitals—giving cosmetic surgeons there ample practice.

Thailand is reported to be the primary medical tourism destination for individuals seeking gender reassignment . It is often easier to qualify for surgery and the cost is significantly reduced. Surgeons are performing the procedures frequently, and as a result, many have become quite specialized in them.

It is often surprising to many medical tourists that their physician was trained in the United States. Not all physicians are, of course, but a surprisingly high percentage of them working in surgery abroad are trained in English-speaking medical schools and residency programs and then return to their home country. These physicians often speak multiple languages and may be board certified in their home country and a foreign country, such as the United States.

Medical tourism isn’t limited to countries outside of the United States, either. Many people travel to the United States for medical care due to the country's cutting-edge technology, prescription medication supply, and the general safety of healthcare.

Medical Tourism Risks

The financial and practical benefits of medical tourism are well known, and you may even know someone who had a great experience. Nonetheless, the downsides of medical tourism can be just as great if not greater. Sometimes, they can even be deadly.

If you are considering a trip abroad for your procedure, you should know that medical tourism isn't entirely without obstacle and risks. These include:

Poorly Trained Surgeons

In any country—the United States included—there will be good surgeons and bad. And just as there are great surgeons abroad, there are also some surgeons who are less talented, less trained, and less experienced.

Regardless of what procedure you are getting or where, you should always do some preliminary research into the surgeon or physician who will be treating you as well as the hospital you will be treated at.

In the United States, it is fairly easy to obtain information about malpractice lawsuits , sanctions by medical boards, and other disciplinary actions against a physician.

Performing this research from afar can be challenging, especially if you don't speak the local language. Yet countless people take the risk anyway, without knowing whether the physicians who will treat them are reputable.

A physician should be trained in the specific area of medicine that is appropriate for your procedure. For example, you should not be having plastic surgery from a surgeon who was trained to be a heart doctor. It isn’t good enough to be a physician, the physician must be trained in the specialty .

Prior to agreeing to surgery, you should also know your surgeon’s credentials : where they studied, where they trained, and in what specialty(s) they are board-certified. Do not rely on testimonials from previous patients; these are easily made up for a website and even if they are correct, one good surgery doesn’t mean they will all be successful.

Quality of Staff

Nurses are a very important part of healthcare, and the care they provide can mean the difference between a great outcome and a terrible one.

A well-trained nurse can identify a potential problem and fix it before it truly becomes an issue. A poorly trained nurse may not identify a problem until it is too late. The quality of the nursing staff will have a direct impact on your care.

Once again, it's important to research the hospital staff where you will be having your procedure done. Read the reviews but don't trust them blindly. If you can, seek out a recommendation from someone who can vouch for the medical staff where you will be going.

Quality of the Facility

While researching healthcare facilities for your procedure, you want to learn not just about the quality of the facilities themselves, but about the country's healthcare system as a whole.

In some countries, there is a marked distinction between public hospitals and private hospitals. In Turkey, for example, private hospitals are considered on-par with hospitals in the states, while many locals will advise you to steer clear of public hospitals if you can.

You will also want to seek out facilities that are internationally accredited. In the United States, the Joint Commission evaluates hospitals and certifies those that provide safe, quality care. The international division does the same for hospitals outside the United States.

Once you have a few options for potential facilities, you can start to investigate specifics. For one, you should find as many pictures and reviews of the facility as you can. Ask yourself whether the facility is state of the art or whether it seems dirty and outdated.

You will also need to find out if the facility has ICU level care available, in case something goes wrong. If not, there should be a major hospital nearby so that you can be transferred quickly.

To learn more about a healthcare facility, consider joining expat groups on social media for the city or country you will be traveling to. Ask the group for recommendations, or inquire about any positive or negative experiences they may have had at a particular facility.

Flying Home After Surgery

Any surgery comes with risks, including infection and blood clots . Flying home increases the risk of blood clots, especially on long-haul flights that are longer than four hours.

Try to avoid flying home in the days immediately after surgery; waiting a week will decrease the chances of developing a blood clot or another serious complication during the flight.

For longer flights, plan on getting up and walking up and down the aisles each hour to improve blood flow in your legs. You might also benefit from wearing compression socks with your doctor's approval.

If you are taking blood thinners or are at-risk of blood clots , be sure to talk to your doctor about how you can reduce your risk of blood clots after your procedure and while traveling.

Furthermore, you should know the symptoms of blood clots and stay alert.

Unplanned Illness

Any time you travel abroad, you run the risk of catching an illness that you have never been exposed to or that your body is not prepared to fight off. This is especially a concern when spending time in a foreign hospital.

If you have a sensitive stomach, you may also want to think long and hard about having surgery abroad. The food is often very different in foreign hospitals, and in some areas, there is a risk that even the water will be upsetting to your body.

Having diarrhea or postoperative nausea and vomiting makes for a miserable recovery experience, especially if you do not have a friend or family member nearby who can help you through it.

Before you travel abroad, check with your doctor to see if you need any vaccines to travel to your destination or if there are any foreign illnesses you should be aware of. Picking up an illness abroad, particularly after your surgery, can potentially be life-threatening.

Language Barriers

If you are having surgery in a country where English is not the primary language, you will need to make preparations in order to be able to communicate with the staff.

You may be pleasantly surprised to learn that the staff speaks your primary language well. If not, then you will need to consider how you will make your wishes and needs known to the surgeon, the staff, and others you will meet.

Whether you are at home or abroad, remember to speak up and advocate for yourself to make sure your needs are met. If you don't speak the local language, download a language translation app on your smartphone and don't hesitate to use it to communicate your needs. Hiring a translator is another option.

A Word About Transplant Tourism

Transplant tourism is one area of medical tourism that is strongly discouraged by organ and tissue transplant professionals in multiple countries. Most international transplants are considered “black market” surgeries that are not only poor in quality, but ethically and morally wrong.

China, for example, the country that is believed to perform more international kidney transplants than any other country, is widely believed to take organs from political prisoners after their execution.

In India, living donors are often promised large sums of money for their kidney donation, only to find out they have been scammed and never receive payment. Selling an organ in India is illegal, as it is in most areas of the world, so there is little recourse for the donor.

Then there is the final outcome: how well the organ works after the surgery is complete. With black market transplants, less care is often taken with matching the donor and recipient, which leads to high levels of rejection and a greater risk of death. Furthermore, the new organ may not have been screened for diseases such as cytomegalovirus , tuberculosis , hepatitis B , and hepatitis C . It is often the new disease that leads to death, rather than the organ rejection itself.

Finally, transplant surgeons are often reluctant to care for a patient who intentionally circumvented the donor process in the United States and received their transplant from an unknown physician.

It is important to arrange your follow-up care prior to leaving your home country.

Many physicians and surgeons are hesitant to take care of a patient who received care outside the country, as they are often unfamiliar with medical tourism and have concerns about the quality of care overseas.

Arranging for follow-up care before you leave will make it easier to transition to care at home without the stress of trying to find a physician after surgery .

Just be sure to inform your follow-up care physician where you are having your procedure done. After you return, they will also want to know what prescription medications you were given, if any.

What are popular countries for medical tourism? 

Mexico, India, Costa Rica, Turkey, Singapore, Canada, and Thailand are among the many countries that are popular for medical tourism.

How safe is medical tourism?

Medical tourism is generally considered safe, but it's critical to research the quality of care, physician training, and surgical specialties of each country. There are several medical tourism organizations that specialize in evaluating popular destinations for this purpose.

What countries have free healthcare? 

Countries with free healthcare include England, Canada, Thailand, Mexico, India, Sweden, South Korea, Israel, and many others.

A Word From Verywell

If you are considering medical tourism, discuss the risks and benefits with your doctor, and consider working with your insurance provider to arrange a trip that balances financial savings with safety. (Also, before you embark on a trip overseas for your procedure, make sure you are financially prepared for unexpected events and emergencies. Don't go abroad if you don't have enough money to get yourself home in a crisis.)

A medical tourism organization such as Patients Without Borders can help you evaluate the quality and trustworthiness of healthcare in various countries. Making sure a high level of care is readily available will lead to a safer, more relaxing experience.

Centers For Disease Control and Prevention. Medical Tourism: Getting medical care in another country . Updated October 23, 2017.

University of the Incarnate Word. Center for Medical Tourism Research .

Patients Beyond Borders. Facts and figures .

Kaiser Family Foundation. Health coverage of immigrants . Published July 2021.

Paul DP 3rd, Barker T, Watts AL, Messinger A, Coustasse A. Insurance companies adapting to trends by adopting medical tourism . Health Care Manag (Frederick). 2017 Oct/Dec;36(4):326-333. doi: 10.1097/HCM.0000000000000179

Batista BN. State of plastic surgery in Brazil .  Plast Reconstr Surg Glob Open . 2017 Dec;5(12):1627. doi:10.1097/GOX.0000000000001627

Johns Hopkins Bloomberg School of Public Health - Global Health Now. Brazilians' risky right to beauty . Published May 2018.

Chokrungvaranont P, Selvaggi G, Jindarak S, et al. The development of sex reassignment surgery in Thailand: a social perspective .  Sci World J . 2014 Mar;2014(1):1-5. doi:10.1155/2014/182981

The Joint Commission. For consumers .

Centers for Disease Control and Prevention. Blood clots and travel: what you need to know . Reviewed February 2021.

Hurley R. China harvested organs from political prisoners on substantial scale, says tribunal . BMJ . 2018 Dec;363(1):5250. doi:10.1136/bmj.k5250

Ambagtsheer F, Van Balen L. I'm not Sherlock Holmes: suspicions, secrecy, and silence of transplant professionals in the human organ trade . Euro J Criminol . 2019 Jan;17(6):764-783. doi:10.1177/1477370818825331

Centers for Disease Control and Prevention. Transplant Surgery. Key facts . Reviewed January 2019.

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

Travel Medicine and International Health

Travel medicine and international health is a specialized branch of medicine that focuses on the prevention, diagnosis, and management of health issues related to international travel and global health. It aims to promote the well-being of travelers by providing pre-travel consultations, vaccinations, prophylactic medications, and post-travel care for various travel-related illnesses and conditions.

Related Fact Sheets

Global health and travel-related maladies, outdoor emergencies and injuries, related news.

Related Departments

Infectious diseases, internal medicine, orthopaedics & rehabilitation.

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• Section 6 - Perspectives : Avoiding Poorly Regulated Medicines & Medical Products During Travel
• Section 7 - Pregnant Travelers

Medical Tourism

Cdc yellow book 2024.

Author(s): Matthew Crist, Grace Appiah, Laura Leidel, Rhett Stoney

• Categories Of Medical Tourism

The Pretravel Consultation

Risks & complications, risk mitigation, additional guidance for us health care providers.

Medical tourism is the term commonly used to describe international travel for the purpose of receiving medical care. Medical tourists pursue medical care abroad for a variety of reasons, including decreased cost, recommendations from friends or family, the opportunity to combine medical care with a vacation destination, a preference to receive care from a culturally similar provider, or a desire to receive a procedure or therapy not available in their country of residence.

Medical tourism is a worldwide, multibillion-dollar market that continues to grow with the rising globalization of health care. Surveillance data indicate that millions of US residents travel internationally for medical care each year. Medical tourism destinations for US residents include Argentina, Brazil, Canada, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, Germany, India, Malaysia, Mexico, Nicaragua, Peru, Singapore, and Thailand. Categories of procedures that US medical tourists pursue include cancer treatment, dental care, fertility treatments, organ and tissue transplantation, and various forms of surgery, including bariatric, cosmetic, and non-cosmetic (e.g., orthopedic).

Most medical tourists pay for their care at time of service and often rely on private companies or medical concierge services to identify foreign health care facilities. Some US health insurance companies and large employers have alliances with health care facilities outside the United States to control costs.

Categories of Medical Tourism

Cosmetic tourism.

Cosmetic tourism, or travel abroad for aesthetic surgery, has become increasingly popular. The American Society of Plastic Surgeons (ASPS) reports that most cosmetic surgery patients are women 40–54 years old. The most common procedures sought by cosmetic tourists include abdominoplasty, breast augmentation, eyelid surgery, liposuction, and rhinoplasty. Popular destinations often are marketed to prospective medical tourists as low cost, all-inclusive cosmetic surgery vacations for elective procedures not typically covered by insurance. Complications, including infections and surgical revisions for unsatisfactory results, can compound initial costs.

Non-Cosmetic Medical Tourism

Cancer treatment.

Oncology, or cancer treatment, tourism often is pursued by people looking for alternative treatment options, better access to care, second opinions, or a combination of these. Oncology tourists are a vulnerable patient population because the fear caused by a cancer diagnosis can lead them to try potentially risky treatments or procedures. Often, the treatments or procedures used abroad have no established benefit, placing the oncology tourist at risk for harm due to complications (e.g., bleeding, infection) or by forgoing or delaying approved therapies in the United States.

Dental Care

Dental care is the most common form of medical tourism among US residents, in part due to the rising cost of dental care in the United States; a substantial proportion of people in the United States do not have dental insurance or are underinsured. Dentists in destination countries might not be subject to the same licensure oversight as their US counterparts, however. In addition, practitioners abroad might not adhere to standard infection-control practices used in the United States, placing dental tourists at a potential risk for infection due to bloodborne or waterborne pathogens.

Fertility Treatments

Fertility tourists are people who seek reproductive treatments in another country. Some do so to avoid associated barriers in their home country, including high costs, long waiting lists, and restrictive policies. Others believe they will receive higher quality care abroad. People traveling to other countries for fertility treatments often are in search of assisted reproductive technologies (e.g., artificial insemination by a donor, in vitro fertilization). Fertility tourists should be aware, however, that practices can vary in their level of clinical expertise, hygiene, and technique.

Physician-Assisted Suicide

The practice of a physician facilitating a patient’s desire to end their own life by providing either the information or the means (e.g., medications) for suicide is illegal in most countries. Some people consider physician-assisted suicide (PAS) tourism, also known as suicide travel or suicide tourism, as a possible option. Most PAS tourists have been diagnosed with a terminal illness or suffer from painful or debilitating medical conditions. PAS is legal in Belgium, Canada, Luxembourg, the Netherlands, Switzerland, and New Zealand, making these the destinations selected by PAS travelers.

Rehab Tourism for Substance Use Disorders

Rehab tourism involves travel to another country for substance use disorder treatment and rehabilitation care. Travelers exploring this option might be seeking a greater range of treatment options at less expense than what is available domestically (see Sec. 3, Ch. 5, Substance Use & Substance Use Disorders , and Box 3-10 for pros and cons of rehab tourism).

Transplant Procedures

Transplant tourism refers to travel for receiving an organ, tissue, or stem cell transplant from an unrelated human donor. The practice can be motivated by reduced cost abroad or an effort to reduce the waiting time for organs. Xenotransplantation refers to receiving other biomaterial (e.g., cells, tissues) from nonhuman species, and xenotransplantation regulations vary from country to country. Many procedures involving injection of human or nonhuman cells have no scientific evidence to support a therapeutic benefit, and adverse events have been reported.

Depending on the location, organ or tissue donors might not be screened as thoroughly as they are in the United States; furthermore, organs and other tissues might be obtained using unethical means. In 2009, the World Health Organization released the revised Guiding Principles on Human Cell, Tissue, and Organ Transplantation, emphasizing that cells, tissues, and organs should be donated freely, in the absence of any form of financial incentive.

Studies have shown that transplant tourists can be at risk of receiving care that varies from practice standards in the United States. For instance, patients might receive fewer immunosuppressive drugs, increasing their risk for rejection, or they might not receive antimicrobial prophylaxis, increasing their risk for infection. Traveling after a procedure poses an additional risk for infection in someone who is immunocompromised.

Ideally, medical tourists will consult a travel medicine specialist for travel advice tailored to their specific health needs 4–6 weeks before travel. During the pretravel consultation, make certain travelers are up to date on all routine vaccinations, that they receive additional vaccines based on destination, and especially encourage hepatitis B virus immunization for unvaccinated travelers (see Sec. 2, Ch. 3, Vaccination & Immunoprophylaxis & General Principles , and Sec. 5, Part 2, Ch. 8, Hepatitis B ). Counsel medical tourists that participating in typical vacation activities (e.g., consuming alcohol, participating in strenuous activity or exercise, sunbathing, swimming, taking long tours) during the postoperative period can delay or impede healing.

Advise medical tourists to also meet with their primary care provider to discuss their plan to seek medical care outside the United States, to address any concerns they or their provider might have, to ensure current medical conditions are well controlled, and to ensure they have a sufficient supply of all regular medications to last the duration of their trip. In addition, medical tourists should be aware of instances in which US medical professionals have elected not to treat medical tourists presenting with complications resulting from recent surgery, treatment, or procedures received abroad. Thus, encourage medical tourists to work with their primary care provider to identify physicians in their home communities who are willing and available to provide follow-up or emergency care upon their return.

Remind medical tourists to request copies of their overseas medical records in English and to provide this information to any health care providers they see subsequently for follow-up. Encourage medical tourists to disclose their entire travel history, medical history, and information about all surgeries or medical treatments received during their trip.

All medical and surgical procedures carry some risk, and complications can occur regardless of where treatment is received. Advise medical tourists not to delay seeking medical care if they suspect any complication during travel or after returning home. Obtaining immediate care can lead to earlier diagnosis and treatment and a better outcome.

Among medical tourists, the most common complications are infection related. Inadequate infection-control practices place people at increased risk for bloodborne infections, including hepatitis B, hepatitis C, and HIV; bloodstream infections; donor-derived infections; and wound infections. Moreover, the risk of acquiring antibiotic-resistant infections might be greater in certain countries or regions; some highly resistant bacterial (e.g., carbapenem-resistant Enterobacterales [CRE]) and fungal (e.g., Candida auris ) pathogens appear to be more common in some countries where US residents travel for medical tourism (see Sec. 11, Ch. 5, Antimicrobial Resistance ).

Several infectious disease outbreaks have been documented among medical tourists, including CRE infections in patients undergoing invasive medical procedures in Mexico, surgical site infections caused by nontuberculous mycobacteria in patients who underwent cosmetic surgery in the Dominican Republic, and Q fever in patients who received fetal sheep cell injections in Germany.

Noninfectious Complications

Medical tourists have the same risks for noninfectious complications as patients receiving medical care in the United States. Noninfectious complications include blood clots, contour abnormalities after cosmetic surgery, and surgical wound dehiscence.

Travel-Associated Risks

Traveling during the post-operative or post-procedure recovery period or when being treated for a medical condition could pose additional risks for patients. Air travel and surgery independently increase the risk for blood clots, including deep vein thrombosis and pulmonary emboli (see Sec. 8, Ch. 3, Deep Vein Thrombosis & Pulmonary Embolism ). Travel after surgery further increases the risk of developing blood clots because travel can require medical tourists to remain seated for long periods while in a hypercoagulable state.

Commercial aircraft cabin pressures are roughly equivalent to the outside air pressure at 6,000–8,000 feet above sea level. Medical tourists should not fly for 10 days after chest or abdominal surgery to avoid risks associated with changes in atmospheric pressure. ASPS recommends that patients undergoing laser treatments or cosmetic procedures to the face, eyelids, or nose, wait 7–10 days after the procedure before flying. The Aerospace Medical Association published medical guidelines for air travel that provide useful information on the risks for travel with certain medical conditions.

Professional organizations have developed guidance, including template questions, that medical tourists can use when discussing what to expect with the facility providing the care, with the group facilitating the trip, and with their own domestic health care provider. For instance, the American Medical Association developed guiding principles on medical tourism for employers, insurance companies, and other entities that facilitate or incentivize medical care outside the United States ( Box 6-07 ). The American College of Surgeons (ACS) issued a similar statement on medical and surgical tourism, with the additional recommendation that travelers obtain a complete set of medical records before returning home to ensure that details of their care are available to providers in the United States, which can facilitate continuity of care and proper follow-up, if needed.

Box 6-07 American Medical Association’s guiding principles on medical tourism 1

• Employers, insurance companies, and other entities that facilitate or incentivize medical care outside the United States should adhere to the following principles:
• Receiving medical care outside the United States must be voluntary.
• Financial incentives to travel outside the United States for medical care should not inappropriately limit the diagnostic and therapeutic alternatives that are offered to patients or restrict treatment or referral options.
• Patients should only be referred for medical care to institutions that have been accredited by recognized international accrediting bodies (e.g., the Joint Commission International or the International Society for Quality in Health Care).
• Prior to travel, local follow-up care should be coordinated, and financing should be arranged to ensure continuity of care when patients return from medical care outside the United States.
• Coverage for travel outside the United States for medical care should include the costs of necessary follow-up care upon return to the United States.
• Patients should be informed of their rights and legal recourse before agreeing to travel outside the United States for medical care.
• Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the United States.
• The transfer of patient medical records to and from facilities outside the United States should be consistent with Health Insurance Portability and Accountability Action (HIPAA) guidelines.
• Patients choosing to travel outside the United States for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.

1 American Medical Association (AMA). New AMA Guidelines on Medical Tourism . Chicago: AMA; 2008.

Reviewing the Risks

Multiple resources are available for providers and medical tourists assessing medical tourism–related risks (see Table 6-02 ). When reviewing the risks associated with seeking health care abroad, encourage medical tourists to consider several factors besides the procedure; these include the destination, the facility or facilities where the procedure and recovery will take place, and the treating provider.

Make patients aware that medical tourism websites marketing directly to travelers might not include (or make available) comprehensive details on the accreditations, certifications, or qualifications of advertised facilities or providers. Local standards for facility accreditation and provider certification vary, and might not be the same as those in the United States; some facilities and providers abroad might lack accreditation or certification. In some locations, tracking patient outcome data or maintaining formal medical record privacy or security policies are not standard practices.

Medical tourists also should be aware that the drugs and medical products and devices used in other countries might not be subject to the same regulatory scrutiny and oversight as in the United States. In addition, some drugs could be counterfeit or otherwise ineffective because the medication expired, is contaminated, or was improperly stored (for more details, see the previous chapter in this section, . . . perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel ).

Table 6-02 Online medical tourism resources

Checking credentials.

ACS recommends that medical tourists use internationally accredited facilities and seek care from providers certified in their specialties through a process equivalent to that established by the member boards of the American Board of Medical Specialties. Advise medical tourists to do as much advance research as possible on the facility and health care provider they are considering using. Also, inform medical tourists that accreditation does not guarantee a good outcome.

Accrediting organizations (e.g., The Joint Commission International, Accreditation Association for Ambulatory Health Care) maintain listings of accredited facilities outside of the United States. Encourage prospective medical tourists to review these sources before committing to having a procedure or receiving medical care abroad.

ACS, ASPS, the American Society for Aesthetic Plastic Surgery, and the International Society of Aesthetic Plastic Surgery all accredit physicians abroad. Medical tourists should check the credentials of health care providers with search tools provided by relevant professional organizations.

Travel Health Insurance

Before travel, medical tourists should check their domestic health insurance plan carefully to understand what services, if any, are covered outside the United States. Additionally, travelers might need to purchase supplemental medical insurance coverage, including medical evacuation insurance; this is particularly important for travelers going to remote destinations or places lacking medical facilities that meet the standards found in high-income countries (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance ). Medical tourists also should be aware that if complications develop, they might not have the same legal recourse as they would if they received their care in the United States.

Planning for Follow-Up Care

Medical tourists and their domestic physicians should plan for follow-up care. Patients and clinicians should establish what care will be provided abroad, and what the patient will need upon return. Medical tourists should make sure they understand what services are included as part of the cost for their procedures; some overseas facilities and providers charge substantial fees for follow-up care in addition to the base cost. Travelers also should know whether follow-up care is scheduled to occur at the same facility as the procedure.

Health care facilities in the United States should have systems in place to assess patients at admission to determine whether they have received medical care in other countries. Clinicians should obtain an explicit travel history from patients, including any medical care received abroad. Patients who have had an overnight stay in a health care facility outside the United States within 6 months of presentation should be screened for CRE. Admission screening is available free of charge through the Antibiotic Resistance Laboratory Network .

Notify state and local public health as soon as medical tourism–associated infections are identified. Returning patients often present to hospitals close to their home, and communication with public health authorities can help facilitate outbreak recognition. Health care facilities should follow all disease reporting requirements for their jurisdiction. Health care facilities also should report suspected or confirmed cases of unusual antibiotic resistance (e.g., carbapenem-resistant organisms, C. auris ) to public health authorities to facilitate testing and infection-control measures to prevent further transmission. In addition to notifying the state or local health department, contact the Centers for Disease Control and Prevention at [email protected] to report complications related to medical tourism.

The following authors contributed to the previous version of this chapter: Isaac Benowitz, Joanna Gaines

Bibliography

Adabi K, Stern C, Weichman K, Garfein ES, Pothula A, Draper L, et al. Population health implications of medical tourism. Plast Reconstr Surg. 2017;140(1):66–74.

Al-Shamsi, H, Al-Hajelli, M, Alrawi, S. Chasing the cure around the globe: medical tourism for cancer care from developing countries. J Glob Onc. 2018;4:1–3.

Kracalik I, Ham C, Smith AR, Vowles M, Kauber K, Zambrano M, et al. (2019). Notes from the field: Verona integron-encoded metallo-β-lactamase–producing carbapenem-resistant Pseudomonas aeruginosa infections in U.S. residents associated with invasive medical procedures in Mexico, 2015–2018. MMWR Morb Mortal Wkly Rep. 2019;68(20):463–4.

Pavli A, Maltezou HC. Infectious complications related to medical tourism. J Travel Med. 2021;28(1):taaa210.

Pereira RT, Malone CM, Flaherty GT. Aesthetic journeys: a review of cosmetic surgery tourism. J Travel Med. 2018;25(1):tay042.

Robyn MP, Newman AP, Amato M, Walawander M, Kothe C, Nerone JD, et al. Q fever outbreak among travelers to Germany who received live cell therapy & United States and Canada, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(38):1071–3.

Salama M, Isachenko V, Isachenko E, Rahimi G, Mallmann P, Westphal LM, et al. Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review). J Assist Reprod Genet. 2018;35(7):1277–88.

Schnabel D, Esposito DH, Gaines J, Ridpath A, Barry MA, Feldman KA, et al. Multistate US outbreak of rapidly growing mycobacterial infections associated with medical tourism to the Dominican Republic, 2013–2014. Emerg Infect Dis. 2016;22(8):1340–7.

Stoney RJ, Kozarsky PE, Walker AT, Gaines JL. Population-based surveillance of medical tourism among US residents from 11 states and territories: findings from the Behavioral Risk Factor Surveillance System. Infect Control Hosp Epidemiol. 2022;43(7):870–5.

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Trip Database: An Overview

The Trip Database is a medical search engine with an emphasis on evidence based practice (EBP), clinical guidelines and queries. Himmelfarb Library provides access to the freely accessible version of Trip. Started in 1997, Trip aims to help users “find evidence fast” with an easy to use search interface that filters results based on the evidence pyramid . A pyramid icon is displayed with the resource that indicates where the resource falls on the evidence pyramid.

Journals covered in Trip include high impact titles such as the New England Journal of Medicine (NEJM), The Lancet , the Journal of the American Medical Association (JAMA), the British Medical Journal (BMJ), and Annals of Internal Medicine . In addition, content from EvidenceAlerts and PubMed ’s core journal content is included. You can learn more about journal content included in Trip in their recent blog post on the subject.

In addition to the journal articles, Trip results provide a full range of resources including e-textbooks, patient information leaflets, educational courses and news. One thing to keep in mind about Trip is that publishers are classified by their output. Cochrane is known for publishing systematic reviews, and therefore Cochrane published resources will appear in the Systematic Reviews filter. The New England Journal of Medicine (NEJM) is classified as Primary Research. This means that if a systematic review is published in NEJM, it will appear in the Primary Research filter. However, when a systematic review is reviewed by the Database of Abstracts of Reviews of Effects (DARE), it will eventually appear in the Systematic Reviews filter, although there is a time delay.

Trip can be used by practicing physicians who would like to broaden their background knowledge on conditions such as diabetes or cancer, or who need to find relevant evidence-based information on testing guidelines or to make sure a “don’t miss” diagnosis is included in their differential diagnosis. Trip is also useful for medical students who may find the PICO search tool an effective way to search for applicable resources. Check out this blog post to learn more about case studies for using Trip.

Trip has responded to the War in Ukraine by creating a combat injuries filter . While this effort is still a work in progress, the filter attempts to gather the best combat evidence available. 

Interested in learning more about Trip? Check out the short video below:

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Stay healthy abroad: Why you should see a travel medicine specialist before your trip

As you get ready to travel to another country, you probably have many details to coordinate and plan. One essential task, depending on where those travels take you, may be to make an appointment to see a travel medicine specialist.

A travel medicine specialist assesses travel-related risks and provides information to ensure your health and safety while minimizing the potential for health-related situations during on your trip.

Adding a consultation to your travel to-do list

A consultation with a travel medicine specialist includes discussing travel-related illnesses, risk factors for infectious and noninfectious diseases, required immunizations , health regulations and drug-resistant organisms you may encounter.

It's crucial to schedule a pretravel consultation at least two weeks or preferably, four to eight weeks, before your trip to ensure you get complete protection from any needed vaccinations.

When requesting a travel medicine consultation, be prepared to provide information about your trip, including:

• All countries you're visiting
• Any transportation, accommodation or other unusual circumstances
• Dates and duration of travel

A travel medicine specialist will review your itinerary before your consultation to identify country-by-country health risks, such as exotic infectious agents, the potential for altitude sickness or heat exhaustion, as well as appropriate vaccinations and possible need for malaria prevention medications.

Your opportunity to learn about staying healthy abroad

A consultation gives you the opportunity to learn about health risks you may face while you're traveling and once you reach your destinations.

Based on your itinerary, the travel medicine specialist may:

• Explain the risks of infection from mosquito-borne illnesses and the steps for protecting yourself. This includes reviewing medications to prevent malaria , which is a potentially life-threatening illness.
• Ensure you receive protection against vaccine-preventable illnesses, such as hepatitis A or typhoid fever , and verify that other routine vaccinations are current.
• Evaluate your overall health for travel and discuss with you how to manage preexisting conditions.
• Give tips for preventing jet lag, motion sickness, altitude illness and blood clots .
• Review how to prevent and treat traveler's diarrhea , the most common travel-related illness.
• Help you reduce the chance of becoming ill during travel.
• Provide a yellow fever vaccination and an International Certificate of Vaccination , also known as a yellow card, if you travel to a country where the vaccine is recommended or required.
• Review food and water precautions. Contaminated food and water can pose disease risk for travelers, many of which are transmitted via swallowing or coming in contact with impure water, such as fresh or sea water and swimming pools.

Be sure to ask the specialist any questions you may have about your personal health, and raise any safety concerns about your travel itinerary.

What to do if you got sick on your trip

Once you return home, a travel medicine specialist also can conduct a comprehensive post-travel evaluation of any illnesses you may have picked up while away, including parasitic infections and other tropical diseases that are rare in the U.S.

No matter the reason for travel — vacation, business, studying abroad, visiting friends or relatives or medical tourism — always be prepared, and take steps to ensure your health and safety.

Raj Palraj, M.B.B.S., M.D. , is an infectious diseases specialist in La Crosse , Wisconsin.

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10 Essentials You Need to Pack for Your Medical Tourism Trip

Packing is always a chore under the best circumstances, but when you are traveling away from home for a medical procedure, it is especially important that you pack with care. Given the heightened security for travelers and the fact that you might not be feeling your best, you want to be sure you don’t add to your stress by forgetting something important.

Making a list of everything you might possibly need and then checking it before leaving the house will ensure your trip gets off to a good start. Here are some essentials you’ll need during your medical tourism trip. ‍

Documents and Paperwork

Getting your papers in order with plenty of time to spare is always a good idea, just in case you have to send off something. If you wait until the last minute, you are setting yourself up for a possible last-minute glitch. For instance, ordering a passport to replace an expired one may take weeks.

If you’re lucky, you already have everything you need for the trip, but it’s always a good idea to triple check to be sure you don’t leave home without something crucial. The last hassle anyone wants to deal with is to be working out of a hotel, trying to get papers sent out and possibly delaying the procedure. ‍

1. Medical Papers

Medical papers and records are a necessity and should be at the top of your list of things to pack. Just to be safe, it is always a good idea to have extra copies of key documents in different suitcases to be covered in case some of your luggage is lost. ‍

2. Passports and Visas

Keep your passport close at all times and have some foreign currency on hand for incidentals. The first thing that should be done during the planning stage is to check the rules for passports in different countries and read them carefully.

In addition to a passport, some countries require travelers to have a visa too. You should always check with the embassy to see if this is a requirement for visiting that country. ‍

3. Currency

Exchanging currency is easier done ahead of time when you can exchange it at a trusted institution in your hometown, getting the best rates. If you wait until you are out of your element on foreign soil, you may not fare as well financially when you exchange foreign currency. It’s always a good idea to get bills in smaller denominations so there is no problem using them and getting change for low cost items. ‍

Bonus Tip: Credit Card Alerts

Credit card limits should be checked ahead of time so you are sure to bring the ones you need. It is also a good idea to let the credit card companies know where you will be, so there is no risk of having them block a transaction for “security reasons.”

While it is nice to know they are watching out for us, it can be problematic when you find yourself trying to pay and your credit card is declined. Save yourself the headache by giving them a “heads up” before you leave. ‍

After Care Medications

4. medication and pain relievers.

You can’t always know what a hospital or care facility in a different country will have on hand. Aspirin and other painkillers may be abundant in your country, but they may be much harder to find in the country where you are headed. Assumptions about other cultures and hospitals in other countries can leave you without something you need. ‍

5. After Care Products

Plan ahead to save money and guarantee your comfort. Depending on the procedure and the country you’re visiting, some common items you might want to bring are wound dressings, gauze, scissors, band-aids, and over-the-counter medications. ‍

Miscellaneous Care Items

6. comfortable clothing.

You will need to include clothes for traveling and for the hospital. Considering how unpredictable the weather can be, it makes sense to be prepared for whatever is possible. The last thing you will feel like doing is going shopping after your medical procedure. Loose clothing that works in a hospital setting should be packed. Pajamas with buttons in the front and a robe offer comfortable choices. ‍

Overseas, you’ll be eating different foods. It is always a good idea to have medicine on hand to treat an upset stomach or motion sickness. Even people who rarely worry about this type of ailment can have problems in other countries where the food and spices can be quite different.

Being over-prepared is always better than the alternative, particularly in countries where you do not know the language and you might struggle to explain what you need. It is important to remember that tablets travel better than liquids and gels, especially if you’re flying. ‍

8. Insect Repellant

Don’t forget the insect repellant. Some areas popular as medical tourism destinations also have a lot of insects. It would be a terrible calamity to travel to a country to take care of one medical problem, only to contract another. Some of the diseases spread by insects can be serious and even deadly. ‍

9. Comforts from Home

Pillows, slippers and even bed linens are recommended for medical tourism trips. By having the comforts of home, you won’t have to depend on the hotel or country you are visiting to have what you need. Given the difference in customs and what is considered adequate by another country’s standards, you might be in for a big surprise if you don’t take some extra measures to take care of yourself. ‍

10. Emergency Contact Information

Be sure to have all doctors’ names, relevant phone numbers, and addresses for the hospital, hotel and any other important destination. In countries where you don’t speak the language, you can always show them the address and get some help. Having everything written down in an easily accessible notebook can make life easier. ‍

Travel Companion

Lastly, it is always recommended that you bring a trusted companion with you on your medical tourism trip. Although, you can’t pack them, it is important to bring someone along in case of emergencies. They will also be beneficial to have someone to keep you company during recovery and assist you during the trip back home. ‍

Medical tourism offers many people a viable solution for healthcare as medical procedure costs continue to rise, making it difficult for everyone to afford the care they require. While traveling for a medical procedure solves one problem, it can create others if you aren’t careful when you pack.

Anytime you travel far from home, there is always the chance that something unexpected can happen and you won’t be able to run home quickly and retrieve something you need. Making a checklist ensures that you are prepared for whatever comes your way and that your trip will be less stressful.

About the Author

British Solomon is a contributing writer and media specialist for  Bacteriotstatic . She regularly produces content for a variety of health and travel blogs.

Exploring the Surge of Cosmetic Tourism: Trends and Considerations in Aesthetic Procedures Abroad

Holistic healing: exploring integrative medicine and wellness retreats, meeting the surge: the growing demand for knee replacement surgeries and advances in the field, innovations in medical technology: how cutting-edge technology drives medical tourism, stem cells have powerful anti-aging properties, breakthrough stem cell treatment for autism, new shift for thailand’s medical travel landscape as mta launches new moves, continue reading, informed decision-making in medical tourism: the significance of clinical outcome reports, avoiding pitfalls: top 5 mistakes medical tourism startups should steer clear of, reshaping cataract surgery with advanced technology, featured reading, dominican republic’s giant strides to becoming a global leader in medical tourism, exploring niche markets in medical tourism, medical tourism magazine.

The Medical Tourism Magazine (MTM), known as the “voice” of the medical tourism industry, provides members and key industry experts with the opportunity to share important developments, initiatives, themes, topics and trends that make the medical tourism industry the booming market it is today.

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Trip database – a different way to find evidence

Posted on 1st July 2013 by Alice Buchan

The Trip database may at first seem like any other search engine for scientific and medical research – plug your key words into the box, press enter, and watch what comes back. What makes Trip different, is what appears on the results page. Trip originally stood for translating research into practice – which is what it aims to help you do.

Searching Trip

To illustrate this, I’ll start by searching the database, with a topical (at the time of writing [1]) entry: “diclofenac heart” . The most obvious point is that results are colour coded – this is made clear by the toolbar at the side, where secondary evidence, such as systematic reviews, is green, primary evidence red, and so on. The order in which the results appear is what makes Trip unique; their algorithm includes research quality, date (more recent first), and a text score (relevance) [2], which combine to give you relevant, recent, and high quality results first (with a few odd exceptions I’ll come to later).

Colour coded results

Back to my search “diclofenac heart” – the default is to sort with quality as the top priority – but you can also make date or relevance more central to the ordering of results. When sorting by date, this highlights one of the idiosyncrasies of Trip; quality is based on journal or source [2], so a meta-analysis, which is high quality secondary research, (Lancet 2013 in the screen grab) is coded red, for key primary research. This isn’t much of an issue, but worth bearing in mind. Flicking through all 3 sorting options can help you find papers the first one might have missed. Another way of finding more relevant papers is by using the synonyms tab at the top of the search results. You may start your search knowing you want a certain type of evidence, such as a Cochrane review or a set of guidelines, and you can filter using the buttons on the right hand side, which also includes filters for evidence relevant to the developing world.

Filtering the results

As with many other databases, Trip features an advanced search, including the ability to define the proximity of key words within the document, but the PICO search is really unique, and I think it’s a fantastic way of finding what you are interested in quickly. For the uninitiated, PICO is Patients, Intervention, Comparison, and Outcome, and the importance of these 4 measures is explained in detail here [3]. Making my search more specific, I searched for heart outcomes in patients with arthritis taking diclofenac.

Searching using PICO

I found Trip really intuitive to use and clearly laid out, but they also have a series of “How-to” videos to help [4] . My favourite features were the wide range of evidence and sources available, including things like guidelines, which aren’t in some other databases, as well as colour-coding.

[1] Trip Database http://www.tripdatabase.com 

[2] Trip Database. About Trip  http://www.tripdatabase.com/about

[3] CEBM. Asking Focused Questions.  http://www.cebm.net/?o=1036

[4] Trip Database. How to use Trip  http://www.tripdatabase.com/how-to-use-trip  

Alice Buchan

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What Does a Travel Medicine Specialist Do?

This article was medically reviewed by Dr. Ellen Hirsh.

Travel is on the rise among Americans, and after weathering the COVID-19 pandemic, travelers are especially aware of the health and safety risks that come with vacations or business trips to many popular destinations. But COVID-19 is only one consideration when traveling today, especially abroad. Many travelers may not be aware that they can contract dangerous infectious diseases through contaminated food, water, soil, mosquitoes, and more. Understanding these health risks is only part of the reason to see a travel medicine specialist before traveling internationally, or domestically if you have health conditions that leave you immunocompromised. In this blog, infectious disease physician Dr. Ellen Hirsh of ID Care explains how these doctors help travelers by addressing the question you’ll need to explore as you plan your trip: What does a travel medicine specialist do?

Travel medicine specialists are like medical travel guides who offer advice, preventive measures, and treatments designed to protect your health during every phase of a trip. Infectious disease doctors like those at ID Care can provide more comprehensive guidance than doctors at walk-in travel clinics, who may simply offer a couple of vaccines and send you on your way. Infectious disease doctors are also the best choice when help is needed after a trip, as they have the most experience treating exotic diseases.

Travel medicine specialists are key partners for travelers to consult:

• Before travel, when they evaluate a patient’s health history, immunization records, and travel itinerary and offer detailed recommendations, vaccinations, and medicine to bring along.
• During a trip, when doctors can be available via phone or telemedicine to advise sick travelers or provide guidance if needed.
• After a trip, when these specialists see sick patients returning for care and treatment, although this is less frequent among those who received pre-travel guidance.

“We hate to see someone get sick abroad with a terrible illness that not only ruins their vacation but sets them back in many ways after they get home,” Dr. Hirsh said. “That’s why anyone who is traveling, whether for business or pleasure, should come see us at ID Care before they leave, as opposed to dropping into a more generalized travel clinic or doing nothing at all. This will not only prepare travelers to protect themselves but will give them somewhere to turn for immediate attention if they do get sick.”

Infectious Disease Doctors: The Best Travel Medicine Specialists

Different parts of the world harbor different types of viruses, bacteria, fungi, and parasites, and while your body may be used to certain pathogens in your native area, it may be very vulnerable to them in distant locations abroad. This is one reason a pre-travel medical consultation is so important.

Infectious disease doctors are the most qualified travel medicine specialists because:

• They understand global health trends , such as which bacteria have become resistant to specific antibiotics that are sold over the counter in some countries. As a result, they are well prepared to diagnose and treat travelers who pick up these germs.
• They can care for patients with complex medical histories. “These patients may need to avoid drug interactions, or they may have a condition that limits the kinds of treatments they can receive,” Dr. Hirsh said. “For instance, people who are allergic to eggs can’t tolerate the vaccine for yellow fever because it contains egg protein. Patients who are immunocompromised also cannot receive the vaccine as it is a live viral vaccine.”
• They are the only physicians with comprehensive expertise about all types of infections, so they are best equipped to guide travelers about infectious disease prevention, along with health risks and treatment options.

What Conditions Do Travel Medicine Specialists Treat?

An array of diseases pose a threat to people who travel internationally, and travel medicine specialists are comfortable treating all of them. Those most encountered by the travel medicine doctors at ID Care are:

• Traveler’s diarrhea , caused by bacteria, viruses, and/or fungi passed through food or water that are prevalent in parts of Asia, Africa, the Middle East, Mexico, and Central and South America.
• Malaria , caused by a parasite passed via mosquito bites and common in Africa, Asia, and South America.
• Typhoid , caused by the bacteria Salmonella typhi that are transmitted through contaminated food or water and prevalent in parts of Asia, the Middle East, Africa, the Caribbean, and Central and South America.
• Hepatitis A , a virus contracted through food, water, or close contact with an infected person and common throughout the world.

Less common but still a risk are several diseases caused by viruses transmitted by mosquitoes:

• Yellow fever, common in certain parts of Africa and South America.
• Japanese encephalitis , present in some parts of Asia and the Western Pacific.
• Dengue fever, present in many countries in the Americas, Africa, the Middle East, Asia, and the Pacific Islands.
• Chikungunya, present in countries within Africa, Asia, and the Americas, and on islands in the Indian and Pacific Oceans.

Who Should See a Travel Medicine Specialist?

As you prepare for your trip, you might wonder if you really need to reserve time to see a travel medicine specialist. Anyone traveling internationally does, especially if the destination is a developing country, a safari, or any place considered exotic – all popular travel destinations.https://idcare.com/blog/a-safety-guide-for-international-travelers/

“Special notice should also be taken by those who have moved to the U.S. but are paying a visit to family or friends in their native country, because the feel familiar with the area and thus immune, but they are not. It’s easier for these individuals to take one pill a day to prevent malaria than to come back sick,” said Dr. Hirsh.

In addition, people who are immunocompromised should see a travel medicine specialist before taking a trip anywhere, as they face a higher risk of contracting an infection.

“People who are immunocompromised may face concerns when going to different areas of the U.S., as certain infections are endemic to specific areas,” Dr. Hirsh said. “There are some fungal infections that are seen only in the Four Corners area in the Southwest, while others are seen only in the Midwest Ohio area. And of course, Lyme disease is often seen in New Jersey, but may be much less likely in other parts of the country.”

When to Book a Travel Medicine Appointment

It’s not too late to see your travel medicine specialist even if it’s the day before a trip, but “it takes two weeks to make full antibodies in response to many of our vaccines and some vaccines require a series of shots, so we like to see you around two months before your trip,” Dr. Hirsh said.

It is recommended that people bring their health and immunization records as well as a detailed itinerary to the appointment, as this information is crucial in determining what kind of care and travel guidance they will need.

The Goals of a Pre-Travel Appointment

During a pre-travel appointment, your travel medicine doctor will ask the details of your trip and anticipate the diseases that could be of concern. In addition, the doctor will assess your health and immunization history, including drug allergies; offer preventive vaccines and advice; and prescribe medications for diseases you may contract while away.

“We are an internal medicine-based field, so we look at everything you need, from head to toe, and advise accordingly,” Dr. Hirsh said.

Evaluating Your Itinerary

In asking about your itinerary, a travel medicine specialist will want to know:

• Timing of the trip. Whether you are visiting a country during its wet or dry season can shed light on the level of concern related to mosquitoes or ticks.
• Altitude of the destination. This can indicate the likelihood of mosquito-borne diseases or altitude sickness.
• Mode of travel. Travel medicine doctors can prescribe medications in advance for motion sickness on planes or ships.
• Activities planned . Handling animals, visiting bat caves, or traveling through an area by bicycle — which can lead to encounters with dogs — may open the door to diseases such as rabies . Meanwhile, spending time in a rural area, where there may be more mosquitoes, could increase the risk of Japanese encephalitis.
• Typical level of food and water safety in the target area. For people not local to an area, the germs that live in food and water can cause illness, even at a five-star hotel. If that problem is likely, the doctor will recommend measures such as drinking only bottled water and remembering not to use tap water when brushing teeth.
• Prevalence of polio in the destination country. Three countries still have active polio cases and others continue to use an oral polio vaccine that can transmit the disease, so travelers planning visits can benefit from a preventive booster.

Vaccines and Other Medications

Based on a traveler’s trip itinerary and health history, travel medicine doctors can determine whether a patient needs preventive measures and care. These often include vaccines given in advance of a trip and medicines to bring along in case of illness.

Vaccines might be designed to protect against diseases in the destination region, such as typhoid, yellow fever, or cholera, or to ensure compliance with standard U.S. immunizations that the patient never received or is due to repeat, which protect against conditions such as diphtheria, tetanus , shingles , and hepatitis A.

“The preventive vaccine for yellow fever, previously recommended every 10 years for travelers, is now given once as a lifetime dose,” Dr. Hirsh said. “Better yet, while not every practice is licensed to give that vaccine, ID Care offers it. This is crucial, because travelers need to show certification that they’ve had the vaccine in order to travel in and out of certain countries. We are fortunate to carry all the travel-related vaccines that are available in the U.S. at all 10 of our locations, and we can give them onsite the day of a patient’s appointment.”

Travel medicine specialists might also prescribe:

• Preventive medications such as pills to prevent malaria.
• Antibiotics that target a disease the traveler may encounter, such as traveler’s diarrhea, along with instructions for when and how to use them.
• Altitude or motion sickness
• Medication to assist with sleep when adjusting to a new time zone.

Good Advice: The Other Preventive Medicine

In addition to medical care, travel medicine specialists provide helpful advice during a pre-travel appointment that falls into several categories:

• Practical safeguards, such as travelers’ health insurance policies, which can pay to transport a patient to a qualified treatment center in an emergency.
• Self-care, such as instructions for using insect repellant to prevent diseases including malaria and yellow fever, and for avoiding and treating traveler’s diarrhea using over-the-counter medications and hydration.
• What to know in an emergency , such as where to find help while traveling internationally – ideally at the largest teaching medical center in the closest city, where doctors are most likely to speak English and provide a good standard of care.

“It’s much easier to prevent a problem than to deal with complications later if something was missed or not handled well,” Dr. Hirsh said. “That’s why it makes sense to consult an expert like those at ID Care before leaving for a trip. Once you have been seen and are a patient of our practice, we can assist whenever you need us.”

Consulting Your Travel Medicine Specialist During a Trip

Those who get sick while traveling in a less developed or exotic area might be concerned about seeking care at a local hospital, especially if they do not speak the country’s language. Fortunately, patients who have already established a relationship with a practice such as ID Care have somewhere else to turn; they can reach out to their travel medicine specialists via telephone or telemedicine.

“We always have a doctor available to help guide our patients if they encounter health problems while they’re away,” Dr. Hirsh said. “We like to have the chance to intervene so that illnesses contracted overseas don’t turn into emergencies.”

When Care is Needed After Travel

The patients who need care after a trip are usually those who did not have pre-travel consultations.

“We get called from the emergency room with questions about how to treat these patients. In addition, doctors from other practices who are not infectious disease specialists and are unsure of how to handle exotic diseases also frequently refer their patients to us,” Dr. Hirsh said. “Fortunately, we have a deep well of knowledge because we see malaria and typhoid cases each year and are comfortable treating them.”

Although it’s unusual for those who are already ID Care patients to come home sick, those who do are swiftly seen by doctors in the practice for diagnosis, treatment, or medical guidance.

Travel Medicine Specialists and Employers: In Good Company

In addition to working with individuals, travel medicine specialists make great partners for organizations that send people on international trips.

At ID Care, specialists are retained by companies to:

• Give talks about the health dangers associated with travel, preventive measures, and how a travel medicine specialist can help with all aspects of travel care .
• Meet with employees one-on-one to evaluate itineraries, assess risk, make recommendations, offer vaccines, and prescribe medicine in case of illness while away.

ID Care Provides Comprehensive Travel Medicine Care

As infectious disease doctors, ID Care physicians are experienced travel medicine specialists who can provide advice and treatment before, during, and after a trip, even for the most medically complex patients. That’s why these specialists are preferred not only by individual travelers, but by organizations, and why emergency rooms and other doctors routinely refer patients to them for diagnosis and treatment of unusual symptoms following international trips.

“One of the benefits of coming to us ahead of a trip is that, if you get sick later, you are already our patient. Our 10 offices are always staffed so that our patients have convenient access to expert help,” Dr. Hirsh said.

Of course, doctors within ID Care are also well versed in preventing, diagnosing, and treating infectious diseases of all kinds, regardless of where they were contracted. To consult with an infectious disease doctor at ID Care or set up a travel medicine appointment for personal or business travel, call 908-281-0610 or visit idcare.com .

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COVID-19: how can travel medicine benefit from tourism’s focus on people during a pandemic?

Irmgard l. bauer.

College of Healthcare Sciences, Academy - Tropical Health and Medicine, James Cook University, Townsville, QLD 4811 Australia

Associated Data

Not applicable.

In 2020, COVID-19 affected every aspect of life around the globe. The spread of SARS-CoV-2 through travel led to lockdowns, travel bans and border closures, crippling the tourism industry. Without tourists, there would be no tourism industry—and no travel medicine. Therefore, scholars started to research the human aspect of tourism immediately to develop strategies for economic recovery. The resulting insights are useful for travel medicine not only to see how tourism dealt with a medical crisis but also to understand travellers better who may be seeking health advice during and after a pandemic.

This article presents tourism research of 2020 covering risk perception and travel intentions including mass-gatherings, the use of technology to protect from infection, impacts on tourism workers, residents’ reactions to potentially infected travellers, discrimination, and racism. A potential fork in the road to tourism’s future may have implications for travel health practitioners. Research recommendations conclude the paper. Understanding the industry response during the early days of panic and uncertainty may help prepare not only appropriate guidelines for travellers but also clearer instructions for tourism, transportation, and hospitality in anticipation of the next pandemic.

Introduction

In November 2019, cases of a pneumonia of unknown cause appeared in Wuhan/China, reported to the World Health Organisation (WHO) on 31 December. Early January 2020, the virus SARS-CoV-2 was isolated. On 12 February, the WHO named the resulting disease COVID-19, declaring it a global pandemic on 11 March. From early 2020, publication floodgates opened from many medical specialties (PubMed on 6 July 2021 for ‘COVID-19’ yielded 150,445, six months later 213,484 results). Early health advice for the public, ‘personal non-pharmaceutical protection interventions (PNPIs)’, included cough and sneeze etiquette, self-isolation, avoiding contact/touch, social distancing, hand hygiene, mask wearing, all reasonable textbook instructions many of which were only feasible in affluent countries. From major outbreaks in China and Italy, the virus spread around the world. Travel, a key facilitator of the spread, was first restricted and then prohibited nationally and internationally in many countries via suspension of visa-on-arrival policies, travel restrictions/bans and closed borders. Not always was the relationship between health and politics harmonious or directives aligned.

Media coverage and social media posts during a crisis influence risk perceptions and travel intentions [ 1 , 2 ]. From the start, WHO alerted to a massive ‘infodemic’, an over-abundance of correct and false messages making it difficult for people to extract useful information, and attempted to debunk myths with accurate information on social media and collaborate with platforms to mitigate the damage [ 3 ]. This attempt was unsustainable and unrealistic considering the volume of data and skills necessary to spot the difference [ 4 ]. It was difficult to agree on what was reality and what were ‘alternative facts’ or strategic misinformation. COVID-19-misinformation has been deplored in medicine, where it provides the ideal ground for anti-science groups to the point of influencing government policy or being spruiked by political leaders [ 5 ]. Anti-vaxxer Facebook posts created doubt about COVID-19-vaccines long before vaccines existed, based on mistrust in the pharmaceutical industry, misinformation and conspiracy theories [ 6 ]. In tourism, misinformation became a serious issue for travellers, such as changes in risk perception or questioning public health measures, and residents, including the rise of racial discrimination [ 7 , 8 ].

The traveller, who is potentially spreading the virus or being exposed to it, is part of the tourism industry. How did tourism respond to the emerging medical crisis? For a for-profit industry (as for stand-alone travel clinics), a downturn in travel is devastating. All global regions experienced a decrease in international arrivals, e.g., Europe and Africa by 85%, Asia and Pacific by 96% [ 9 ]. In the US alone, the pandemic led to $645 billion in cumulative losses for the travel economy through March 2021 [ 10 ], costing the US economy 41.1 trillion in economic output [ 11 ]. Forecasts and potential recovery strategies responded quickly [ 12 – 14 ]. However, to plan for a post-pandemic future, the tourism and hospitality sector had to look not only at balance sheets but focus more than ever on the heart of the industry, the travelling public, employees and residents, to understand their response, concerns and perceptions regarding current and future travel decisions. Many questions arise, for example, how tourism cooperates with health authorities and receives, responds and implements health directives, how the accommodation and food industry executes instructions, how the industry trains staff to be COVID-19-safe, how it looks after expats and local employees, and how these measures are communicated to instil trust in all involved. Furthermore, and directly important for travel medicine, what are travellers’ perceptions of the pandemic? How has travellers’ interest and confidence in travel been affected by constantly and rapidly changing, often perplexing, directives that were different for the same situation in different countries?

Medicine published on COVID-19 right away – and so did tourism academia. While travel medicine uses the combined evidence of several medical specialties to care for the health and wellbeing of travellers, tourism is much better in understanding them. Therefore, it is useful to take advantage of this knowledge to inform travel medicine and travel health clinicians’ work now and in the post-pandemic future. This article presents and discusses tourism research conducted over the first year of COVID-19 as it relates to people involved in the industry: travellers, employees and residents at destinations, the very population that is travel medicine’s focus of care.

At the time of the literature search (July 2021), the Scimago Journal & Country Rank site listed 123 academic tourism and hospitality journals. Starting with the top-ranked journals (from IP 10.982) and descending the list, ‘COVID’ was entered into English-language journals’ search engine. The search covered all papers published in 2020 with a focus on people. Later advance publications were added if data were collected in 2020. Excluded were papers on industry economics, e.g., forecasts, business, and management. This article starts with a general assessment of the targeted literature before addressing individual themes.

Tourism literature’s focus on people in COVID-19 times

It is fascinating to witness the start of an entirely new thread of literature triggered by a novel topic of concern (see AIDS-literature in the 1980s). As soon as SARS-CoV-2 used travel to spread, the tourism industry responded to a threat that could devastate an entire industry. Rapidly designed research started as early as February 2020. Most papers present original research utilising social science or econometric methods and are highly complex, testing often more than ten hypotheses with the subsequent complex statistical analyses and presentation. Using mainly online surveys due to restrictions, the samples are large and comprehensive, resulting typically in an intricate network of causal relationships between variables. This much detail may be of no direct use to clinicians, but the overall trends give meaningful insights and inform travel health advice. Apart from references to the WHO, there are few cited medical sources; no paper was co-authored by health and tourism practitioners or scholars. Many studies originate in the Far East or in countries with high COVID-19 burden. Due to the delay between acceptance and publication, some statements are now outdated. Authors at the time could not foresee the duration of the pandemic, and one needs to think back to the early months of bewilderment and uncertainty when vaccination and the many attempts ‘to return to normality’ were unknown. As all authors had the same starting line, publications started independently without cross-referencing until later in the year. From 1 May 2020, the author guidelines of the high-profile Journal of Travel Research stipulated that submissions ‘must not ignore the effect of COVID-19’ [ 15 ]. An early warning to expect a COVID-19 research paper ‘tsunami’ prompted the call for a system-based research approach [ 16 ]. Lacking such a structure, papers presented here are organised into thematic clusters starting with risk perception and travel intentions including mass-gatherings, the use of technology to minimise infection, the impact of the pandemic on hospitality employees, residents’ reaction to travellers, hostility and discrimination, and a look into the future of tourism. Research recommendations for travel medicine, as they emerge from the tourism literature, conclude this discussion.

The traveller – To travel or not to travel

Without tourists, there is no tourism. The rapidly evolving existential threat to the industry within the context of global bewilderment triggered studies focusing strongly on (potential) travellers. Researchers’ differing academic backgrounds guided the choice of research questions, resulting in a wide range of topics. These can be categorised into aspects out of people’s control and those where travellers play an active role.

Being subject to outsider-control and disallowed the freedom of movement one is accustomed to, impacts mental wellbeing [ 17 ], in line with the exceptionally diverse psychology of pandemics [ 18 ]. Denied mobility, the ‘lockdown captivity phenomenon’[ 19 ] and ‘travel craving’[ 20 ] have been studied in Italy and Hungary in May/June, while an analysis of National Geographic promoted Instagram posts in April demonstrated a marked change in expression of personal experience and skills, social facets and in lifestyle [ 21 ]. In the pre-travel stage, in April, sentiment analysis on over 600 Italian online posts showed customer concern with airline cancellation and compensation, but also the much-unexpected result that a rise in COVID-19-deaths, not cases, increased empathy with struggling airlines [ 22 ]. In February, three US-studies demonstrated that the threat of infection decreased the willingness to accept price inequalities [ 23 ].

Other aspects can be controlled by travellers: the avoidance of crowding [ 24 ], or a willingness to pay for enhanced safety measures [ 25 – 28 ]. Most importantly, adherence to PNPIs lies very much with the individual. End of April, of over 400 Kosovar, 90% planned to travel to Albania that summer. At the time, 15% did not follow strict health ministry directives, 25% sometimes to never socially distanced, while 28% sometimes to never wore masks appropriately around others [ 29 ]. In the US, men were more likely to refuse masks for international travel [ 30 ]. In China, more women adhered to pro-social behaviour [ 31 ]. A far greater area of research covers people’s risk perception and subsequent intentions to travel during and after the pandemic.

Risk perception and travel intentions

The notion of the ‘crisis-resistant tourist’ who ‘travels despite’ or ‘not cancels because of’ crises, but does not risk-shift, i.e., take out travel insurance more than others [ 32 ] may help appreciate the following results. Because of the economic impact of reduced/cancelled travel, border closures and lockdowns, the industry is keen to understand potential travellers to be able to develop strategies to get people travelling again. First, it is especially important to appreciate people’s perception of risk during a pandemic.

Risk perception

Travel medicine is interested in risk perception (274 hits in Journal of Travel Medicine and 134 hits in Travel Medicine and Infectious Disease , 22 Dec 2021) because it influences decisions to visit a travel clinic, destination and behaviour choices, and subsequent adherence (or not) to health advice. For tourism, risk perception influences business decisions to secure profits. In contrast to real risk, perceived health risks are based on cognitive, affective, individual and contextual components and, therefore, subjective [ 33 ], influenced, for example, by the media [ 1 , 2 , 34 ]. In the first four months of the pandemic, media coverage influenced risk perception in Korea more than case numbers [ 35 ]. In two secondary data analyses from Hong Kong combined with four original US-surveys ( n  = 744), the perceived threat of infection increased the tendency to avoid extreme travel options [ 36 ]. A South African survey (May/June) of 323 potential tourists from Africa, Europe and Asia assessed psychographic factors: dogmatic, sceptical and apprehensive, depending on risk perception and level of caution [ 37 ]. Important for travel medicine, dogmatic tourists may not follow risk mitigation measures. Over 1000 Indian travellers perceived risk differently depending on their fear of infection. Women, married and older travellers saw COVID-19 as more severe and adopted PNPIs more readily. While education made no difference in risk perception, higher education levels increased PNPIs usage. People on lower incomes and travellers for work and education were less willing to implement such measures [ 38 ]. Surveys in Germany, Austria and Switzerland ( n  = 1370) before and immediately after the WHO-proclamation demonstrated relative low concern about COVID-19 before but strong increase in risk perception after, viewing as irresponsible business trips and travel to destinations with cases. Contact with tourists in one’s hometown were to be avoided [ 39 ]. Mothers avoided business trips to protect their family from potential infection [ 40 ].

Consumer distrust in hotel hygiene standards existed before, based on the assumption that service providers act negligently and incompetently [ 41 ]. Almost 99,000 Chinese hotel reviews of all 185 five-star hotels in Shanghai demonstrated a shift in consumer preferences beyond hygiene expectations. Breakfast, location and surroundings lost importance while in-hotel, in-room experience, service, cleanliness and front desk gained importance due to the ‘cocooning’, i.e. staying in hotel rooms for one’s own safety [ 42 ]. Staying in ‘love hotels’ in Ho Chi Minh City rather than tourist hotels appeared less risky, possibly because of less crowding and low tourist contact [ 43 ].

End of 2020, US restaurant and hotel customers ( n  = 809) were reluctant to eat in sit-down restaurants, wanted visible evidence of sanitising efforts and accepted technology and robots [ 25 ]. A comprehensive exploration of tourists’ risk perception of COVID-19 proposed a conceptual model to interpret and explain travellers’ behaviour patterns. The section on risk included the obvious health and psychological risks as well as social risks (disapproval of one’s travel plans), performance risk (not receiving expected service), image risk (stigma of a location), and time risk (time-related costs, quarantine) [ 44 ].

For tourism and travel medicine, it may be important to consider shifting the public’s concentration on risk avoidance to risk management [ 45 ]. Normally, travel insurance provides some reassurance in case of misfortune. However, most insurer policies exclude pandemics and known events, and travellers were unable to purchase cover when they most needed it, leading to a ‘reverse moral hazard effect’, i.e., a reluctance for future travel. Yet, insurers need to exclude catastrophic events to remain solvent [ 46 ]. Willingness to pay (WTP) for perceived or actual better service/goods is a well-known tourism concept, which also emerged during the pandemic. WTP related to the expectation of particularly stringent health measures on transport, in restaurants and accommodation, for example, in Italy where, however, WTP was lower in regions with COVID-19 [ 28 ]. Because high adherence to hygiene measures was expected, no WTP was evidenced in Spain, especially when there was a strong intention to travel [ 47 ]. To manage risk, apart from WTP for superior crisis management, some type of travel allows crowd avoidance, for example, camping [ 27 ] or a ‘safe’ destination, e.g., geological sites in Oman [ 48 ]. To enable the public assessing a location’s safety from epidemics as part of travel preparations, a ‘country-level index of epidemiological susceptibility risk’ was proposed built on health infrastructure, demographics, environmental safety infrastructure, economic activity, communications infrastructure and governance institutions [ 49 ]. The onus would be on tourists to assess if the chosen destination can deal with potential risks adequately – a formidable task. It is unclear who was to compile this index, especially in poor countries. Regardless how this risk is perceived, what counts for travel medicine and tourism is the public’s actual plan to travel.

Travel intentions

Intentions differ from desire as they are perceived as more realistically ‘do-able’ within a firm timeframe [ 50 ]. At the time of data collections, as everybody else, neither researchers nor study participants knew how long this pandemic would last or if there was a clear end. Nobody knew of the varying individual and global policies and travel bans or about potential vaccines. Therefore, people’s travel intentions could not always be classified clearly as during, post-pandemic or loosely ‘sometime later’, nuances usually lost in quantitative data. Interviews with potential travellers and tourism professionals in Western Australia formed the basis for a motivator-demotivator approach to travel during COVID-19. Motivators were needs for mental wellbeing and social connectedness including personal growth and relaxation. Demotivators consisted of health and safety risks including the level of perceived competence of authorities to handle the crisis [ 51 ].

In Greece, travel was unlikely not because of COVID-19 but lack of funds [ 52 ]. In Italy – as in Egypt [ 53 ] – trust in responsible provision of safety protocols influenced travel plans [ 28 ]. In May, among 1144 18–90-year-old Italians, age influenced vacation preferences [ 54 ]. In the same month, students and workers in Macau reduced their travel intentions but felt safe due to strict policies; however, tourists were urged to stay away [ 55 ]. In contrast, in India, intended travel did not necessarily mean adoption of PNPIs [ 38 ]. Unexpectedly, in June, Spanish data suggested that living in an area with worse case numbers and having personal experience with the disease, increased plans to travel this very summer, especially in men and those very concerned about the pandemic. Adhering to health rules, such travel may be mentally beneficial [ 56 ]. Some intended travel leads to the accumulation of large numbers of people, for example, travelling on cruise liners or gathering for religious or cultural festivals.

Mass-gatherings

The close distance between people and their mingling at large gatherings provides the perfect scenario for ‘super-spreader’ events.

One such example are ocean liners where large numbers of passengers are inescapably confined by the perimeter of the vessel. The unfortunate outcome revealed itself in the dramatic events on cruise ships early in the pandemic. On 1 February, a passenger leaving the Diamond Princess earlier in Hong Kong tested positive. The ship arrived in Japanese waters on 3 February, and 3711 passengers and crew were quarantined [ 57 ]. On 19 March, 2650 passengers disembarked the Ruby Princess in Sydney before COVID-19 test results were known, to avoid missing connecting domestic and international flights. This mishandling became the single largest source of Australia-wide infections [ 58 ] resulting in over 900 cases around the country and 28 deaths [ 59 ]. Especially frightening for the public were the rapid deaths, the first on 24 March. On 15 March, four days after the WHO declared a pandemic, and while companies cancelled cruises and ships at sea were denied access to ports, the Australian luxury expedition ship Greg Mortimer left Argentina for Antarctica with 217 people on company advice that no virus was on board. Day 8 recorded the first fever. The original itinerary abandoned, and Argentinian ports closed, Uruguay allowed docking offshore. Eight passengers and crew were evacuated, including one ship physician. Of all 217 on board, 128 (59%) tested positive [ 60 ]. One Filipino crewmember died [ 61 ]. What polished written reports cannot convey is captured brilliantly in the 2-part documentary Deadly Trip of a Lifetime [ 62 , 63 ]. Staff are often forgotten when the focus is on travellers. After passengers disembarked, the crew of many ships were stuck at sea, often confined to their small windowless bunks instead of being moved to the then vacated passenger cabins, away from their families, with often limited communication and, in some cases, exposed to irresponsible company pressures [ 64 – 66 ]. Staff’s mental distress led to a number of alleged suicides on-board [ 64 ].

By the end of March, many ships were still wandering the high seas unable to find a port to dock. The cruise industry came to an abrupt halt with massive economic losses. Trust in a company’s crisis management was essential for lower-income US-travellers who were willing to cruise again with a steep discount [ 67 ]. In contrast to new customers, influenced by other consumers’ negative experiences, repeat customers were guided by their own previous experiences [ 67 ]. This interesting concept could be explored in travel medicine research on risk perception of new vs repeat travellers in general.

Trust in government/public health agencies and cruise companies played an important role in risk-reducing behaviour and future cruise intentions of 504 Australians. To regain trust, the perception of competence, consistency, consideration (in the best interest of public) and conviviality (good will toward the information provider based on trust) will need to be restored [ 68 ]. Almost 55,000 tweets (1 Feb – 18 June) reflected the global public sentiment toward cruising, mirroring the evolving events during the early pandemic. A growing interest in river cruising showed attempts to gain distance from the masses [ 69 ]. Legal questions regarding humanitarian obligations to assist cruise passengers in need vs a country’s obligation to safeguard its population [ 70 ] also involve health and medicine.

Religious tourism

Religious travel spans from crusades, historic pilgrimages, and missionary travel to today’s faith-based conventions or retreats. Modern day international examples are Hajj and Umrah, the Shia pilgrimage to Iran and Iraq, Kumbh Mela in India, Easter at the Vatican, or Christmas in Bethlehem, and smaller local festivities. A pandemic requires sudden decision-making of health authorities at the faith-based destination, e.g., the Ministry of Hajj and Umrah [ 71 ] and in countries of pilgrims’ origins [ 72 ]. Cancelled in 2020, in 2021 only 60,000 vaccinated pilgrims were admitted to the Hajj. Not only is overcrowding of concern, but the touching/kissing of objects such as walls of shrines [ 73 ] or statues of saints. There is a clear concern for the economic effect on religious destinations [ 73 , 74 ], and the impact of COVID-19-measures on the faithfuls’ ability to follow religious obligations.

Appreciating the role faith plays in a crisis, WHO published in April 2020 practical recommendations for religious leaders and faith-based communities, asking to share clear, evidence-based steps to reduce fear, provide reassurance and promote health-saving practices [ 75 ]. The detailed guidelines focus on gatherings, safe burial practices and leaders’ role in COVID-19 education. The recruitment of religious leaders was crucial with the introduction of vaccines. While Pope Francis saw vaccinations as a moral obligation [ 76 ], others warned of vaccines causing homosexual tendencies, inserting microchips, or being produced from cow’s blood (to harm Hindus) or slaughtered foetuses [ 77 ]. In the Serbian Orthodox Church, Holy Communion during Easter is of highest importance as medicine for soul and body. The church’s appeal to observe health directives was met with strong resistance and many requests to lift the travel ban during Easter. The ban represented not only ‘physical’ social distancing, but social (and religious) distancing in its true sense [ 78 ].

An Indonesian study compared pre-Eid travel intentions in February 2020 and actual travel (despite a travel ban) after festivities in May. Lack of travellers’ personal agency, e.g., perceived obligation to religion and family, promoted risky behaviour and ‘wished away’ potential health risks [ 79 ]. In India, before the Delta variant, people were willing to continue travel post-COVID-19 to religious sites provided reliable health and safety measures were in place during travel and stay [ 80 ]. An often-overlooked travel situation is being stuck overseas due to unforeseen events. A study with Pakistani pilgrims to Iran, unable to return home, explores the topic of travel burnout [ 81 ]. Where normally spirituality is a source of well-being, pilgrims were confronted with unexpected out-of-their-control situations of border closures, delays, need for food and shelter on top of the fear of becoming infected. Pilgrims showed low self-efficacy (existential fear, xenophobic response on return, restricted mobility), travel exhaustion (stress, new protocols, friction among the group, homesickness) and emotional maladaptation. Coping strategies included faith, better future travel planning, and reliance on friends and family. Coping with being trapped unexpectedly during travel is much under-researched and fits easily the travel medicine research portfolio.

Technology meets health directives

The understanding that close human contact, an important part of travel, increases the spread of infection, prompted tourism to find ways to provide safe travel experiences, using robots and virtual travel. Artificial intelligence devices have been employed in tourism previously and consumers’ attitudes towards them studied eagerly [ 82 ]. Now they are an important attempt to minimise person-to-person contact with the bonus of frequent sanitising.

During COVID-19, anthropomorphic robots, robotic vehicles and other autonomous devices were used in hospitals, communities, airports, recreation areas, and hotels and restaurants [ 83 ]. There are challenges, as in the unfortunate Henn na Hotel in Nagasaki [ 84 ], but also job losses, privacy and data security, misuse by governments [ 83 ], and a robotic barman unable to listen to personal problems. However, in pandemic times, the acceptance of robots may be greater [ 85 ]. Just before COVID-19, over 500 TripAdvisor reviews (2013–2019) of three robotic hotels in the US and Japan were positive, though the sample may be biased towards technology-fans who enjoy robots as added preference. In a pandemic, robots could assist those who want to travel [ 86 ]. As physical distancing reduces the risk of infection, 1062 US and Chinese customers’ risk perception when interacting with hospitality staff influenced their acceptance of service robots [ 87 ]. Tourists from 18 countries preferred anthropomorphic robots to all other types, but robots should not replace the innate anthropocentric nature of travel. The increased use of robots during and after COVID-19 may change acceptance as a means to avoid infection [ 88 ].

Travel bans, lockdowns and social distancing favoured the increase of webcam-travel and virtual tours – free or purchased. Though of differing quality, technology brings attractions to the ‘traveller’s’ home. University students and staff ( n  = 401) in Oman and Germany found virtual travel beneficial for the disabled and those less affluent, and during lockdown or crises. Not replacing real travel, it could entice people to visit the actual site after the pandemic [ 89 ]. Locals, of course, gain little from virtual tourism. US citizens suggested that perceived high COVID-19 threat severity, response efficacy and self-efficacy raised social distancing behaviour which increased the likelihood of using virtual tours, while those with perceived low threat severity continued to travel in person [ 90 ]. Feelings of freedom, nostalgia and connection triggered by webcam-travel were associated with happy memories made before lockdown, and so uplifted people’s mood [ 91 ].

The impact of COVID-19 on hospitality employees

While a pandemic can cripple an industry economically, an industry only exists on the shoulders of employees who are not only personally at risk of infection but experience a dramatic change in demands on them. Tourism workers suddenly had to clean, serve, communicate, distance, and implement bespoke instructions without a health background, much like the general public who was supposed to follow rules without understanding the link between the required activities and viral behaviour. The first studies into the impact of COVID-19 on tourism workers focussed on hotel and hospitality employees. The comments of 36,793 employees on the US-site Reddit, posted 3 January to 19 April, displayed real-time perceptions. Up to April, anxiety led all other negative emotions, when anger joined other factors, such as employment and racism [ 92 ]. In Turkey, 151 staff from two 5-star hotels responded in June to the risk of infection with increased mental health problems, absenteeism and low life satisfaction, the latter somewhat balanced by being married with children. Companies should, therefore, demonstrate a level of care by offering stress management programs (resilience, alcohol, finances), affordable groceries and medical care [ 93 ]. Unemployment, pandemic-induced panic and lack of social support caused distress in US tourism employees ( n  = 1231), especially in women and young employees [ 94 ]. US immigrant hospitality workers, disproportionally represented in hotel and food services, on low wages and poor working conditions, were even more affected considering their ineligibility for COVID-19-aid despite paying taxes [ 95 ]. A company’s response to COVID-19 influences employees’ perceptions on risk. In Vietnam, a surprising result was obtained from almost 400 employees in that satisfaction with the organisation not only helped raise job performance but strengthened the positive effect of a perceived health risk on job performance; full trust in organisations allowed concentration on the job [ 96 ]. This might indicate the importance of an employer when lacking national relief polices; it could also mean that desirable responses were collected.

Socially responsible workforce management influences employee anxiety. Over 400 Chinese tourism workers (almost half from Wuhan) indicated in February the importance of trust in the organisation to overcome fears, especially of unemployment, and poor mental health [ 97 ]. Similar results arose from 1594 employees from 23 Chinese hotels. Close person-to-person contact makes hotel-employment a high-risk occupation. Using the constructs: safety coaching, control, motivation, care, compliance, participation, adaptation, perceived susceptibility, perceived severity and belief restoration, employee perception of a hotel’s socially responsible initiatives promoted compliance with specific directives and citizenship behaviour. Hotels should assist employees in managing perceived risk by providing objective up-to-date information, assisting in dealing with negative emotions, providing stability, developing emergency response plans and support belief restoration [ 98 , 99 ]. While COVID-19 highlighted the immediate effect on tourism workers, the question arose if this is, indeed, a different situation ‘from the precarious lives they normally lead or just a (loud) amplification of the “normal”’ [100,p. 2813]. The authors propose that hospitality work in a pandemic is a magnification of misery, not something new, and highlight the problem at three levels. At the top level (macro), governmental, international agency and global policies ensure a framework of low wages, poor working conditions, and insufficient social security, e.g., ‘flags of convenience’ with uncontrolled exploitation of cruise ship workers. At the meso level, organisations control through outsourcing, ‘business hibernation’ and furloughing. In a pandemic, this leaves the employee at the micro level even more vulnerable to crises, especially young, women, immigrants, and international student workers [ 100 ].

Residents’ reaction to travellers during COVID-19

An important part of the tourism experience is the interaction with local people who, in general, and even if only for economic reasons, welcome visitors. Does this welcome change with visitors potentially bringing disease? In February, comparing the perception of social cost (shortage of necessities, travel restrictions, pressure on hospital beds) of a combined 3364 residents in Hong Kong, Wuhan and Guangzhou by using two hypothetical scenarios, confidence in authorities was easily lost when policies were compiled hastily. Positive framing of messages and ‘mental accounting’ of pros and cons, based on evidence, are important to ensure trust in directives [ 101 ]. In the same cities, in February/March, 1627 residents were most concerned about the risk of cross-infection due to tourism activities and, especially younger people, showed a WTP for risk reduction and appropriate action [ 26 ]. From March, and for a year, a qualitative study monitored the impact of COVID-19 on tourism in Bali. Already a mass tourism destination producing 55% of GDP, Bali’s original plan was to increase international arrivals to 20 million in 2020. While the Balinese people followed health directives, initially without any official advice for the tourism industry and with rising case numbers and deaths, those dependent on tourism had grave fears for their economic survival. On the other hand, those without links to the industry saw the break in arrivals as a welcome pause in ‘over-tourism’ and pointed to the need for more respectful, sustainable approaches. For them, COVID-19 was a wakeup call from God to the Balinese regarding the unsavoury sides of tourism. The official line, however, appears to support a return to mass tourism to make up for the losses [ 102 ]. In May/June, 634 residents on the Korean Jeju Island, which experienced an increase in domestic tourism, indicated that the perceived risk of being infected by visitors influenced their level of welcoming emotions. Residents cannot identify infected tourists. In contrast to tourists who can avoid hotspots, residents cannot leave [ 103 ]. The dilemma between supporting the economy and risking infection emerged from a Japanese survey. The ‘Go to Travel’ campaign, providing discounts and vouchers to increase domestic travel, was unwelcome by many. Even if residents followed all health directives, they could not escape tourists [ 104 ].

The vulnerability of indigenous destination communities has been of concern. They suffer equally a loss of business, but being often in remote or isolated settings and further away from suitable health care, infections would be disastrous. In Australia, most indigenous communities were off-limits to individual and organised tourists. Canada [ 105 ], New Zealand [ 106 ] and Brazil [ 107 ] voiced similar concerns with a shift to more emphasis on social and environmental wellbeing and respect rather than the insistence on the ‘right to travel’[ 105 ].

COVID-19 and travel: hostility, discrimination, racism

Fear of infection also shows in discriminatory reactions of residents to visitors. Press reports emerged very early on from India of international tourists being directed to leave accommodation and country, refused food or met with severe hostility [ 108 , 109 ]. Even more pronounced were aggressive reactions around the world towards not only travellers of Asian appearance but also residents in non-Asian countries [ 110 – 112 ]. Chinese international students in the US found that their mask wearing indicated illness and put them at even greater risk of racial abuse [ 113 ]. In February/March, 26 tourists to India reported a sense of mistrust towards tourists, subsequent negative emotions towards India and a lack of willingness to interact with locals due to the perceived rejection, but also an observed lack of implementation of health directives [ 114 ]. A similar link between unwelcoming resident behaviour and destination perception emerged in Hong Kong [ 115 ]. In February, 203 US citizens indicated that residents who experienced everyday discrimination themselves based on some social attributes, were more likely to support hostile responses against tourists, especially Mainland Chinese [ 116 ]. A study on host–guest relations in Singapore mid-2019 offered a chance to compare such views with those in April 2020 (combined n  = 468). Before COVID-19, Mainland Chinese were tolerated for their spending power despite being stereotyped unfavourably. Perceived risk of infection and expected restrained spending may lead to increased intolerance towards these visitors [ 117 ]. Much blame for this discrimination lies with the media [ 7 , 8 ].

Tourism has studied xenophobia before. The xenophobic tourist anticipates and/or experiences unpleasant emotions related to the encounter with locals at foreign destinations. For example, the more xenophobic a traveller, the higher the uptake of travel vaccination, insurance, group travel and booking through an agency, and the lower the interest in local food. Men were more xenophobic; education or age made no significant difference [ 118 ]. This deep-seated unease extends to purchasing behaviour in general, e.g., buying local products, but also choosing familiar airlines and hotels when travelling to a destination similar to home [ 119 ]. COVID-19 added the unpleasant perception of crowding [ 120 ].

Tourists’ fear of the ‘other’ (host) originates from the same ancestral disease-avoidance mechanism as the fear of residents of the ‘other’ (visitor). In ancestral social groups (in-group), people learned about the potential ill effect from contact with people from other social groups (out-group) and developed adaptive behaviours. Based on cues of ‘strangeness’, i.e., an otherness to one’s own ‘normality’, out-group people were avoided not only for cues, such as their physiognomy, food and hygiene practices, but the perception of vulnerability to potential disease. Negative attitudes including disgust then led to the culturally evolved behaviour of keeping a distance [ 121 ]. Furthermore, staying within one’s own group poses less of a risk of disease transmission as well as ensures the likelihood of being cared for and supported in need [ 122 ]. This ‘behavioural immune system’, the avoidance of contact and sticking to the in-group, is easier to implement [ 123 ]. After all, pathogens are invisible; therefore, other cues need to be employed. This leads to in-group conformity and out-group exclusion [ 124 ]. However, this exclusion also applies to in-group members who had the misfortune of being caught out at an out-group location, such as Balinese cruise ship workers returning home [ 102 ] or Pakistani pilgrims returning from Iran [ 81 ]. Having limited or no control over COVID-19-events, people’s own locus of control may also attribute blame, for example, on destinations [ 125 ] or on marginalised people, such as refugees and asylum seekers [ 126 ], and perhaps, in the future, the unvaccinated. Evolutionary motives are the ultimate explanation of discrimination during COVID-19, but this does not condone the widespread hostility experienced by travellers and residents alike. Media misinformation and conspiracy promoters have much to answer for, although health and medicine have not excelled in improving general health literacy on which to base appropriate health information in the event of a pandemic.

Future directions in tourism

For decades, scholars have warned of negative outcomes through relentless growth in tourism. As late as 2019, these warnings demanded a ‘de-growing’ and reprioritising, while proposing wide-ranging strategies for change [ 127 ], strategies widely ignored by corporate giants. Ironically, just one year later, COVID-19 showed precisely not only the trouble tourism had created for itself, but also how it contributed to the spread of the virus. To salvage some profits, like everybody else, business owners and executive boards had to make decisions based on knowledge of the virus, constantly changing government and public health directives and their different interpretations in different countries, personal opinions of health professionals, poorly constructed messages to the public, often questionable media involvement and crass conspiracy theories. The questions arise how the pandemic has shaped our desire to travel, and what tourism will look like after the crisis. Two aspects may support a change in direction, long asked for by tourism scholars and residents at destinations.

First, lengthy lockdowns and restrictions have modified many people’s worldviews, lifestyles and previous behaviours. Mindfulness, ‘slowing-down’, a measured approach to consumption and a focus on ‘what is really important’ gained prominence, at least for those who can afford such luxury. This view may now extend to many more travellers beyond those who travelled mindfully before. Second, media reports of wildlife moving into seemingly abandoned suburbs, cleaner water in rivers and oceans, better air quality, less waste (apart from an unprecedented increase in medical waste [ 55 ]), and peace and quiet showed an almost forgotten picture of a different world. Considering tourism’s involvement in and suffering from COVID-19, how the industry will progress from here is important for travel medicine as it may influence travellers’ different care requirements depending on changes in destinations or holiday activities. There are two opposing schools of thought: either return to growth and mass tourism or take advantage of the opportunity to reset.

The first view is that tourism must recuperate the enormous losses and get ‘back to normal’ as soon as possible, trusting that people have short memories (shortly after the Ruby Princess debacle, long waiting lists for the next possible cruise filled quickly). Opening borders, spare funds, boredom, and fear of missing out may lead to ‘revenge travel’ or ‘catch-up travel’ [ 128 ] without considering impacts or consequences. The economic benefits of tourism, driven by the World Tourism Organisation and supported by government interventions, may again be the driving force behind the ‘business-as-usual’ return to pre-COVID-19 business behaviour, a possibility that sparked a fiery debate between the two tourism camps [ 129 ]. This dilemma is evident in Bali, where residents who depend on tourism desperately want it back while others relish having the island to themselves. Government intentions seem to favour a return to growth-tourism [ 102 ]. Similar concerns apply to Nepal, which had declared 2020 the ‘Visit Nepal Year’, with a potential return to excessive over-tourism that prevailed before the pandemic [ 130 ].

The second view, recognising that mass-tourism is not resilient and inert in responding to sudden changes, suggests treating the pandemic as a chance to transform global tourism away from unsustainable and destructive growth towards mindful and equitable forms that prioritise quality over quantity [ 131 , 132 ]. Suggestions are a preference for slow nature-focused tourism [ 133 ] and its mental health benefits [ 134 ], avoidance of mass-cruises [ 135 ] and a greater consideration for host communities [ 136 ]. In April 2020, Tourism Geographies devoted a highly recommended special issue to the discussion of how COVID-19-events can contribute to a ‘substantial, meaningful and positive transformation of the planet in general and tourism specifically’ [ 137 ,p. 455] where growth is in well-being, not profit. This goes far beyond the call for responsible tourism, i.e., the call for having less damaging impacts, and requires a radical transformation away from systematic inequalities [ 138 ] towards a balanced, resilient and just post-pandemic tourism [ 139 , 140 ]. Pleasingly, small operators may turn out more resilient due to their potential flexibility within a specific local community than unwieldy multinationals [ 141 ].

Compared to previous pandemics and large-scale disease outbreaks over the last 100 years, COVID-19 will be the costliest, at least in economic terms. While some locations may opt for a mindful change, it is highly likely that the focus remains on growth, which may prove even more unsustainable than before [ 142 ].

Recommendations for research

Looking at other disciplines’ research topics and methods can unearth useful ideas adaptable by travel medicine for better travel health care and understanding of travellers’ motives, attitudes and behaviour [ 143 ]. The criticised lack of a structural research agenda at the beginning of the pandemic [ 144 ] and the subsequent flurry of diverse topics and approaches nevertheless provides travel health practitioners with a vast range of frameworks, topics and methods useful in novel travel medicine research. Theories, such as the Protection Motivation Theory, Theory of Planned Behaviour, Risk Aversion Theory, Attribution Theory (Locus of Control), Cognitive Appraisal Theory, Theory of Reasoned Action, Motivations Reasoning Perspective, and many more are useful to study travel health behaviour, risk perception, coping strategies and so on, thereby elevating the usual KAP (Knowledge, Attitudes and Practices) studies to a more robust level. Equally, several tested tools could be explored and modified to suit travel medicine concerns, such as the Tourist Worry Scale [ 145 ], Tourism Fatigue Scale [ 146 ], Travel Safety Attitude Scale [ 147 ], Pandemic Anxiety Attitude Scale [ 148 ], Tourist Xenophobia Scale [ 118 ], or Sentiment Analysis [ 69 ] for text-mining of social media data.

This article has covered a wide range of topics, all of which could be examined from a travel medicine perspective and in multidisciplinary teams, the latter a particularly valuable way to develop fresh research questions [ 149 ]. The impact of infectious disease on travellers’ psychological state [ 23 ], distrust in service providers [ 41 ] including travel health providers, perceptions of inconsistent/conflicting medical advice, vaccine acceptance influenced by religious leaders or ‘anti-vaxxers’, or the acceptance of travel health advice during a pandemic are only some examples. Assaf et al. suggested 17 topics for future research for consumer/traveller behaviour alone [ 150 ]. Many harbour health aspects. The effects of sensational media coverage regarding travel medicine concerns are little understood. Discrimination and racism may influence certain health behaviours abroad, e.g., choosing familiar food from questionable hotel kitchens over freshly prepared ‘foreign’ local food. For more detailed insight, the times of data collection for the presented studies could be linked to the respective country’s case numbers, health directives, government policies, travel restrictions and lockdowns at that time, for example, matching the medical response in Vietnam [ 151 ] to a study on employees in Vietnamese hotels [ 96 ]. Travel medicine research usually focuses on travellers’ wellbeing. So far, travel health professionals themselves, especially during a pandemic, have been of limited interest to researchers.

Limitations

This article only utilised English-language academic tourism journals, potentially missing important findings. Journals of other specialties, such as aviation, transport, food and catering, were not consulted. No doubt, there were many manuscripts still in the peer-review or revision phase. With evolving knowledge of the virus’ behaviour and subsequent policy responses, there may be a shift to an entirely different focus of concern in later studies.

Even before the pandemic was announced, tourism scholars recognised the existential threat to the industry, reacted quickly and commenced research depending on their respective area of expertise. Although these early studies were, naturally, uncoordinated, many focused on the lifeblood of tourism: travellers, workers and residents, the very core of travel medicine. Parallel interests emerged. Risk perception and travel intentions are examined here from the industry’s perspective. Health directives advise strongly against mass-gatherings, yet people insist on getting on cruise ships as soon as possible or wish to follow religious or cultural obligations. On the other hand, technology in the shape of virtual travel or robotic devices keeps people at safe distance and so minimises person-to-person contact. The impact of COVID-19 on tourism workers and residents at destinations including the arising hostility and discrimination, are firmly based in a health context. If and how tourism learns from the current business model’s vulnerability will affect travel health practitioners’ work.

While the results are tourism results, they allow a better insight into people than travel medicine research typically can, with implications for travel health practitioners. If travellers are reluctant to travel for a long while, travel health clinics lose revenue and practitioners may lose recency of practice. People who will travel regardless may present to clinicians different sets of issues, require a modified approach to travel health advice, ask different questions, e.g., ‘do robots really protect me?’, or state their distrust in (health) authorities and so challenge practitioners to provide evidence so that travellers can make sensible informed decisions.

Travel medicine and the tourism industry are tightly connected via the traveller, yet there is still little cooperation, collaboration and acknowledgment of the other. This connection should be exploited more for the benefit of travel health and medicine and, ultimately, for the traveller. The first 6–12 months of the pandemic seem now a long time ago due to vaccination, anti-viral treatment and adoption of a ‘new normal’, with the realisation that COVID-19 will not disappear in a hurry. It is prudent to remember those first months and the ‘hits and misses’ in medicine and tourism. Presumably, the next pandemic is aided by travel again – and may be just around the corner.

Acknowledgements

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The author read and approved the final manuscript.

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WHAT IS A MEDICAL MISSION TRIP?

What is a Medical Mission Trip?

Medical mission trips are a great way for medical professionals to use their skills and knowledge to help those in need. They are organized trips to areas of the world where medical care is limited or nonexistent. Medical mission trips are often organized by non-profit organizations, churches, or other groups, and are usually staffed by volunteers.

Mission Discovery medical mission trips provide opportunities for medical professionals to travel to impoverished countries and use their skills to provide healthcare services in resource-limited settings. Medical mission trips typically involve a variety of activities, such as providing basic medical care, conducting health screenings, distributing medications, leading educational programs on health topics, and providing preventive healthcare education.

Along with medical professionals, those who are not professionals are also needed for medical mission trips. These volunteers provide essential services such as providing emotional and spiritual support to the people they are helping, serving meals to those in need, and doing administrative work. Medical mission trips can be both physically and emotionally challenging but also incredibly rewarding experiences.

Medical mission trips often have a lasting impact on the communities they serve and the volunteers themselves. Medical mission trips provide much-needed medical care to those in need while also creating lasting memories and experiences for all involved. Ultimately, medical mission trips are a great way to help people in other parts of the world who don’t have access to healthcare and make meaningful connections with people from different cultures.

The Benefits of Medical Mission Trips

Medical mission trips provide a unique opportunity for medical professionals to use their skills and knowledge to make a difference in the lives of those in need. By providing medical care to those who may not otherwise have access to it, medical mission trips can have a lasting impact on the health and well-being of those in the communities they serve.

In addition to providing medical care, medical mission trips can also provide an opportunity for medical professionals to learn more about different cultures and better understand global health issues. By working with local healthcare providers and community members, medical professionals can better understand the challenges faced by those in need and how best to address them.

The Challenges of Medical Mission Trips

Medical mission trips can be challenging for medical professionals. Working in a new environment with limited resources can be difficult, and medical professionals may find themselves facing language barriers and cultural differences. Additionally, medical mission trips can be physically and emotionally demanding, and medical professionals may find themselves dealing with difficult situations and difficult patients.

It is important for medical professionals to be aware of the potential challenges of medical mission trips before they embark on one. It is also important to be aware of the resources available to help medical professionals prepare for and deal with any challenges they may face.

How to Get Involved in Medical Mission Trips

Medical mission trips are a great way for medical professionals to use their skills and knowledge to make a difference in the lives of those in need. If you are interested in getting involved in a medical mission trip, contact Mission Discovery. Our experienced mission coordinators will work with you to help you find the perfect medical mission trip for you and connect you with the resources necessary to prepare for and participate in your mission trip.

We hope this short overview of medical mission trips has helped inform your decision on whether or not a medical mission trip is right for you. If you have any further questions, please don’t hesitate to reach out. We are here to help! Contact us today and let us show you how medical mission trips can be life-changing experiences!

Medical mission trips are a great way for medical professionals to use their skills and knowledge to help those in need. They provide an opportunity to make a lasting impact on the lives of people in resource-limited settings, while also providing a unique learning experience. Despite the challenges that medical mission trips can present, they are ultimately rewarding experiences that provide an opportunity to make a difference in the lives of those in need.

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Pharmaceutical patents and the TRIPS Agreement

The purpose of this note is to describe those provisions of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement) that relate to the standards of patent protection to be accorded to inventions in the area of pharmaceuticals.

• that, together with some 25 other legal texts, it is an integral part of the Agreement Establishing the World Trade Organization (and therefore subject to the WTO dispute settlement system);
• that it covers not only patents but all the other main areas of intellectual property rights; and
• that it lays down not only the minimum substantive standards of protection that should be provided for in each of these areas of intellectual property, but also the procedures and remedies that should be available so that rights holders can enforce their rights effectively.

What pharmaceutical inventions must be patentable under the TRIPS Agreement? 

The main rule relating to patentability is that patents shall be available for any invention, whether a product or process, in all fields of technology without discrimination, where those inventions meet the standard substantive criteria for patentability — namely, novelty, inventive step and industrial applicability. In addition, Members are required to make grant of a patent dependent on adequate disclosure of the invention and may require information on the best mode for carrying it out. Disclosure is a key part of the social contract that the grant of a patent constitutes since it makes publicly available important technical information which may be of use to others in advancing technology in the area, even during the patent term, and ensures that, after the expiry of the patent term, the invention truly falls into the public domain because others have the necessary information to carry it out.

Three types of exclusion to the above rule on patentable subject-matter are allowed. These may be of interest from a public health perspective:

• inventions the prevention of whose commercial exploitation is necessary to protect ordre public or morality, including to protect animal or plant life or health;
• diagnostic, therapeutic and surgical methods for the treatment of humans or animals; and
• certain plant and animal inventions.

What are the rights conferred by a patent under the TRIPS Agreement? 

The minimum rights that must be conferred by a patent under the TRIPS Agreement follow closely those that were to be found in most patents laws, namely the right of the patent owner to prevent unauthorized persons from using the patented process and making, using, offering for sale, or importing the patented product or a product obtained directly by the patented process.

Term of protection 

Under the TRIPS Agreement, the available term of protection must expire no earlier than 20 years from the date of filing the patent application. It should be noted that, although the issue of patent term extension to compensate for regulatory delays in the marketing of new pharmaceutical products was raised in the Uruguay Round negotiations, the TRIPS Agreement does not contain an obligation to introduce such a system.( 1 )

Limitations/exceptions to these rights 

Under the TRIPS Agreement, patent rights are not absolute but can be subject to limitations or exceptions. These can be put into four categories:

the Agreement allows limited exceptions to be made by Members provided that such exceptions do not unreasonably conflict with a normal exploitation of the patent and do not unreasonably prejudice the legitimate interests of the patent owner, taking account of the legitimate interests of third parties. Thus, for example, many countries allow third parties to use a patented invention for research purposes where the aim is to understand more fully the invention as a basis for advancing science and technology. The WTO Panel in Canada — Patent Protection for Pharmaceutical Products decided that this provision, allowing limited exceptions, covered a provision of Canadian law which permits the use by generic producers of patented products, without authorization and prior to the expiry of the patent term, for the purposes of seeking regulatory approval from public health authorities for the marketing of their generic version as soon as the patent expires. (This provision is sometimes referred to as the “regulatory exception” or as a “Bolar” provision.) The Panel Report was adopted by the WTO Dispute Settlement Body on 7 April 2000;

the Agreement also allows Members to authorize use by third parties ( compulsory licences ) or for public non-commercial purposes ( government use ) without the authorization of the patent owner. Unlike what was sought by some countries in the negotiations, the grounds on which this can be done are not limited by the Agreement, but the Agreement contains a number of conditions that have to be met in order to safeguard the legitimate interests of the patent owner. Two of the main such conditions are that, as a general rule, an effort must first have been made to obtain a voluntary licence on reasonable commercial terms and conditions and that the remuneration paid to the right holder shall be adequate in the circumstances of each case, taking into account the economic value of the licence;

the Agreement recognizes the right of Members to take measures, consistent with its provisions, against anti-competitive practices and provides more flexible conditions for the grant of compulsory licences where a practice has been determined after due process of law to be anti-competitive. For example, the conditions referred to above for the grant of compulsory licences may be relaxed in these circumstances. The Agreement also provides for consultation and cooperation between Members in taking action against anti-competitive practices;

the TRIPS Agreement makes it clear that the practices of WTO Members in regard to the exhaustion of intellectual property rights (e.g. a Member’s decision to have a national exhaustion regime, under which right holders can take action against parallel imports, or an international exhaustion regime, under which they cannot) cannot be challenged under the WTO dispute settlement system, provided that they do not discriminate on the grounds of the nationality of right holders.

Other policy instruments 

Governments have a range of public policy measures outside the field of intellectual property to address issues of access to and prices of drugs. For example, many countries use price or reimbursement controls. Article 8 of the TRIPS Agreement makes it clear that WTO Members may, in formulating or amending their rules and regulations, adopt measures necessary to protect public health and nutrition, provided that such measures are consistent with the provisions of the Agreement.

Transition provisions 

The TRIPS Agreement lays down some transition provisions which gave WTO Members periods of time in order to adapt their legislation and practices to their TRIPS obligations. Those periods differ according to the type of obligation in question and the stage of development of the country concerned. With respect to those transition provisions which relate to the application of the obligations on substantive standards for the protection of pharmaceutical inventions, the obligations are mainly divided into two categories of countries:

(i) as the basic rule, developing countries had until 1 January 2000 to apply the provisions of the TRIPS Agreement, including the obligations regarding the protection of process and product patents. As regards product patents for pharmaceutical products, those developing countries which did not grant such protection on 1 January 2000 had an extra period until 1 January 2005 to introduce it. Since most developing country Members of the WTO already provided for product patent protection for pharmaceuticals, a relatively small number of countries were concerned( 2 );   

(ii) least-developed countries originally had until 1 January 2006 to meet their TRIPS obligations. The TRIPS Council has extended this deadline three times, most recently until 1 July 2034 (Decision of 29 June 2021).

In both cases, the rules of the TRIPS Agreement apply or will apply not only to new patent applications but also to patents still under protection at the end of the respective transition periods.

Notwithstanding proposals to the contrary, the TRIPS Agreement did not require the bringing under protection of pharmaceutical inventions that were in the “pipeline” in these countries at the time of entry into force of the WTO.(3) However, with effect from that date (1 January 1995), those developing and least-developed countries that did not already make available patent protection for pharmaceutical products, were under an obligation to provide a system whereby applications for patents for pharmaceutical product inventions could be filed (often referred to as a “mailbox” system). These applications did not have to be examined until after 1 January 2005 in the case of developing countries. If found to be patentable by reference to their filing (or priority) date, a patent would have to be granted for the remainder of the patent term counted from the date of filing. The General Council has waived this obligation for least developed country members until 1 January 2033 (Decision of 30 November 2015).

In the event that a pharmaceutical product that was the subject of a “mailbox” application obtained marketing approval prior to the decision on the grant of a patent, an exclusive marketing right of up to five years had to be granted provided that certain conditions were met. The General Council has also waived this obligation for least developed country members until 1 January 2033 (Decision of 30 November 2015).

Concluding remarks 

Most developing and least developed countries already granted patent protection for pharmaceutical products prior to the entry into force of the TRIPS Agreement. In these countries, the TRIPS Agreement therefore did not lead to fundamental changes in this regard, although a certain amount of adjustment in legislation, for example in respect of patent term and compulsory licencing, was often necessary. With respect to the countries that did not provide patent protection for pharmaceutical products at the time of entry into force of the WTO Agreement, some, including Brazil and Argentina, decided to bring such protection into effect more quickly than is required under the TRIPS Agreement.

The TRIPS Agreement pays considerable attention to the need to find an appropriate balance between the interests of rights holders and users. This was an important theme in its negotiation. This is not only reflected in the basic underlying balance related to disclosure and providing an incentive for R&D, but also in the limitations and exceptions to rights that are permitted and in the transition provisions. The flexibilities in the TRIPS Agreement have subsequently been clarified and reinforced by the Doha Declaration on the TRIPS Agreement and Public Health, as well as by the Waiver Decision of August 2003 and the Amendment Decision of December 2005 to facilitate compulsory licenses for export to needful countries.

It should also be appreciated that the protection of pharmaceutical inventions was one aspect of a much wider agreement, covering not only the protection of intellectual property in general in a coherent and non-discriminatory way but also further liberalization and strengthening of the multilateral trading system as a whole. While it is true that some countries put particular emphasis on TRIPS matters in the Uruguay Round negotiations, it is also true that other countries attached great importance to other areas, for example textiles and agriculture. It is a belief shared by all WTO Members that a strong and vibrant multilateral trading system is essential for creating conditions for economic growth and development worldwide. This in turn provides for the generation of the resources required to tackle health problems.

> back to text

(2) Thirteen WTO Members (Argentina, Brazil, Cuba, Egypt, India, Kuwait, Morocco, Pakistan, Paraguay, Tunisia, Turkey, United Arab Emirates and Uruguay) have notified “mailbox” systems to the TRIPS Council, thus indicating that they did not grant patent protection to pharmaceutical products. Some of them, such as Argentina, Brazil and Turkey, have since introduced such protection. (It cannot be excluded that there were a few other WTO Members who should have notified but did not done so).

(3) The “pipeline” refers to the backlog of inventions of new pharmaceutical products that were no longer patentable on that date, because disclosed, but not yet on the market because pending marketing approval.

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Fact Sheet on FTC’s Proposed Final Noncompete Rule

• Competition
• Office of Policy Planning
• Bureau of Competition

The following outline provides a high-level overview of the FTC’s proposed final rule :

• Specifically, the final rule provides that it is an unfair method of competition—and therefore a violation of Section 5 of the FTC Act—for employers to enter into noncompetes with workers after the effective date.
• Fewer than 1% of workers are estimated to be senior executives under the final rule.
• Specifically, the final rule defines the term “senior executive” to refer to workers earning more than $151,164 annually who are in a “policy-making position.”
• Reduced health care costs: $74-$194 billion in reduced spending on physician services over the next decade.
• New business formation: 2.7% increase in the rate of new firm formation, resulting in over 8,500 additional new businesses created each year.
• This reflects an estimated increase of about 3,000 to 5,000 new patents in the first year noncompetes are banned, rising to about 30,000-53,000 in the tenth year.
• This represents an estimated increase of 11-19% annually over a ten-year period.
• The average worker’s earnings will rise an estimated extra $524 per year. 

The Federal Trade Commission develops policy initiatives on issues that affect competition, consumers, and the U.S. economy. The FTC will never demand money, make threats, tell you to transfer money, or promise you a prize. Follow the  FTC on social media , read  consumer alerts  and the  business blog , and  sign up to get the latest FTC news and alerts .

Press Release Reference

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What the New Overtime Rule Means for Workers

One of the basic principles of the American workplace is that a hard day’s work deserves a fair day’s pay. Simply put, every worker’s time has value. A cornerstone of that promise is the  Fair Labor Standards Act ’s (FLSA) requirement that when most workers work more than 40 hours in a week, they get paid more. The  Department of Labor ’s new overtime regulation is restoring and extending this promise for millions more lower-paid salaried workers in the U.S.

Overtime protections have been a critical part of the FLSA since 1938 and were established to protect workers from exploitation and to benefit workers, their families and our communities. Strong overtime protections help build America’s middle class and ensure that workers are not overworked and underpaid.

Some workers are specifically exempt from the FLSA’s minimum wage and overtime protections, including bona fide executive, administrative or professional employees. This exemption, typically referred to as the “EAP” exemption, applies when: 

1. An employee is paid a salary,  

2. The salary is not less than a minimum salary threshold amount, and 

3. The employee primarily performs executive, administrative or professional duties.

While the department increased the minimum salary required for the EAP exemption from overtime pay every 5 to 9 years between 1938 and 1975, long periods between increases to the salary requirement after 1975 have caused an erosion of the real value of the salary threshold, lessening its effectiveness in helping to identify exempt EAP employees.

The department’s new overtime rule was developed based on almost 30 listening sessions across the country and the final rule was issued after reviewing over 33,000 written comments. We heard from a wide variety of members of the public who shared valuable insights to help us develop this Administration’s overtime rule, including from workers who told us: “I would love the opportunity to...be compensated for time worked beyond 40 hours, or alternately be given a raise,” and “I make around $40,000 a year and most week[s] work well over 40 hours (likely in the 45-50 range). This rule change would benefit me greatly and ensure that my time is paid for!” and “Please, I would love to be paid for the extra hours I work!”

The department’s final rule, which will go into effect on July 1, 2024, will increase the standard salary level that helps define and delimit which salaried workers are entitled to overtime pay protections under the FLSA. 

Starting July 1, most salaried workers who earn less than $844 per week will become eligible for overtime pay under the final rule. And on Jan. 1, 2025, most salaried workers who make less than $1,128 per week will become eligible for overtime pay. As these changes occur, job duties will continue to determine overtime exemption status for most salaried employees.

The rule will also increase the total annual compensation requirement for highly compensated employees (who are not entitled to overtime pay under the FLSA if certain requirements are met) from $107,432 per year to $132,964 per year on July 1, 2024, and then set it equal to $151,164 per year on Jan. 1, 2025.

Starting July 1, 2027, these earnings thresholds will be updated every three years so they keep pace with changes in worker salaries, ensuring that employers can adapt more easily because they’ll know when salary updates will happen and how they’ll be calculated.

The final rule will restore and extend the right to overtime pay to many salaried workers, including workers who historically were entitled to overtime pay under the FLSA because of their lower pay or the type of work they performed. 

We urge workers and employers to visit  our website to learn more about the final rule.

Jessica Looman is the administrator for the U.S. Department of Labor’s Wage and Hour Division. Follow the Wage and Hour Division on Twitter at  @WHD_DOL  and  LinkedIn .  Editor's note: This blog was edited to correct a typo (changing "administrator" to "administrative.")

• Wage and Hour Division (WHD)
• Fair Labor Standards Act
• overtime rule

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