key: cord-022266-nezgzovk
authors: Henderson, Joan C.
title: Tourism and Health Crises
date: 2009-11-16
journal: Managing Tourism Crises
DOI: 10.1016/b978-0-7506-7834-6.50008-9
sha: 
doc_id: 22266
cord_uid: nezgzovk

nan

Health and tourism are connected in many ways and there are several distinct areas of study which include the physical and psychological benefi ts of vacation travel, the pursuit of improved health being a major motivator for tourism. However, there are dangers to health arising from participation in tourism and they can result in the emergence of tourism crises. Such situations and approaches to their resolution represent the subject of this chapter in which health risks when traveling and on arrival at destinations are considered, with a section devoted to infectious diseases affecting humans and animals and birds.

A distinction is made between involuntary and voluntary health threats, the latter illustrated by sexually transmitted illnesses and adventure tourism, which are also examined. Responses to these various types of tourism crises are then reviewed and detailed case studies of the 2003 outbreak of SARS and airline policy regarding deep-vein thrombosis (DVT) are presented at the end of the chapter. These examples afford insights into the impact of health-related tourism crises and their management at an international and national, and industry and corporate level, respectively.

Health is a major public and private concern in general and a key element in destination choice and visitor satisfaction, with individuals and the tourism industry likely to shun environments where there might be a risk to tourist well-being. While tourism's contribution to an enhanced state of mind and body is widely accepted, many health hazards confront overseas and domestic travelers (Clift and Grabowski, 1997; NCBI, 2003; WHO, 2002) . These hazards have the potential to become crises for organizations and destinations when problems are severe and impact on a place's reputation and arrivals (Thompson et al., 2003) .

Some studies have concluded that the health of as many as 50% of participants is impaired by the experience of international tourism (Dawood, 1989) and the rise in foreign travel has been accompanied by an increased incidence of disease, especially that of a tropical nature (Connor, 2005) . An ageing population also means elderly travelers who are often more vulnerable to health risks. Tourism has additional repercussions for the health of destination residents (Rodriguez-Garcia, 2001) who tend to be neglected in any discussion (Bauer, 2003) , but this theme is not explored here.

Government and commercial tourism agencies must therefore face the likelihood of health-related crises occurring and manage their consequences, as well as undertake preventive action where possible. Tourists themselves also have a part to play in terms of seeking information, taking precautions and behaving in an appropriate manner.

The act of travel poses dangers, detailed in the next chapter within the context of technological failure, and each mode is distinctive from fl ying to cycling (Nikolic et al., 2005) . There may be accidents due to mechanical failures, human error and adverse weather either independently or in combination and public vehicles are popular targets for terrorist attack, crises which are examined more fully in other chapters. Air travel in particular has attracted considerable publicity with regard to both such events as well as its relationship with DVT and other medical conditions (see Case One).

It is not just tourists who are transported, but animal life which is a source of infection. The presence of rodents on planes, also a practical hazard, has been recorded as well as mosquitoes. Shipping ports and airports may be infested by rats and insects, with implications for the health of those exposed to them and inhabitants of countries where the diseases they carry are imported (Gratz, 2003) .

Cruising is a means of transport, although ships can be seen as fl oating resorts, and outbreaks of gastrointestinal illnesses on cruise liners are regularly logged (CDC, 2003) . Even the most luxurious cruises are not immune from health problems which are aggravated by the higher age profi le of the cruise market, close proximity of passengers and the popularity of group activities. Norwalk-like viruses, with symptoms of diarrhea and vomiting, infected about 1,000 passengers and crew members on two Florida-based lines in late 2002. The operators abandoned voyages so that the ships could be thoroughly cleaned and disinfected. There was a similar instance the following year, although the cruise proceeded as scheduled (see Boxed Case One). Other reported maladies on board cruise ships are infl uenza, E. coli infections and shigellosis, which is a bacteria causing diarrhea (Schlagenhauf, 2004a) .

The Aurora was on a 17-day Mediterranean cruise in 2000 when there was an outbreak of a very contagious Norwalk-like virus. There were 1,800 passengers on board, over 500 of whom fell ill with sickness and diarrhea alongside 29 of the 800 crew. The company maintained that everyone had recovered when the cruise ended at the British port of Southampton.

The virus is believed to be transmitted by personal contact and a "no touch" regime was imposed on the ship in a bid to contain its spread. Shared utensils and condiments were withdrawn from eating areas and furniture in public spaces was carefully cleaned after use. Passengers described how they had avoided touching surfaces like door handles. The usual medical complement of two doctors and four nurses was augmented by another doctor and nurse. The Greek authorities refused to let the ship into the port of Piraeus and Spain sealed its border with Gibraltar following its arrival there, despite offi cial protests.

There were mixed reactions among the passengers on returning home about their experiences. Some expressed themselves satisfi ed with the vacation and the company's response to the problems on board, believing that fellow passengers were embellishing the situation with a view to obtaining compensation. Others were critical of the company for being slow to act in the initial stages of the outbreak and demanded refunds for expensive cruises which were priced between £1,000 and £5,000. The managing director accepted that the circumstances had been unparalleled and exceptionally demanding for the medical and other staff. With regard to the compensation issue, he said that all the relevant correspondence would have to be considered and each case would be assessed individually.

After docking and the disembarkation of passengers, the Aurora was thoroughly disinfected by cleaners who had donned face masks. It then sailed away for a short Channel Islands cruise, having been booked for a conference.

Source: The Guardian, 2003.

Having survived the journey, tourists then face the possibilities of sickness and accidental injury on their arrival at destinations. The most prevalent forms of sickness resulting from tourism are often connected to standards of hygiene at destinations. Poor sanitation and inadequacies of water supply and sewage disposal may cause intestinal infections like gastroenteritis, with contaminated seafood another source. Diarrhea is a particular concern among travelers and one of the most common of travelers' complaints (Ericsson et al., 2003) . These infections can strike and spread rapidly at venues where tourists gather such as hotels. Malaria, yellow fever, cholera and dengue are more serious and can have fatal consequences. There are also bites, stings and skin infections to contend with as well as unaccustomed sun and high or low temperatures (Keystone et al., 2004; Zuckerman, 2001) .

The severity of health hazards and sensitivity to them partly depends on location, activity and the tourist's physical fi tness. For example, those traveling off the beaten track in regions such as South East Asia, the South Pacifi c and Amazon Basin are in danger from endemic ailments (Rudkin and Hall, 1996; Shaw and Leggat, 2003) . It seems probable that more tourists will succumb to both common and rarer diseases as peripheral areas of the world become accessible, a trend fueled by enthusiasm for ecotourism and other manifestations of alternative tourism in which travelers seek to escape the trappings of the mass industry. Articles in the Journal of Travel Medicine portray a rather alarming picture of medical perils awaiting visitors in remote places, although these perils also lurk in mainstream centers (Schlagenhauf, 2004b) .

Cities too pose "myriad" threats which are especially acute in the developing world. They include "infectious diseases, trauma, air pollution, heat illness, crime and psychiatric illness" (Sanford, 2004, p. 314 ). The catalogue extends to "sexually transmitted diseases" and "recreational drug use" which perhaps belong to the category of volitional risk. These circumstances could be a principal or secondary cause of tourism crises and indicate how certain classes of tourism crisis overlap as environmental and socio-cultural factors are also at work.

Threats are not confi ned to developing countries or tropical climates and can be found in temperate zones in the developed world. Legionnaire's disease is contracted when mist is inhaled from tainted water sources such as air conditioning cooling towers, central plumbing machinery and whirlpool spas. It can therefore be caught within accommodation properties and conference centers and on cruise ships. There is a chance of tourists falling ill with respiratory viral infections like infl uenza, especially older people and those on organized group tour packages. Poor food hygiene gives rise to food poisoning, cholera, E. coli infections, hepatitis A and salmonellosis. Pathogens can be transmitted by food and ensuring food safety is an urgent task both currently and for the future (Kaferstein and Abdussalam, 1999) .

Discussions about health and tourism tend to focus on sickness and disease, additionally, accidents must not be overlooked, although empirical data are limited (Page and Meyer, 1996) . Health considerations at destinations thus extend to personal accident and injury, vulnerability to these is perhaps greater overseas when tourists fi nd themselves in unknown environments. Those injured may also not have easy access to appropriate facilities and treatment, aggravating the damage and impeding their recovery. Unintentional injury is a universal health issue, but its prevalence can be partly explained by the extent of new travel opportunities in the current era when unprecedented numbers are on the move (McInnes et al., 2002) .

Particular problems unrelated to tourist behavior and culpability are partly determined by the features of the destination. A BBC television program quoted by Page and Meyer (1996) examined some risks met by British holidaymakers in the Mediterranean. These risks were often due to building construction and maintenance faults like improperly serviced gas fl ues in self-catering accommodation units, unsatisfactory fi re safety provision and swimming pool defi ciencies. Any resulting crisis could therefore also be defi ned as technological in another example of crisis convergence. Engaging in new pastimes may be risky and even familiar pursuits like driving can be dangerous, with statistics dominated by motor accidents. Traffi c accidents involving hired vehicles are routine occurrences and may not always be the fault of the driver. Resulting injuries and fatalities refl ect badly on any commercial operators implicated and, should they recur, on the location which could be tainted by perceptions that it is unsafe and regulations are lax.

Infectious or communicable diseases can be caught when traveling or after arrival and some have the ability to advance at great speed. Rapid diffusion is facilitated by modern travel patterns and is diffi cult to control. Containment is especially challenging for countries which lack resources, expertise and an adequate health-care infrastructure. Any epidemics are not just a crisis for tourism, but for society at large and can assume a global signifi cance. Resultant fears among tourists may be magnifi ed out of proportion, but the industry has to react to perceptions and not realities. Although few tourists were directly in danger, pneumonic plague in India in 1994 led to a "global alarm which escalated in meteoric fashion" (Clift and Page, 1996, p. 3) . There was a 70% drop in arrivals and companies in overseas markets canceled their Indian tours.

Reference has already been made to established diseases, but there are new fears about those which are emerging such as West Nile fever and SARS. There have been outbreaks of the former in the USA and SARS had a devastating effect in 2003, severely damaging tourism in parts of Canada and across much of East Asia despite the relatively small numbers affl icted (see Case Two). The virus led to health warnings being published by governments and offi cial bodies, the damaging infl uence of such advisories having already been discussed in Chapter 4, and their revocation was a major step on the road to recovery.

Questions of health may impact on tourism in a more indirect manner as evidenced by agriculture and food industry emergencies which infl uence the attractive-ness of destinations and visitor volumes. One example is foot and mouth disease, which affects cloven-hoofed livestock and not humans, but can be carried on the soles of their shoes and vehicle wheels so that curbs on movement are a key instrument in fi ghting the disease.

There was a particularly severe and prolonged bout of foot and mouth in the UK in 2001 when it was also detected in some countries in Continental Europe (Horwath Consulting, 2001) . News and photographs of the mass slaughter of herds of cattle and their incineration portrayed an unattractive picture of the British landscape, an offi cial report condemning "sensationalist" and "hysterical" media reporting at home and overseas (UK Parliament, 2001) . Restrictions imposed on access to farmland and misunderstanding about personal safety were other disadvantages with which the industry had to contend. Footpaths in rural areas and some roads in National Parks were closed, making it diffi cult to reach certain visitor attractions.

Fears that the UK was being depicted as a "disease-ridden hellhole" prompted a senior government offi cial to promote inbound tourism at a meeting he was attending in New York, and there was a wider campaign to assure visitors that Britain was safe and "open for business." Tourism suffered, with estimated losses of about £6 billion (The Financial Times, 2003) , but the effect was concentrated in the countryside. Hotels and attractions responded by intensifi ed marketing, price discounting and cost cutting and several businesses demanded assistance from government to alleviate their fi nancial plight.

The ramifi cations of foot and mouth were felt elsewhere due to anxieties about its being unwittingly exported. Busch Gardens in Tampa Bay, Florida, directed foreigners away from susceptible animals like giraffes and gazelles. Visitors with a history of travel to infected areas were requested to desist from joining the optional tours, the highlight of which was close proximity to wildlife, and offered alternatives such as half-price entry to the water park (The Business Journal, 2001). Immigration procedures were also modifi ed in an attempt to prevent the disease invading countries such as the Irish Republic where livestock farming is a key economic sector. International arrivals were asked to complete declaration forms concerning their travels and walk across disinfected mats when entering countries.

Avian infl uenza or bird fl u is a more serious illustration as humans can catch it from infected birds and now it appears endemic in parts of Asia. Cases in Hong Kong discouraged tourism in the late 1990s and have the potential to do so elsewhere. An especially virulent strain was discovered in several East and South East Asian countries in late 2003. Subsequent years saw further eruptions and its appearance in other continents, leading to the widespread culling of birds and attempts at immunization. There were also a number of human infections and several deaths.

Although most victims in Cambodia, China, Hong Kong, Indonesia, Thailand and Vietnam had been in contact with sick poultry, there are forecasts that it is only a matter of time before the potentially lethal virus mutates into a form which will allow human-to-human transmission among populations that have no immunity (WHO, 2005) . This could trigger a global infl uenza pandemic with millions of casualties and is a subject of grave anxiety for both health and tourism authorities. Some countries have discussed closing their borders in a bid to protect nationals and it seems that international tourism would almost come to a halt and the international industry effectively cease to function if the worst scenarios were to be realized.

The above health threats are largely involuntary, although certain measures can be taken to reduce their magnitude and possibly avert a crisis. However, other types of risk can be classed as voluntary and tourists frequently engage in careless behavior which endangers their health. It has also been noted that individuals perceive risks differently depending on personality and social circumstances (Carter, 1998; Lepp and Gibson, 2003) . Irresponsibility fi nds expression in several ways such as carelessness over food consumption, underestimation of dangers and a corresponding absence of preparedness and protection (Casteli, 2004) .

Traffi c accidents and drowning account form a signifi cant proportion of deaths and injuries among international tourists (McInnes et al., 2002) and many cases are attributable to thoughtlessness. Drivers may be reckless, over-tired, insuffi ciently knowledgeable about local conditions, diverted by the passing sights, under the infl uence of alcohol and not using seat belts (Wilks et al., 1999) . Sexual activity is one important high risk area described in the next section, followed by an account of adventure tourism which can also be seen as a type of willing engagement with danger.

Some tourists may abandon their personal inhibitions when traveling and ignore norms to which they conform at home, thereby exposing themselves and those with whom they have contact to harm (Wickens, 2003) . Such an attitude applies to sexual adventures with a heightened chance of catching or perhaps communicating a sexually transmitted disease, including HIV/AIDS, unless appropriate precautions are taken. The HIV/AIDS epidemic has been linked to international travel and sex tourism based on prostitution, traffi cking in women and children and pornography is regarded as one vehicle for its spread. Cheaper air fares and the marketing of more Third World countries have favored sex tourism and the Internet has also created more opportunities for tourists in search of sexual gratifi cation abroad, advertising adult and child pornography internationally. Such tourism is now a worldwide phenomenon which has benefi ted from inadequate laws in certain regions, especially regarding the welfare of minors.

Studies of sex tourism emphasize its complexity and variety (Bauer and McKercher, 2004; Clift and Carter, 2003) , sex tourists shown to exhibit contrasting expectations from lonely individuals seeking a holiday "romance" to more commercial relationships (Oppermann, 1999) . Provision also varies in terms of legality, offi cial regulation and conditions and attitudes of sex workers. The morality of adult prostitution and its capacity to demean the sellers of services are topics for debate, although the view of prostitutes as naïve and innocent victims of more powerful tourists has been contested (Cohen, 1993; Ryan and Kinder, 1996) . Nevertheless, all casual sex carries certain health risks for both parties.

The participation of children cannot be defended and has been widely condemned for the physical and emotional damage it infl icts. A Save the Children report maintained that about two million children aged between three and 17 in Africa, South East Asia, Latin America and Eastern Europe are being used for sex. Tourists come principally from France, Italy, Germany, Belgium and Spain and number about 3.5 million (The Lancet, 2004) . It should, however, be remembered that customers are not confi ned to Western tourists and include Asians and local residents.

Opposition to such practices is intensifying and offi cial organizations and pressure groups are trying to raise awareness and encourage action by the tourism industry and governments. Two examples are EPCAT (End Child Prostitution, Child Pornography and Traffi cking of Children for Sexual Purposes) and UNESCAP (United Nations Economic and Social Commission for Asia and the Pacifi c). There have been some advances with signs of willingness in South East Asia to deal more rigorously with the sexual exploitation of children and pursue court convictions for organizers and offenders. In terms of demand, there have been endeavors in the UK to restrict overseas travel by certain groups of known sex offenders. Prosecutions can also now be conducted in the country of residence of the accused, not just where the alleged offences took place.

The negative connotations of sex tourism, particularly child prostitution, may discourage visits by many tourists to destinations where it is known to be rampant. Associated high rates of HIV/AIDS may also be a deterrent. Locations which have acquired a seedy and unsavory image could have diffi culty promoting themselves to particular markets such as families, provoking a crisis for parts of the industry. One such example is Thailand. The TAT has been seeking to position the country as more exclusive with an emphasis on its natural and cultural heritage. At the same time, the authorities are faced with the realities of a thriving commercial sex sector in tourist hubs such as Bangkok, Pattaya, Koh Samui and Chiang Mai.

The TAT has tried to resolve this dilemma by publicly professing an abhorrence of sex tourism and its pursuit of the eradication of the worst excesses. It asks its overseas offi ces to report companies selling sex tours to Thailand and claims to be enforcing the country's anti-prostitution laws, together with the police. These laws impose penalties of fi nes and imprisonment on customers, procurers, brothel owners and those forcing children into prostitution who are sometimes parents (Tourism Authority of Thailand, 2001 ).

An end to illegal and unregulated sex tourism in Thailand and elsewhere is, however, problematic because of the economic rewards. It represents a major industry in some places and can be a vital source of income; for example, over 90% of young female Cambodian prostitutes may be the principal family breadwinner. Many commentators also question the commitment of offi cials to the drive against prostitution in general and involving children in particular. There is a lack of political will and changes will require immense effort. Campaigns do not always receive the full support of the local police and other bodies, corruption being a major obstacle. Sexual exploitation has socio-economic roots and is a product of poverty, lack of education and drug addiction. Until these issues are addressed, it seems that the more unacceptable manifestations of sex tourism in the developing world will continue to thrive (BBC News, 2000; UNESCAP, 2004) .

Adventure tourism is perhaps worthy of note as a kind of tourism in which participants deliberately search out danger, often taking part in what are described as "extreme sports." Such forms of tourism are popular in Australia, New Zealand and North America and have seen worldwide growth in recent years (Ryan, 1996) . There are a variety of motives for taking part and the concept of adventure is subjective, reaching beyond specifi c recreational pursuits to encompass more passive groups taking part in overland tours (Weber, 2001) . However, the term usually applies to physically demanding activities such as caving, white water rafting, canyoning (the entering of gorges and body surfi ng without a raft down the rapids and waterfalls which fl ow through them), climbing, sea kayaking and horse riding.

Participants thus expose themselves to accident and injury, although these are unlikely to be welcomed or desired. A degree of organization and commercialization is implied and operators are expected to protect their customers from undue risk with an assumption that they have given proper attention to safety matters (Bentley and Page, 2001; Hall, 1992) .

It is impossible, however, to guarantee absolute safety and accidents do occur (see Boxed Case Two). Another tragedy happened in 1998 when two American divers died at sea after being mistakenly left behind on the Australian Great Barrier Reef (Wilks and Davis, 2000) . The skipper of the vessel concerned was later charged with manslaughter on the basis of criminal negligence. It is not just the major catastrophes which are of relevance; minor incidents such as "slips, trips and falls" account for many injuries and insurance claims (Bentley et al., 2004) . Again, events of this nature damage individual companies, the industry as a whole and possibly the destinations where they take place. Authorities in New Zealand have expressed concern over the number of adventure sports deaths there and the consequences they might have for tourist demand.

There is thus great diversity in the characteristics and intensity of tourism crises arising from health and many cases of illness and personal accidents are limited in their scope and outcome. This makes any emergent crisis easier to manage, although instances such as the death of airline passengers from DVT or adventure holiday could pose serious challenges to particular businesses and destinations. Other situations have the capacity to become major crises and this applies especially to disease which attracts intense media interest and may raise doubts about the competence of responsible authorities. Travel is an agent of globalization which can assist in the dissemination of communicable disease and many destinations are inadequately equipped to meet the ensuing demands on health services.

The tourism industry cannot ignore such developments as offi cials are predicting the recurrence and intensifi cation of epidemic-prone viral and bacterial diseases which do not respect territorial boundaries. There have also been warnings about

A total of 21 people, 18 tourists and three guides, were killed in a fl ash fl ood in July 1999. The accident happened on a canyoning trip near Interlaken in central Switzerland which had been organized by a Swiss adventure company. The dead tourists, from 18 to 31 years of age, came from Australia, Britain, New Zealand, South Africa and Switzerland and belonged to a larger party of 45 tourists accompanied by eight guides. The guides failed to evacuate them from a gorge which fi lled with water during a fl ash fl ood and many were washed away.

The trial in 2001 lasted seven days and was attended by the families and friends of the deceased. Lawyers defending the company, which was then no longer in business, argued that the accident could not have been predicted and was the outcome of exceptional weather. Those who survived claimed that arrangements had been rushed and there were no clear explanations. The judge said in court that employees had not been appropriately trained and safety procedures were completely unsatisfactory. The fatal trip should have been canceled as there had been clear warnings of a storm, the progress of which could easily be seen. He ruled that six staff members had been guilty of negligent manslaughter and declared two junior guides innocent. The three directors were fi ned US$5,000 and received fi ve-month suspended prison sentences while the three senior guides faced lower fi nes and reduced sentences.

There had been an earlier trial involving the same company in 2000 when two staff had also been convicted of negligent manslaughter and received suspended sentences of fi ve months. The case related to the death of an American in his early 20s whose bungee jump cord was defective. The incident had contributed to the company's end. Partly in response to these events, Switzerland launched a code of conduct for extreme sports operators and introduced education programs for guides.

Source: BBC News, 2001b. an increase in new infections and drug-resistant pathogens. In addition, there is the possibility of a coalescence of the threats to tourism from terrorists and ill health due to speculation that disaffected groups may gain samples of deadly viruses and toxic substances. These substances could then be employed as instruments of terror, perhaps specifi cally aimed at tourists, by such "bioterrorists."

Rampant infectious disease is not the only concern and there may be numerous other health risks at certain locations which are extremely attractive to tourists. Transportation and some leisure activities also have inherent dangers. Tourists and the industry will shun places where there is a known threat to visitor health, but may fi nd themselves caught up in unexpected events. Coping with the worst of these situations is a daunting exercise for the tourism industry, but readiness is essential in view of the inevitability of health-related tourism crises.

Preventive steps can help to avert the evolution of a full-scale tourism crisis, but the industry has sometimes shown itself reluctant to deliver appropriate health warnings because of fears about scaring customers away and losing business (Lawton and Page, 1997; Stears, 1996) . Analysis of Australian travel brochures (Bauer, 2002) and international commercial travel websites (Horvath et al., 2003) reveals that little useful information is provided and that which is available is insuffi cient.

Authors of these studies advise that customers should be fully informed about problems and advised to take precautions and purchase travel insurance. Destinations could also be classifi ed on the basis of risk and overall awareness promoted through education. There are opportunities for greater collaboration between medical workers, health educators and the travel trade with advice and guidelines channeled by way of travel agents. Specifi c information about sexually transmitted diseases can be distributed to tourists before departure, counseling about safe sex and condom use.

In terms of child prostitution, the abuse of minors represents a crisis of ethics for the industry, which must acknowledge and act upon its responsibilities regarding the transgressions of customers. There has been some progress in this direction and EPCAT has cooperated with the French hotel group Accor in an initiative against child prostitution in Asia. It is also liaising with the WTO to promote acceptance of a code of conduct among industry members (EPCAT, 2003) , although campaigners argue that much more needs to be done.

With regard to accidents, travel health professionals can again try to educate the traveling public through material covering active and passive protection (Hartgarten, 1994) . The industry has ethical obligations regarding the safety of its customers and there are additional legal reasons for giving due regard to health and safety matters. The European Commission Directive on Package Travel, for example, insists that travel organizers and agents must provide health and safety details for their clients and may be liable for any harm they suffer.

Some initiatives to minimize unnecessary dangers and avoid serious injuries in the fi eld of adventure tourism are operator accreditation schemes, strict health and safety rules, codes of conduct, staff training and the education and prior assessment of participants (Bentley and Page, 2001) . Risk management is also critical (Wilks and Davis, 2000) . Such moves are still voluntary in most countries and statutory regulation might be deemed imperative, extending to other areas such as general road safety. It is unfortunate that tragic loss of life, such as that in Switzerland, is often the catalyst for long-overdue reforms. Promoting a culture of safety would also reduce the number of more common minor incidents (Bentley et al., 2004) which collectively constitute a crisis.

The industry can also cooperate with destination authorities in upgrading utilities and public services for the benefi t of the whole community. Investment in water supply and sewage disposal facilities would alleviate sickness arising from poor hygiene and training in food handling and regular inspection and monitoring of premises could be introduced. Many countries lack basic health-care provision and priority should be allocated to improving the lives and health of residents as well as to meeting tourist needs, an approach in correspondence with the philosophy of sustainable tourism development. Such displays of corporate social responsibility will assist in reducing the likelihood of another type of crisis, those derived from resentment toward tourists among residents when the former are believed to be receiving preferential treatment.

Action is thus required at a company and industry level, with governments and tourists also having a vital contribution to make. The WTO has stressed the significance of health as an aspect of tourist safety and proposes that member states pursue the following program to enhance their capabilities in dealing with diffi culties (WTO, 1991) :

Identifi cation of risks to tourists related to particular activities, locations and sites. Introduction and strict enforcement of safety standards and practices at facilities and venues. Establishment and distribution of operator guidelines. Provision of information to the public about possible health hazards, protective steps and sources of assistance. Proper staff education and training. Clarifi cation of liability issues and formulation of rules and regulations. Development of national tourism health policies, including systems of reporting to inform the international community.

At a Caribbean Tourism Organization seminar (CTO, 2003) , a WTO representative cited four critical considerations pertaining to the effective handling of health crises. They were the allocation and acceptance of responsibilities, transparency, assistance mechanisms and management of fear. The tourism sector was urged to improve its responses by being more proactive and there were calls for greater global cooperation. Eradication or minimization of both health and safety risks at resorts is a collective effort involving stakeholders of owners, operators, staff, visitors, offi cials and medical experts (Phillip and Hodgkinson, 1994) .

However, some damage to tourism is to be expected even when such systems are in place. SARS, and to a lesser extent foot and mouth, overwhelmed the industry, which had little scope to react or room for maneuver. Tourism was at the mercy of the epidemic dynamics and initiatives to generate business were thus constrained. It was only when the health crisis abated that advertising campaigns and product development started to yield signifi cant results, although discounting and a focus on domestic markets did generate some revenue prior to the onset of recovery.

Questions of health therefore represent a potential source of tourism crises, although their severity varies considerably. The magnitude of any crisis will depend partly upon the numbers involved and whether there are any fatalities, dimensions which determine the amount of publicity generated. Media coverage is a critical infl uence on popular opinion and handling external communications is a core element of crisis management.

The examples cited in the chapter suggest that prompt efforts to enhance safety and security systems following a critical incident are essential to demonstrate a commitment to safeguard tourists and inspire confi dence that the event will not be repeated. Matters of compensation also need to be resolved in a fair manner and this is related to questions of liability and obligations to next of kin when there have been fatalities. Negligence must be seen to be punished and companies to make amends for their shortcomings if an organization and its reputation are to survive the crisis. These issues are returned to in Chapter 8, which deals with transport accidents as an illustration of technological failure.

Health is perhaps an arena of crisis which is more amenable to avoidance than some others. While certain contagious diseases and their progress are unpredictable and uncontrollable, the likelihood of other illnesses and accidents occurring may be minimized by increased awareness, changed behavior and better hygiene and safety standards. These goals are easier to achieve within controlled environments such as cruise ships, individual hotels, attraction sites and aircraft cabins, but are more formidable and costly tasks for destinations. The latter cannot be left to the tourism industry alone, but demands intervention by governments and relevant international agencies as well as responsible behavior from tourists themselves.

Medical reports indicate that as many as 10% of long-haul fl yers could be at risk from DVT, or so-called "economy class syndrome." Some experts believe that sitting for long periods in the cramped seating of an aircraft cabin encourages the formation of blood clots in the legs which can break away and travel to the lungs, leading to potentially deadly pulmonary embolism. There may also be a relationship between reduced cabin air pressure and blood oxygen which could promote dizziness, nausea and fainting on long-haul fl ights.

Several victims of DVT and their families have sued airlines, contending that air travel caused the malady. American Airlines, United Airlines, Delta, Northwest, Japan Airlines, Qantas, Singapore Airlines, British Airways, KLM and Virgin Air were among a total of 27 carriers named in a 2001 lawsuit. A London court concluded that blood clots were a "serious personal injury" and could not be defi ned as an "accident" under the Warsaw Convention; the 1929 treaty recognizes that airline liability regarding damages applies only to the latter. The Supreme Court in the Australian state of Victoria, however, decided in favor of the plaintiffs in a parallel case, permitting a landmark lawsuit to proceed. American Airlines, the world's largest carrier, reportedly reached an out-of-court settlement in a blood clot dispute at the end of 2002. Analysts were watching for any court judgment in the United States where the award of damages would probably be very high and perhaps set a precedent.

Following the London ruling, British Airways said that it sympathized with DVT sufferers. However, it also stated its belief that any link with air travel was uncertain and this would inform its position on other claims. It had, nevertheless, introduced a new Manual of Infl ight Medical Care in late 2001 to assist crew in looking after passengers who became ill during fl ights. The manual provided instructions on dealing with many scenarios and was complemented by staff training and a CD-ROM version, the company's intranet used for additional training purposes. These materials are supplemented by a telephone link to a 24-hour advice center on the ground. Other measures to minimize the risks of DVT had been in operation for some time. Sources of information and advice included the corporate website, phone lines, in-fl ight videos and magazines and ticket wallets. A Healthy Journey leafl et recommended that passengers drink plenty of fl uids, eat moderately and limit their intake of alcohol and caffeine. They were also advised not to remain seated for the whole of a long-haul fl ight and appropriate exercises were suggested.

It was announced in early 2002 that British Airways would be cooperating with the medical school of Birmingham University in a study of DVT. Travelers drawn from a sample of about 1,000 members of its frequent fl yer loyalty program were to be surveyed. Respondents would be asked about any precautions they took regarding DVT, attitudes toward the disease and extent of alarm. It was considered a signifi cant step, being the fi rst occasion that a British airline had been willing to participate directly in such a research project.

The company's support for the research study was welcomed, especially as there had been reports that a similar World Health Organization (WHO) project was facing funding problems. Critics and campaigners had been arguing that the industry was refusing to acknowledge DVT risks and evading its responsibilities regarding informing passengers. Reporters suggested that Britain's airline industry was anxious to avoid any further damaging news stories about deaths resulting from fl ying in the aftermath of 11 September.

Sources: BBC News, 2001a; The Observer, 2002; One News, 2002; Travel Telegraph, 2003. 

A new virus which initially surfaced in the south of China in 2002 was given the name of Severe Acute Respiratory Syndrome (SARS). It is a type of pneumonia which seems to be transmitted by vapor droplets and close personal contact, although little was known about its characteristics in the early months. While knowledge has subsequently increased, there is still no vaccine or cure and control depends upon the rapid identifi cation of sufferers and their isolation. Any people they have been in association with also need to be quarantined in order to interrupt transmission.

Authorities in China were caught by surprise and slow to inform the international community about the disease so that preventive measures were not taken immediately. Infected travelers were thus free to carry the virus abroad to locations such as Toronto in Canada, Hong Kong, Singapore, Taiwan and Vietnam. These locations recorded the highest numbers, but there were isolated cases found elsewhere in 29 countries altogether. Despite fears of a global pandemic, the virus proved less contagious and fatal than originally feared and the outbreak had essentially ended by mid-2003. There had been a total of 8,096 infections and 774 deaths, the majority of these in Asia.

Initial ignorance and the speed at which SARS was advancing created great anxiety and a degree of panic among resident populations and tourists. Governments and international agencies such as the WHO identifi ed places affected by SARS and advised against visits to where it was spreading in the community due to risks of contraction. The WHO intervention was unprecedented and its pronouncements carried considerable authority. Offi cials were concerned about the importation of the disease and inbound arrivals from SARS states were monitored. The WHO also recommended certain procedures for airlines and airports to follow and SARS came to be associated with air travel, with some airline crew donning face masks. The virus dominated the headlines in much of Asia and received extensive publicity around the world. The media broadcast disturbing accounts of a mysterious deadly illness on the rampage and pictures of deserted streets and locals wearing masks.

Tourism was immediately affected as people were unwilling to travel, especially by plane, for fear of catching SARS. The worst hit areas were shunned by inbound tourists and outbound travelers faced various restrictions. Countries saw falls of over 70% in arrivals during the worst months and there was also a slump in domestic tourism and consumer spending in general. The transport, accommodation, attraction and retail sectors all lost business and the survival of some companies was threatened.

Recovery was dictated by the progress of the epidemic and the lifting of the WHO travel advisories was a major turning point for individual countries. Nevertheless, worries about a return of the virus persisted and fi gures for the year were depressed with declines of 10.4% for China, 6.2% for Hong Kong, 24.5% for Taiwan and 18.5% for Singapore. The WTTC estimated that the industry's contribution to GDP would drop by 24.5% in China, 41.1% in Hong Kong and 43% in Singapore. Vietnam had only 40 cases and fi ve SARS deaths, all confi ned to a Hanoi hospital, but tourism there too was forecast to be worth 14.5% less in terms of its GDP contribution. The reverberations were felt in countries where there were very few or no cases of SARS such as Thailand and the contraction in travel throughout the Asia Pacifi c region of 9.3% in 2003 was attributed to the outbreak. Outside Asia, Toronto was estimated to be losing C$5 every day in April due to the cancellation of major conventions.

There was a common pattern of reaction among offi cial institutions and private enterprises which included the gathering and communication of information, marketing aimed at reassurance, efforts to sell to domestic markets, price cutting, a search for cost savings and greater effi ciency, rationalization, capacity reduction and staff redundancies. A great deal of attention was also given to the devising and implementation of health and safety regimes designed to convince customers that the industry was prepared and particular sites were safe. Governments were also active in support of tourism businesses and in initiatives to enhance standards of public hygiene. It proved very diffi cult to combat the adverse impacts of SARS when it was still spreading and even after it had been contained, but marketing efforts were intensifi ed when places had been formally declared free of SARS. The WHO announcement was the occasion for re-launching affected destinations such as Hong Kong and Singapore in a bid to generate maximum publicity.

Sources : Euromonitor, 2004; Henderson, 2003; McKercher and Chon, 2004; WHO, 2003; WTTC, 2003. 

Adventure tourism: A form of tourism involving participation in physically demanding activities which expose the tourist to risks of injury. Economy class syndrome: Another name for DVT (deep-vein thrombosis), potentially lethal blood clots which may be caused by seating conditions in commercial passenger aircraft. Sex tourism: Tourism in which the primary motivation is the satisfaction of sexual needs, often met by prostitutes and seen as a source of sexually transmitted disease. Tourist health risks: Factors and forces which threaten the physical and psychological well-being of tourists.

4. What preventive strategies can be employed by the tourism industry regarding the contracting of illness and disease by tourists and what will their success depend on? 5. Have airlines responded appropriately to the risks of DVT among passengers? 6. Was there an over-reaction to the threat of SARS by tourists and the tourism industry in generating countries and could this have been avoided?

Additional Readings Castelli, F. (2004) . Human mobility and disease: A global challenge. Journal of Travel Medicine, 11 (1) 

In what ways are issues of health a major concern for the tourism industry? 2. What are the principal types of health-related crises that accommodation

How do health questions impact on the work of destination marketing organizations?

Health advice in Australian travel brochures

The health of host communities: Missing from printed travel health advice

Sex and tourism: Journeys of romance, love and lust

Asia's child sex tourism rising

Airlines face legal action over DVT

Scoping the extent of adventure tourism accidents

The safety experience of New Zealand adventure tour operators

Disease daunts tourism

Tourists' and travellers' social construction of Africa and Asia as risky locations

Human mobility and disease: A global challenge

Vessel sanitation program

Tourism and sex: Culture, commerce and coercion

Tourism and health: Risks, research and responses

Health and the international tourist

Open-ended prostitution as a skillful game of luck: Opportunities, risk and security amongst tourist-oriented prostitutes in Bangkok

Trends in travelers

Tourism sector responsiveness to health crises

Tourists' health: Could the travel industry do more? Tourism Management

Annual report

Travelers' diarrhea

Travel and tourism in Canada

UK tourism 2001: Open for business

Cruise ship health alert exaggerated, say passengers

Adventure, sport and health tourism

Injury prevention: A crucial aspect of travel medicine

Managing a health-related crisis: SARS in Singapore

Travel health information at commercial travel websites

Foot and mouth crisis hits hotels in the Veluwe

Food safety in the 21st century

Travel medicine

Spain makes plan to combat sex tourism

Evaluating travel agents' provision of health advice to travellers

Tourist roles, perceived risk and international tourism

Unintentional injury during foreign travel: A review

The over-reaction to SARS and the collapse of Asian tourism

Medical problems in cycling tourism

BA hauls in fl yers to check DVT risk

One News website at http: onenews.nzoom.com/onenews

Sex tourism

Tourist accidents: An exploratory analysis

The management of health and safety hazards in tourist resorts. World Tourism Organization

The health-development link: Travel as a public health issue

Off the beaten track: The health implications of the development of special interest tourism activities in South East Asia and the South Pacifi c

Linkages between holiday taking travel risk and insurance claims: Evidence from New Zealand

Sex, tourism and sex tourism: Fulfi lling similar needs? Tourism Management

Urban medicine: Threats to health of travelers to developing world cities

Focus on cruise ship travel

Travel-associated infectious diseases

Life and death on the Amazon: Illness and injury to travelers on a South American expedition

Travel health promotion: Advances and alliances

Incidence of health crises in tourists visiting Jamaica, West Indies

TAT supports fi ght against child prostitution

Select Committee on Culture, Media and Sport. Tourism-the hidden giant-and foot and mouth

United Nations Economic and Social Commission for Asia and the Pacifi c website at

Outdoor adventure tourism: A review of research approaches

Health risk-taking and tourism

Risk management for scuba diving operators on Australia's Great Barrier Reef

International tourists and road safety in Australia: Developing a national research and management programme

International travel and health. Geneva: World Health Organization

Avian infl uenza

Recommended measures for tourism safety

Madrid: World Tourism Organization

Principles and practice of travel medicine