E15: 7 Domains of Travel

Humans Are a Traveling Species

We are a traveling species. It turns out when we evolved about 100,000 years ago, when we stood up instead of swinging from trees or walking on our knuckles, we actually developed a way of moving that was incredibly calorically efficient. We had to change our muscles in our rear, we had to change our angles of our ankle, we actually put our shoulders back, our head was more erect, and we looked forward. So not only could we see around us, we were curious as a species, we could stand up and walk, and we traveled all over the world.

The great apes don't really leave home, but humans have been leaving home to go places since we called ourselves Homo sapiens. And we traveled because maybe for new resources or new food sources, or to get stuff that we wanted, like chocolate, and pretty shells, and stuff, and feathers, and things that we wanted. And wherever we went, we took our diseases with us, and whenever we found ourselves in a new place, we met new diseases there. So now that we travel all over the world easily, we spread our diseases all over the planet. We are a traveling species.

Healthy Traveling

Now, thinking about this, we're going to talk about the physical domain here about travel and we're going to have some expert help. With us in the studio is Theresa "Terri" Sofarelli. She is physician assistant, and she spent a lot of her time talking to and taking care of people who are going to travel. Terri, welcome and thanks so much for joining us.

 

Terri: Thank you, Dr. Jones, for inviting me.

Dr. Jones: So I want to hear about how you got this really cool job.

Terri: I was invited to work with the travel and tropical medicine division of infectious disease at the University of Utah with Dr. DeVon Hale probably in 2004. He was the supervising physician at the time and . . .

Dr. Jones: And a great guy. What a wonderful guy.

Terri: He is a wonderful person, and I jumped at the opportunity to work with him. I also believe that this is my destiny job because when I was a little girl, I wanted to grow up to be an airplane so I could travel.

Dr. Jones: Oh.

Terri: Since I couldn't be that, this is the next best thing.

Dr. Jones: So I'm going to tell you a little travel story in that when I was in college . . . this is at the University of Colorado. It was very popular to go to Mexico during spring break, and I did, and I knew that you could get sick. So I drank out of bottles and I made sure my food was cooked, and I wanted to make sure I stayed healthy. But sure as shoot, as soon as I got back, I got Montezuma's Revenge.

Now, maybe you don't use that politically incorrect term anymore. But I didn't even think about going to a traveler's clinic or asking, even when I was in medical school, "What can I do to prevent this and what can I do if I get it?" So talk about how you help people prepare for wherever they might be going.

Terri: Good question. And I do enjoy your story because I similarly . . . my first travel was in the Peace Corps in Costa Rica. And even though I did receive extensive information and education about how to stay safe, I did end up getting amebiasis and giardia. I lost a lot of weight. I think that was a good experience for me to actually accept this help.

So what we offer in our travel clinic is a combination of things from pre-travel consult to post-travel consults if people come back sick. So in a pre-travel consult, we'll review a patient's medical history, their medications, what activities they plan to do abroad, look at their vaccine history and make recommendations on vaccines, make recommendations on malaria prophylaxis, certain activities to avoid. And also, we give them information on where to receive medical help abroad.

Dr. Jones: Here's a story. So I have traveled the world. We packed up and moved every couple years all over. I was born in Germany and then we came to the States, and then we moved to Mexico where my mom got pregnant with my brother, and she developed amoebic hepatitis. So she got amoebas in her liver and lost a lot of weight when she was pregnant.

And they were afraid . . . she was living in a mining camp . . . that she was going to lose the baby. So they shipped her off to Boston where her parents were and she got seen by the infectious disease people. She gave birth to a healthy kid, but she had to leave the country because she was so sick. Did you have to get shipped home when you were in the Peace Corps?

Terri: I didn't have to get shipped home, but on the note of having people flown in from other countries, we also work very closely with the LDS Church and we will see missionaries that are sick abroad. We will sometimes get phone calls in the middle of the night from the medical advisor abroad about what's going on with their missionary, and depending on what they tell us, we may make the recommendation to have them come back can be seen at our travel clinic the next day.

Dr. Jones: Right. So for people who might be listening who aren't from Utah, many, many, many young LDS men and women travel for several years to go to all parts of the world mostly, and they certainly are seen and vaccinated before they go, but they might find themselves in situations where they get sick.

Terri: Absolutely. Our travel clinic is also one of the GeoSentinel sites.

Dr. Jones: Can you explain a GeoSentinel site? I like the name coming out of my mouth, a GeoSentinel site.

Terri: So we're one of 60 travel clinics around the world that collects data on return travelers, and we submit that information to the CDC to help them know when a new arising disease is occurring.

And our site is unique in the sense that we've got the most number of long-term expatriate travelers coming back to our clinic. And that would include the LDS missionaries returning. Whereas a site from Kathmandu, for example, would mostly be seeing travelers coming into their clinic from out of the country for acute problems.

Dr. Jones: Actually, my brother was in the Peace Corps and went to Colombia and he started coughing up worms. So coughing up worms was the sign that he was not well. There you go. So he wasn't well and they shipped him back to Bogota where he got to see somebody in the hospital there.

Terri: Wow.

Dr. Jones: He didn't have to get shipped out. He got treated and he stayed in-country and was studying malaria. So I think that as traveling species who goes places, we want to be well when we get there. And whether we're going for social reasons, or emotional reasons, or for whatever reason, we want to be well over there. We do want to be sick while we're there. We don't want to be sick when we get back.

Terri: So for the person that does travel abroad and comes back with any kind of unique symptoms, specifically a fever or chills, I would strongly encourage them to see a travel medicine expert, whether it's at the University of Utah or abroad.

There is a organization called ISTM, which stands for the International Society of Tropical Medicine, and they list all travel medicine providers. And this is important because if somebody with a fever goes into maybe the urgent care, or the ER, or primary care doc, and they don't tell them that they've been traveling, they might get diagnosed with a viral infection where they could have malaria, for example, which can be deadly. Just wanted to reinforce that piece.

Social Traveling

We're now going to move a little bit into the social domain of travel. I hadn't really thought about it. I know that there are internet brides, people that might meet even through an agency where they might connect people, or there are people who want to be a Facebook friend that you don't know, and then you hook up with Facebook and you want to see them.

 

Terri: So a couple years ago, one of our travel nurses noticed that a lot of the patients coming in for pre-travel consultation actually going to visit their internet fiancés. He was very astute with finding this information out because a lot of these travelers would not give this information up. And we started to collect data, actually two years' worth. We realized that out of about, say, 4,000, we found probably about 40 people that were traveling to visit internet fiancés and about half were women, half were men.

And so we collected data on where they were going, how long they were staying for, and where they were traveling to meet these fiancés and realized that this was a special population that was at higher risk for problems than other travelers.

So, for example, women were usually single, they had never been married, and they were usually traveling to Africa. So we wanted to make sure we spoke to them about protecting themselves against STIs or unprotected pregnancies, being a victim of assault or victims of fraud. So we actually wrote up that and published it in the "Journal of Travel Medicine" back in 2014.

Dr. Jones: The thought of traveling to meet your fiancé sounds . . . to me, that sounds a little risky, and you've confirmed that.

Terri: We felt like it was more risky for the women traveling because they would usually have open-ended itinerary and plan to stay with their future husband and the family of the husband, whereas the men that were traveling planned a closed-end trip with the intent to bring the bride back to United States and get married here. And that seemed safer.

Dr. Jones: Did you find out of those who went, how many came back with a bride or a groom?

Terri: We didn't do follow-up on them, but we did find though that some of the brides and grooms that would come back would leave their new partner at a certain timeframe, and that was usually related to once they got their green card at 3 months, they would leave their new partner, or after 2 years once they got residency, or even after 10 years when they got their citizenship.

Dr. Jones: That's only just slightly illegal.

Terri: That's correct.

Dr. Jones: So that was travel and they might have even been paid to make that arrangement, but you didn't know about that.

Terri: Well, I think some of the folks that were marrying the U.S. citizen, that was their intent, was to get citizenship.

Dr. Jones: Right. Well, what about destination weddings that are . . . let's move on to something happier. Not that that isn't interesting because it's really interesting, but how about something happier, like a destination wedding?

Terri: Oh, we see a lot of those. So sometimes we have travelers going on their honeymoon abroad or they're going to get married abroad, or attend a friend or family's wedding abroad. For example, in India, I believe their high wedding season is in December and January. So we have to consult on eating the appropriate food when you're abroad, and it's usually not that exciting of a recommendation because we usually say, "Don't eat fresh foods. Don't drink tap water." So that would exclude a lot of the delicious-looking food that you would see at an Indian wedding.

Dr. Jones: Yeah. I have a very good friend, a young woman, who went to learn yoga in India and got dengue. And she was pretty sick. You take things from malaria and hope maybe you won't get dengue. It can be risky out there. It can be really risky out there.

Terri: Absolutely. Yeah, we can give prophylaxis to treat for malaria, but can't do that for dengue, chikungunya, or Zika. So if we're recommending that someone avoids mosquito bites when they go to the tropics, that would essentially mean wearing long sleeves, top and bottom, wearing sunscreen, sleeping in a bed net. And I've had friends that say they don't want to tell me about their trip to the tropics because I'm going to ruin their trip with recommendations.

Dr. Jones: Well, I'm a big fan of all of those things for that very reason, because you can get pretty sick. We know when you're traveling for fun and you're young, you just don't . . . you've got that super surfer, "Nothing is ever going to happen to me. I'm young and invincible," problem going on and you just don't think.

Travel with a Smart Conscious

So I've been watching the news and seeing all these spring break parties, particularly in Mexico and Miami, with young people who were going places that they can go during the COVID pandemic. But they all go out there and nobody is in their tiny bikini with a mask that's bigger than their bikini. They're drinking stuff that makes them have bad judgment, and there they are in a super spreader event.

 

Dr. Jones: Have you been making any conversations with people about going during the COVID epidemic?

Terri: That's a good question. We are seeing an increase in our pre-travel consults for travel abroad. People have been anxious to get traveling again. We will look up a patient's travel destination and see that actually the CDC and the World Health Organization are commonly advising travelers not to go to these destinations unless it's deemed necessary. So a spring break to Mexico isn't deemed necessary. The country of Mexico has no regulations for travelers coming in right now.

But something to think about for everyone traveling, including myself because I would like to travel internationally again, is that when we travel from high-resource country to a low-resource country, we could be bringing the COVID disease to that area. We could be bringing a resistant strain. And they're resource-poor countries. They might not be able to accommodate or treat you appropriately. They might not be able to treat the locals if you get them sick. So we could be putting a burden on those local communities.

Dr. Jones: Oh, absolutely. Recent data from New Guinea, which didn't really have any cases until recently and who knows where they came from, but now New Guinea is being overwhelmed because they just don't have the infrastructure to take care of their own people who get sick, much less anybody else who decides they want to travel there.

I have a friend who actually works and runs a cancer research lab in Singapore. He's an American citizen, but he has been in the United States for the last year and can't go back to his home in Singapore because they will put him in quarantine for two weeks. And in Singapore, they are serious about that. They will put you in a hotel room, lock it up, make sure you stay there for two weeks. So some places you might go take quarantine very seriously.

Terri: Absolutely. And as of a month or so ago, the CDC did require any traveler coming back into the States to get tested for COVID, and that can also be challenging thing to find in a resource-poor country. So you might have to get tested at the airport at possibly a $200 test. So that's also a consideration for travelers right now.

The Emotional Need to Travel

But for me and for many people, we haven't seen our families. I have a real emotional need. My needs to travel around the world are much less now. I did that when I was young. But I want to see my family. And people say it's not necessary, but it's necessary. I'm getting old. I might not see them again, and I just want to see them. Luckily, they all live in the United States.

But for people who have family overseas, that's been a real burden for folks not to be able to go visit. That's part of the emotional domain. They feel cut off from their family. And then some people just can't wait to get home.

 

Terri: I've been seeing that also. People do want to travel to see their family, whether it's just to see them to reconnect or for a special event, whether it's a graduation, retirement, birth of a new child. I think it's important for our mental health too to be able to connect with their family.

Dr. Jones: And funerals. I think having had a number of friends whose parents have died from COVID, but they can't have the kind of in-person funeral. A funeral is a gathering of souls and of bodies, and to be emotional together, and tell funny stories. And Zoom just doesn't cut it.

Terri: Absolutely.

The Financial Aspect of Traveling

I'm thinking about people who travel for financial reasons in the sense of the financial domain. Some people travel because it's required for their work. All the traveling that I did growing up was because my father would get a job and we would just move to another country or another place.

 

Dr. Jones: There are people called road warriors. You know that term road warriors?

Terri: I do. I would call myself one of them.

Dr. Jones: Oh, you're a road warrior? Do you travel for work?

Terri: I travel for work and for fun. I have been involved in global health missions where we've taken University of Utah medical students abroad in a collaboration with another university to set up clinics and provide medical care for people in rural areas. And that's been very eye-opening for the students and for myself.

Dr. Jones: Of course. People I know at the CDC have traveled all over the world, as part of their work for the CDC is to travel internationally and it's their job to be in the air all the time. And transmeridian flight, thinking about jet lag, do you talk to people who are constantly going from one place to another about how they might manage their jet lag when you're in travel clinic?

Terri: We do. When a patient comes in for the pre-travel consult, we do find out what exact countries they're going to, how many days in each one of those countries, and if we do anticipate jet lag, we do talk to them about that.

So usually, non-pharmaceutical ways of managing that. Everything from trying to change your sleep cycle to the destination, trying to stay hydrated, trying to sleep when it's dark, and stay awake when it's light. But we do have people that struggle that, especially the frequent flyers that are going back and forth between different time zones.

Dr. Jones: Right. So you can move your clock maybe an hour a day if you use bright light and other thing. So if you're going for three or four days, you're just going to be tired when you get there and then you'll have moved three hours, and you get tired when you get back. And people who have short trips all over, I just hope that they've got a great flight plan so they can sleep on the plane.

Terri: Another factor with the low-budget traveler historically is a little bit higher risk for infections because they are usually traveling similar to the locals where they could be on the bus, they could be staying at lower-end hotels, or be camping. So we have different education for that traveler versus someone who's going to an all-inclusive resort and having everything paid for and high-end food.

Dr. Jones: Well, I have to say that I have a fondness for street food wherever I travel, whether it's Asia or South America. I think the very best food is when you're on your feet walking through a town and you get street food. And I understand the risks involved in eating street food. Are you a fan of street food, Terri?

Terri: Oh, I was a fan before I became employed in travel medicine.

Dr. Jones: Oh, no.

Terri: So I used to eat street food. In Costa Rica, I lived with a family, ate whatever they prepared. But like I said earlier, I did get sick from that. And eating from street food, you have to just realize that the vendors usually don't have access to running water and food. Their plates that they're serving you on might not be clean. So it's a great place to get Hepatitis A and typhoid.

Dr. Jones: And amoebas.

Terri: And amoebas, yes.

Dr. Jones: Oh, no.

Terri: If you don't eat the local food, then you're not necessarily engaging in the culture as you'd like to. So it's a hard call.

Know Where You're Traveling

Thinking about engaging in the culture brings us to the intellectual domain. Many people travel. When I talked about when we stood up and we looked around and we are very curious as a species, we want to learn something new. And going someplace to learn something new, or see some new geography and learn about it . . . I learned a lot about plate tectonics when I went to Iceland.

But when you're going someplace new, you have to learn something about the culture and there are things that you probably ought to know before you arrive.

 

Dr. Jones: Do you help people with some cultural awareness or give them some places to go that they can start reading about behaviors that are inappropriate?

Terri: We used to give out a handout from an organization called CultureGrams, and that would list every country and different social norms, the dos and don'ts. I don't believe we give that anymore, but that I thought was invaluable information. I personally learned in Costa Rica, for example, that if a woman goes to the bar, sits at a bar seat by herself, that means she's a prostitute.

Dr. Jones: Oh, good. That's good to know.

Terri: Yeah. And I unfortunately sat at a bar once. Or if you spend time with a single male alone that that means that you're interested in them, or that . . .

Dr. Jones: Looking for business.

Terri: Looking for business. So it was things like that. CultureGrams would also discussed that if you were a guest in someone's home, what would be appropriate to bring or not to bring? Or, for example, if you were going to Asia, they don't recommend sitting with your feet facing someone. That's a . . .

Dr. Jones: Yes, I read that one. Terri: Yeah. So we do talk to them about that. We do hand out a travel book that we've created at the university. And the very last page, it has essentially 10 recommendations on how to be a gracious visitor to that country. And that does include trying to reduce your environmental impact there.

So for people who are going to go on backpacking or trekking, sometimes they'll think that they can just buy all the water they need and then just toss the plastic bottle somewhere. But a lot of countries with poor resources don't have the ability to discard that plastic. And when you go on treks, whether it's Machu Picchu, you will see a lot of garbage that trekkers have left behind.

Travel, but Remember to Take Care of Your Surroundings

And that fits right in with our environmental domain, because international travel, often . . . in fact, it always has a significant environmental impact because of whatever method you used to get there, whether it's planes or trains, which have a big environmental impact. And then, of course, the stuff you carry and the stuff you leave behind in environmentally sensitive places.

 

Dr. Jones: I think of the Galapagos as being a very popular place to visit, but we've made significant inroads, unfortunately, into the quality of the environment for the animals there. So you have to make some decisions about could you possibly get this on video instead of going there yourself.

Terri: Also, traveling to communities that haven't seen many people from the outside also affects the culture and the community.

Dr. Jones: Yes. We were traveling in Indonesia to some islands that had not seen any white people, Caucasian-Europeans, since maybe World War II. And some people in dugouts came out to the ship that we were on, the little boat, and they had leprosy. So leprosy was still active in that community. And our ship's doc said although we weren't likely to get leprosy, he wouldn't let us off the boat. And they were very curious and, of course, we were all very curious, but we didn't want to do anything to harm them or for them to harm us.

So we bring our diseases with us and we pick up some from where we go. I think that's important in terms of our health.

Finally, as we start thinking about travel, some people travel for spiritual reasons. Have you had anyone decide that they wanted to walk the Santiago de Compostela?

Terri: We have had people come for that, but I'd say our number one spiritual destination is for the Hajj.

Dr. Jones: Of course.

Terri: With the travelers going to the Hajj, a lot of times we'll see these patients as . . . we categorize them as VFRs, which stands for visiting friends and relatives. And that category is a higher risk traveler. That's someone who's usually born abroad, moved to the United States, and then goes back to visit family and friends, but then lives similarly to what they left. And they're usually at a higher risk for infection.

So when we see the folks coming in to go to the Hajj, they're usually not amenable to getting other vaccines besides the ones that are required to go to the Hajj, which would be a pneumococcal vaccine.

Dr. Jones: But they're surrounded by people who are bringing their diseases from all over the world.

Terri: Yes.

Dr. Jones: But it's a spiritual . . . it's one of the pillars of Islam. And people who have made the Hajj, they then are given the honorific of being a haji. So it's an important thing.

Traveling is a Spiritual Journey

I think of the Santiago as a long walking trip in Europe for people who take this walk, and there are spiritual conversations and churches along the way. For many people, a spiritual journey is a walking journey. People who traveled into the desert . . . and we think of our great prophets who walked into the desert to have insight into themselves. And of course, our very own culture has many examples of that.

 

Terri: I also think again of the LDS missionaries. So for these young men and women that are going abroad, that is a spiritual calling for them.

Dr. Jones: It is. Right. So I think people are looking to fulfill a spiritual mission or they're looking perhaps for spiritual enlightenment, and the very nature of just walking ends up being a spiritual practice. So people may travel either short distances or long distances in physical space to make some travel in emotional and spiritual space. Don't you think?

Terri: Absolutely. Another category . . . I don't know where this fits in, but including myself, I enjoy traveling for high adventure sports. For some people, that's a religion. To go rock climbing, ice climbing, skiing, mountaineering, scuba diving in places around the world is a form of religion in my mind.

Dr. Jones: I think so, and they're looking for a very . . . they do something that's very hard. Any time we do something that's very hard, it's transformative. And some people go to climb big mountains is what I think of. Climbing big mountains becomes a religious experience because it takes you out of the quotidian, the ordinariness of your day. And if you can't build it into your daily life where you are . . .

I think of Emily Dickinson, who never traveled, or Thoreau, who said you didn't need to travel and you could get all of your inner work done where you are. But for many people, that's not quite what they're looking for and they do their inner work by doing some outer work.

Terri: I agree with that. I've traveled to some of the bigger mountain ranges around the world, and for those that don't travel, they don't understand why I would need to go see Everest or go see the Andes when I've got my own mountains in United States. So it's a hard question to answer.

Dr. Jones: I think it's a matter of phrasing what your heart . . . helping other people understand what your heart wants and why this is actually something that's very powerful for you.

Terri, tell me about your favorite travel memory and I'll tell you about mine.

Terri: I do have many, so I have to pick one, and one that comes to mind is when I had the opportunity to trek along the Inca Trail. We had to leave our last camp at maybe 3:00 in the morning to arrive for sunrise into Machu Picchu, and so I saw the sun beaming through the gates. And the place was empty because the buses hadn't dropped off all the other thousands of tourists yet. So that was pretty spectacular. I believe a llama came into the scene right at that moment.

Dr. Jones: Oh, that must have been beautiful.

Terri: That was really beautiful.

Dr. Jones: That must have been so beautiful.

Well, my favorite memory is telling my brother, who was in the Peace Corps in Colombia, that I was going to come visit him. I had no way to contact him because he was in the back of beyond. I sent a telegram. I had no idea whether he got it. I got on a plane. I arrived in Bogota. I then got on a little puddle jumper where there were many chickens in seats as there were people and arrived in a town in the middle of nowhere, and I had no idea whether he would be there. And my Spanish wasn't great.

I was looking forward to seeing him and to being in this amazing country. And as I got off the plane, I walked down the stairs and was walking, and I could feel his presence. I looked up at a walk-bridge over my head and he was up there looking at me. It was a powerful sense of how big the world is, but how my heart was just so ecstatic to be there on this trip in this beautiful place.

Terri: And you connected with him.

Dr. Jones: Him and this place together. And that was so special.

Terri: Wow. Wonderful.

 

I think that's part of travel. As we think about who we are as a species, we occupied the earth by just getting out there on our feet, and then we got out there on boats, and now we get out there on planes. But we're still looking for new and higher and different. It's who we are.

Well, we're very grateful to have you join us, Terri. And we're encouraging anyone who's going to someplace exotic, especially during the COVID pandemic, to check in with a travel clinic and make sure that you've got all your business covered, and you've got the right vaccinations, and you know what to do if you get sick.

And of course, if you get sick on the way back or when you come home and are sick, please make sure that you see people who are familiar with where you've been.

Thank you for joining us on the "7 Domains," Terri, and we'll look forward to seeing you in our travels.

We'll wrap it up with a little haiku.

 

All senses turned up
Travel with your feet and heart
To see something new

 

Now, I want to thank everyone for listening. We've been through a winter of a number of episodes, and we're going to take a little spring break. We're going to go out and look at our trees, and look at our flowers, and think about getting closer as we get vaccinated, and that's going to be just great. We're going to be back soon with new episodes.

So for those of you who haven't listened to all of our episodes, please go to womens7.com. And in our first set of episodes, we've covered some very heavy topics. These are topics you might want to share with your daughter, with your mom, with your friends to open up a conversation, because this is really all meant to have a conversation with the women and the men in your lives.

So when does a girl become a woman? It'd be really great for you to share that with an adolescent daughter or with your mom, who tried to figure out if you're ever going to grow up. Or talk about migraine. If you've got someone who really should listen to a little bit about migraine, struggling maybe like you with migraine, it gives you a platform on which to have a conversation.

And of course, the 7 Domains of Love lets us think about our love language. If you're having a hard time talking with someone you love about love, have them give a little listen and maybe you'll be able to talk about your love language.

And of course, while you're thinking about travel either to interior or exterior spaces, you can enjoy our travel plan, one that we're just finishing. So this is an opportunity to share. We'd love it if you'd share and let it launch a conversation for the women in your lives.

So we're going to take a little time off and be creative while we grow new wonderful things in our garden, and we will be back soon.