The following outline should be studied in conjunction with my culture shock outline. Many of the points in that outline are relevant to this topic but will not be repeated.  Paul Assad

Long-term travelers and Expatriates

Long-tern traveler applies to those who have or are planning the take residence in a foreign country for more than 6motnths. Expatriate would apply for a stay between 6 months and longer. Important health factors must be taken into account in the assessment of the long-term travelers. Many of these are different from short term or tourism travel. I will try to outline these in the following outline.

Long-term  travelers  are made up of quite an heterogeneous population:

• Missionaries
• Consular staff
• Geologists    
• Relief workers
• Corporate Employee
• Government

Pre-departure stage

1-Pre-departure medical preparations:

• Thorough medical assessment should include
• Detailed Medical History
• Complete physical
• Lab examinations ( CBC-Full chemical panel- HIV-PSA Lipid profile.
• TB skin test Chest film
• ECG Dental assessment.
• Necessary vaccinations
• Review of current health recommendations for the area of travel.

2-Pre-departure travel preparations:

• Special work visas.
• International driving license
• Special reading on local laws and customs.
• Decision on renting or selling home in Canada
• Contacting agency that will help with finding a house at the other end.
• Special items to pack: converters-clothing appropriate for destination climate-photocopies of all important documentation( passport, visas, permits, medical dental records, blood type cards, birth certificates, custody forms, social security cards etc..)
• Inventory list or videotape of possessions being shipped overseas.
• Selection of reliable shipping company. Ship early.
• Notification of move to postal service, Income tax department.
• Selection of trusted person who will take care of outstanding bills to come after departure.

Embassy / consulates:

Long-term travelers should register with local consulate ( can be done on the Internet). This will permit them to contact the traveler in case of security issues, or natural disasters.

Once in a foreign country one is subject to the laws of that country. Canadian citizenship does not protect travelers who bring the law in a foreign country

Women’s health:

• Full gynecological evaluation ( PAP – Ultrasound Pelvis- Mammogram)
• Contraception counseling including source of contraception products .
• Discussion re post coital contraception – STD – Post exposure prophylaxis.

• Pregnant woman, particularly with gestation greater than 5 months, may want to defer expatriation until after the delivery or consider establishing contact with a good obstetrical facility inside  or outside the country of destination.

Child health:

Children will also need complete assessment by their family Md. or pediatrician. With intensive intercultural exposure and counseling, most children will adapt well to living in foreign cultures. Teenagers may have more difficulty. Leaving friends and family- changing schools- learning a new language may be resisted by young people. The advantages of this type of experience may not be obvious to them. In general children will have the same number of illness that would have at home with the exception of diarrhea. Good living accommodation, a well controlled diet, health screening of servants, up to date vaccinations will help keep children healthy.

Schooling:

Relationship problems: Choosing a school for children is important. Choice include local school, private international school , “American” style school, home schooling.

Relationship issues:

Moving and traveling abroad and brings considerable psychological stress for both members. The employed spouse has the stress of a new position while the other spouse ( often the mother) is left to deal with all of the family obligations from findings schools, hiring servants, leaving friends and family, new accommodations, hosting strangers, and many other every day tasks. All of this places stress on even the strongest of  relationships.  The couple may even be separated for many months when the employed spouse leaves by himself. Therefore the stability of the union must be considered when deciding on accepting the foreign posting.

Psychological problems:

Psychological issues are the most likely problems leading to premature return. In the corporate world 25% to 40 % of expatriate staff fail to complete  their overseas tour. This leads to added expense, reduced investments, loss of valued employee. Psychological screening prior to departure can help reduce these losses. However testing is not always accurate and can lead to legal challenges against the company  by employees who have been denied the advancement of foreign posting.  Counseling on issues of culture shock and reverse culture shock helps to reduce losses. Certain psychological conditions such as obsessive compulsive and bipolar disorders have been known to be associated with greater risk.

HIV issues:

HIV testing requirement varies depending on the destination. It should always be done before departure in order to reduce risk of contamination and false positive  because of poor laboratory control.

HIV testing should be accompanied by risk avoidance counseling. A negative test is reassuring and can be used for control.

Although devastating, it  is better to detect a positive result before travel. HIV positive individuals might be excluded from overseas posting, low CD4 counts should not leave.

STD issues during travel :

Major risk of HIV while living abroad continues to be unprotected intercourse and exposure to poor local health care systems. Stress, loneliness, anonymity, relaxed restrictions, easy access to prostitutes,  may lead to promiscuity and increase high risk sexual contacts.

Health and Medical Issues:

Health care overseas:

Selection of medical practitioner and hospital; Try to get the best available: American style, private, local, military, missionary hospital.

Travel health insurance that covers you for extended length of stay and all services needed including evacuation.

Obtaining prescription medication may be a challenge: Drugs may not be legal or available in the country or the pharmacy may not have the same high quality pharmaceutical standards as in Canada. Extra supplies may need to be brought by visitors or mailed. Generic names should always be noted on the prescription.

Vaccinations:

The need for vaccinations tend to be broader in the long-term traveler. If there is doubt, further vaccinations can be administered on arrival.

Tropical diseases such as Malaria:

Special considerations should be given to malaria. It is often difficult to convince the long-tern traveler of the risk of malaria and the need for prevention. Groups such as missionaries and relief workers are a special challenge.

Chemoprophylaxis compliance is often difficult and malaria outbreaks in expats often follow poor compliance. Expats will often take chemoprophylaxis on a seasonal basis or when traveling to zones know for high attacks rates of malaria. The choice of medication may also not be satisfactory. Older, less effective pharmaceutical agents may be chosen more of the basis of tradition, or  general acceptance by the expat community, versus medically acceptable medications.

Important strategies of mosquito avoidance with proper screening, netting, repellant, insecticides, avoidance of mosquito  feeding times, should be followed.

Environmental Hazards:

Air and  Soil Contamination ( chemical – pollutants- radioactive byproducts-heavy metals- smoke)

Security

When working overseas in an area of risk one should take special precautions against  terrorism, kidnapping, robbery ,etc.. Special security briefing and training may be indicated. Keeping a low profile, carefully selection of hired domestic help, avoiding remote areas, using alternate routes, avoiding expensive cars, clothes, and teaching children safety habits will help minimize the risk.

Transportation:

• In order to minimize accidents,
• Consider using  sturdy private vehicle in good working order
• Use of local driver.
• Avoid night time and bad weather driving.
• Avoiding main roads.
• Avoid local buses in poor working order
• Avoid scooters/bikes.
• Use seat belts
• Avoid alcohol/drugs
• Choose small aircraft companies carefully.

Drowning prevention:

• Avoid alcohol
• Swim in safe life guarded ( not always assured) areas.
• Avoid night swimming
• Use of life vests.

Alcohol and drug abuse

• Any substance abuse should disqualify a person from overseas assignment.
• Still, high number of expatriates exhibits substance abuse problems. Ranks among the highest reason for medical referrals.
• Lead to worsening of chronic medical conditions,
• Poor work performance
• Increase arrests and legal problems ( jail time or even execution in some countries).
• Increase chance of premature termination of contract.
• Increase STD contacts.

Return Health Assessment:

On return a medical assessment should be performed:

• Medical history of health status overseas
• Physical exam
• Lab examination depending on medical history-  signs and symptoms-  – exposure – illness abroad- ( no routine asymptomatic  testing)
• TB skin test
• Chest x-ray if indicated
• Psychological debriefing.