Unfamiliar germs in food, water and air can spread.
Kevin Keogh spent the morning doing ordinary chores. By afternoon, he was climbing out the window of his Mercedes and onto the roof as it sped down a busy street. Standing on top of the car, his arms outstretched as if he were surfing, he jumped to his death
What would make the chief financial officer for the city of Phoenix do something so bizarre?
A leading theory is a parasite he caught on a trip to Mexico several years earlier. The bug can live for years inside the body, travel to the brain and cause seizures and hallucinations -- symptoms Keogh started suffering a few months after his trip.
His death in December is an extreme example of an exotic illness picked up in a foreign land. It's a goes-with-the-territory downside that many people underestimate when they venture into territory far from their back yards.
American travelers made more than 56 million foreign trips in 2003, up from more than 44 million a decade earlier. They often bring back germs that can take weeks or months to cause symptoms and diseases, which American doctors may be slow to recognize.
It took eight months for doctors to figure out Keogh's illness, said his wife, Karlene. A blood test showed he had cysticercosis, a parasitic illness often acquired from undercooked pork and common in Latin and Central America. The Maricopa County Medical Examiner's office is awaiting more tests to determine whether that led to his death.
"He was in excellent health, otherwise. Whether he was in his right mind or not, no one can say," said Dr. Rebecca Hsu, who is handling the case. "I do believe something horrible happened to this poor man."
Keogh had traveled to a remote part of Mexico to explore artifacts and ruins, which he loved. A growing number of Americans are traveling overseas and to more non-traditional tourist destinations.
"Paris, London, Rome used to be exotic travel," said Dr. Phyllis Kozarsky, an Emory University professor and senior travel health consultant to the federal Centers for Disease Control and Prevention. "Now people want to outdo each other" by heading for more obscure destinations.
Usually, the risk is limited to the traveler because most germs aren't easily spread person-to-person, Kozarsky said. But SARS showed some germs can affect public health. Another example is American travelers who returned with malaria, which was then passed onto mosquitoes that bit them back home in the Carolinas, New York City and Palm Beach, Fla. These mosquitoes then bit local residents who had no reason to suspect they had a tropical disease because they hadn't gone anywhere tropical.
Some illnesses are especially harmful to children, said Dr. Tina Tan, medical director of the travel clinic at Children's Memorial Hospital in Chicago.
"We've seen kids come back with malaria," and unusual spider or insect bites, she said. "A lot of times they go unrecognized for a while because they're going to their pediatrician or family doctor, and they don't think about exotic diseases."
Illness can be more annoying than the easily treated "travelers' diarrhea" that develops in half of all people who visit a developing country for two weeks or longer.
A Minnesota town is the namesake of Brainerd diarrhea, first identified there in 1984. Dr. Robert Tauxe, head of foodborne illness at the CDC, calls it "diarrhea for life." It sickened 200 people on successive voyages on a small boat around the Galapagos Islands in 1992. A 1998 report on the outbreak found many still suffering from it.
"We've studied it extensively, but to this day we don't know the cause of this yet. We don't know if it's a virus or bacteria or what," Tauxe said.
Mary Steigerwald, a Phoenix nurse who is vice president of communications for Ottawa University, knows that kind of misery. Doctors think she got a parasite on a trip to Asia, where she felt pressured to eat things like shark-fin soup at business meetings. She had diarrhea for 18 months.
"I went through eight different courses of antibiotics. Nothing could stop it," she said.
Tauxe teases his sister, Lisa Tauxe, a geologist at the Scripps Institution of Oceanography in La Jolla, Calif., who got hepatitis from a trip to Africa. She doesn't know what did it: the miniature zoo in the water she swallowed while windsurfing in a polluted bay or the raw sea urchin she had afterward.
"It walked across my plate as I was trying to eat it. It's sushi. It's stupid. I don't do that anymore," she said.
Flirting with danger
The boom in extreme travel and adventure tourism has some health experts worried.
"Many people feel that their lives are overly routine, overly bureaucratized, that they're constrained by institutions," said Lori Holyfield, a University of Arkansas sociologist who has studied people who seek ultimate experiences like rock-climbing in remote places. "They don't want real danger, just the feel of flirting with it."
But they often get more than they bargained for. A whitewater rafting expedition in Costa Rica in 1996 gave five rafters leptospirosis, a serious disease that can lead to organ failure. It's caused by rodent urine contaminating water.
A bigger outbreak of it occurred in 2000, when more than 100 people from around the world competed in an endurance event called EcoChallenge in Malaysia. Health officials at first had trouble figuring out what sickened them because of the endless possibilities: competitors had swum in rivers, crawled through bat-dung-encrusted caves and hiked through jungles where everything from malaria to tsetse flies were present.
Adventurous hunters and fishers have to worry, too.
A few years ago three Wisconsin hunters got trichinosis from eating the meat of a bear they'd shot in Alaska. Bear meat is notoriously full of parasites.
Don't let down guard
Sometimes exotic illness does public health a favor. The germ cyclospora, recently linked to raspberries from central America, was first identified in the early 1990s in people on a high-altitude expedition who got sick on lettuce.
"We're very grateful both to the hikers and the lab and the clinic people in Nepal," Tauxe said.
But besides these germs, there are more mundane hazards: Accidents are the leading cause of medical problems involving travelers, said Dr. Michael Zimring, director of the Center for Wilderness & amp; Travel Medicine at the Mercy Medical Center in Baltimore.
Dr. Ben Koppel, medical director of Medex Assistance, a Baltimore-based travel insurance firm, tells of having to airlift a woman out of Tibet who had been riding in a Jeep that went off the road.
She suffered a punctured lung, made more serious by the blood-thinning medication she was taking for heart problems. The nearest hospital was portrayed on the Internet as being a top-tier facility, but it turned out to have no blood bank, X-rays or 24-hour care, let alone sterile needles.
"We took her to Bangkok, which has excellent medical care," Koppel said.
"The moral of the story for adventure travelers is, you go to places that you might think have facilities and you find out the facilities are horrific. Even in Italy there are hospitals where the nurses go home at night. There's no staff."
The woman's medical evacuation cost $75,000, covered by her $4-a-day travel insurance plan. Even an air ambulance from the Caribbean to Miami costs $11,000 to $15,000, Koppel said.
Many travelers don't even check their insurance coverage ahead of time, and most policies don't cover medical care abroad -- Medicare doesn't.
Many travelers also don't get vaccines or medications to prevent illness.
If you do travel, experts say you shouldn't let your guard down on the way home.
Food on the plane usually comes from the country you visited, not where you are going.