221
IMPLICATIONS TO INDUSTRIAL ORGANIZATIONS
N. W.
ASHWORTH, M.A., M.B., B.CHIR., D.I.H., Senior Medical Adviser, Shell International Petroleum Co. Ltd. ALTHOUGH worldwide colonial connections and have dwindled considerably since the JL last war, great numbers travel regularly overseas on behalf of employers, or live abroad as expatriate employees of International Companies or advisers to overseas Governments or commercial enterprises. Conversely, with growing participation of foreign nationals in their own affairs, regional employees of International Companies and their own Government agencies are being sent overseas for periods of residence on training assignments. As an example of this, at the present moment there are approximately 10,000 expatriates working in Lagos, and in one oil company’s operations in Turkey, staff of 18 different nationalities are employed. Many Britons are seeking variety and higher material rewards abroad, and to maintain overseas earnings, successive Governments urge us to promote our export drive. &dquo;Export or Die&dquo; has been a political catchphrase. In health care for itinerant employees we must ensure that the paraphrase &dquo;Export and die&dquo; does not result.
obligations
HEALTH SELECTION AND EDUCATION FOR TRAVELLERS overseas on short trips, and especially for employees and families assigned abroad for contracts of several years, it is obviously good sense, for all parties, to screen carefully their state of health. The physical and mental strains associated with life in an alien country vary greatly, depending upon the climatic, political, cultural and social environment. A varying standard of medical services is available to treat any breakdown in health, both from country to country and often in different areas of one country. When suffering ill health in a strange land, the natural anxieties attendant upon ill health are compounded by the need to seek medical treatment from a foreign medical service possibly with language difficulties and misunderstandings, and a different style of dispensing medical attention and handling patients. In practical experience, one usually finds a male employee, on a bachelor posting. overseas, is quite willing to take his chances with local medical care, particularly if he is well checked before his overseas assignment. When he takes his wife, and particularly young children, a heightened anxiety about standards of medical care available immediately becomes apparent. This is understandable, as young children are likely to develop sudden, unexplained illness such as high fevers. Such episodes occurring where there is inadequate or tardy medical opinion available can be the last straw for an inexperienced and apprehensive young expatriate family, and may precipitate a resignation by the employee and return to the known conditions in his own country.
In the author’s particular organization, it is routine policy to examine international staff and dependants every two years. Where a change of posting occurs within this interval, complete examination is carried out if one year has elapsed since the previous check, where less than this, a medical interview is conducted with the he is questioned about possible medical employee when problems which may have arisen with himself or his family. Such examinations and interviews are best carried out by medical advisers with experience of living and practising in various overseas terriroties, and particular experience of the physical and social conditions that candidates are being assigned to. A first-hand knowledge of such conditions and of the differing environments is an pattern of disease in different invaluable asset that can be added to the service one provides to one’s associates. A doctor with such experience not only has a better understanding of the style of life his patients are going to, but also will be in greater accord with them and be more credible. In addition, a first-hand knowledge of medical facilities available in various countries and their capabilities, whether private practitioners and clinics, state medical services, or occasionally Company hospitals and clinics, will help to avoid wishing an unreasonable medical burden on these medical services often hard pressed with their own problems. Finally, a serious or long-term breakdown in health of the employee or family will inevitably cause upset and collapse of morale for all, and considerable expense. Such an event will necessitate evacuation of the whole family for definitive investigation and treatment of the sick member. Often, the expenses for such -
event are willingly met by employing organizations. Naturally, they are keen for their employees to be carefully screened, to avert such an event, for it will result in disruption of career planning for the individual involved and also his employing company. While an alternative space is being found in the organization at an
short notice, a man’s career progress can be held up for much as two years. It must be emphasized that the above consequences will usually follow when an accompanying wife’s health breaks down, for prolonged separation from an ill spouse is not usually acceptable to employees and indeed is not encouraged by enlightened employers. Many changes in overseas conditions have occurred in the twenty-five years and physical conditions of life have generally improved considerably. The almost universal introduction of air conditioning to the living and working environment in hostile climates, together with much better quality and more varied fresh and chilled foods available in most countries, and improved communications and transport, have combined to make as
last
Downloaded from rsh.sagepub.com at QUINNIPIAC UNIV on March 22, 2015
222
healthy for all. Notwithstanding physical hazards still exist and can provide a nasty surprise for the unwary or imprudent. Not all employees will enjoy comfort of air life abroad
more
agreeable
and
these advances,
conditioned offices to work in, and may have to cope with the adverse climate of a brilliantly hot desert where temperatures up to 55°C occur and sand penetrates into everything, a steaming hot jungle with 100 per cent humidity where clothing and belongings go mouldy, or the fierce cold of the Arctic. Other physical hazards include sharks and sea snakes, whether one is an offshore diver or merely relaxing in the sea. Snakes, scorpions and other hostile species can be a background worry, despite the small number of encounters that in practice occur. More serious and real medical hazards areposed by such widespread diseases as malaria, which is increasing at present, a variety of gastrointestinal diseases and infestations, filariasis, bilharzial infestation and sleeping sickness. More recently, Lassa Fever and Marburg’s or Green Monkey disease, have produced a degree of apprehension out of proportion to its real prevalence and the actual chances of overseas travellers or residents contracting the disease. A sensible, well informed approach to health in overseas locations is essential and adequate education of employees will pay dividends for any organization with staff going overseas. At any medical examination or interview the opportunity should be taken to give individual counselling in these matters and allow individuals to clear any doubts they may have with an experienced medical adviser. Many organizations supplement this with booklets about various areas containing general hints on health, and with special information courses for its employees and their wives, to impart background information on the area to which they are assigned. In many cases, larger companies will run courses themselves, or alternatively such organizations as the Centre for International Briefing at Farnham Castle supply this need. Topics covered will be the language, culture, politics, history and customs of the Area, as well as general health advice. Comprehensive advice on immunization and health protection is an essential function of employers who are nowadays expected to provide such services before exposing their employees and dependants to predictable health hazards. Most individuals readily accept
protection against Typhoid/Paratyphoid and
Smallpox,
Cholera,
Yellow Fever, but complamet with is often concerning immunization cency against tetanus and poliomyelitis. This must be kept up, as tetanus is worldwide and poliomyelitis is endemic in many overseas territories. Routine administration of human immunoglobulin against infective hepatitis is advocated by many for travellers visiting many countries and for short assignments in certain areas. For longer stays abroad, administrative difficulties occasionally prevent follow up or individuals may not be keen to continue with comparatively large injections every six months. Similarly, with the advent of better anti rabies vaccines, immunization for those living in areas of high endemicity, or in regular contact with warm-blooded mammals, may become routine. Malaria prophylaxis is essential for those posted to malarial zones or even travelling briefly through such zones. In practice, scepticism is sometimes found in expatriates living in malarial areas, who for a variety of reasons, usually specious, do not see the need to take such pills. It is the more necessary for employing organizations continually to remind their members of the danger of malaria, and the need to adhere scrupul-
ously to the advised prophylactic regime. In some companies it is policy to circulate letters to employees, at least annually, reminding them of the reality and hazards of malaria, particularly the Plasmodium Falciparum strain the so called malignant variety and the need to take appropriate measures. They are also reminded of the hazards to schoolchildren flying out to the Tropics for their holidays, and the need to send them back to school in Europe with a month’s supply of pills even if they have only spent one day or an hour in transit through an infected area, and a note to the Scool Matron with instructions for continuation of prophylaxis, reminding them of the possibility of malaria developing despite all precautions. Unfortunately, no single drug seems yet to be the ideal preventive treatment for all four species of malaria, and all parts of the World. The author’s particular Company has settled on a policy of advising Proguanil, of &dquo;Paludrine&dquo;, as its single, worldwide prohylaxis. One tablet daily is given to the average adult, and an appropriate dose for children, -
-
and in certain areas, where infestation with P. Fal-
ciparum is particularly rife, or reports of drug resistance occur, this dosage is doubled. A very good resume of considerations of fitness for travel and medical assessment for living in warm climates is given in Dr. Anthony C. Turner’s book Travel
Medicine I, and a detailed consideration of these criteria is
beyond the scope of this paper. Any assessment of individuals’ fitness for life overseas must take into account the following factors :1. Fitness for the Journey In practice, this is rarely an obstacle except in the case of evacuation to home country following ill health or accident. For short term business travellers in particular, due account must be paid to the abnormal environment of air travel, with a mild degree of decompression usually equivalent to an altitude of 5,000 to 8,000 feet, relative dehydration of the cabin’s atmosphere, the fatiguing effects of crossing several time zones and the tiring experience of physical confinement for several hours. Most companies now realize the value of advising a complete rest for 24 hours after a journey involving 4 or 5 hours time change, though such sound and practical advice is often ignored by high-pressure tycoons spurred on more by business motivation than by elementary prudence and concern for their own health and the quality of advice they may contribute in their state of circadian disarray. Also, in an effort to increase the efficiency of their more senior employees, the discomforts of long flights are mitigated by the company sending their representatives by first-class travel. Some companies also grant this facility to all individuals of unusual dimensions, for example all employees of 6 feet 5 inches or more in stature. z
2.
Simple Physical Effects of Climatic
Environment
Often, when considering overseas assignments, tropical conditions are thought of, as most developing countries
are situated in the Tropics. However, other climatic variations must be remembered including hazards of extreme cold. In a paper to the International Association of Physicians for the Overseas Services in 1974, Dr. J. G. Clothier described the extreme and dramatic hazards for people working in the oil industry on the shores of the Arctic.2In practice, simple physical effects of climatic variation are seldom a practical bar to travel or
employment
Downloaded from rsh.sagepub.com at QUINNIPIAC UNIV on March 22, 2015
overseas.
223 Some examples are certain infected skin conditions, which are exacerbated by hot sunlight and excessive sweating. Skin cancers may be a reason to advise against living in areas with high ultra violet irradiation, particularly for those with notably fair complexions. Certain cardiovascular disease cases are poor risks for overseas service; uncontrolled hypertension or cardiac failure and recent myocardial infarcation are examples. Recent tuberculous infection is usually a contraindication to transfer, while asthma needs very careful evaluation. Certain notoriously smoggy areas such as the the Tokyo-Yokohama area have a generally adverse effect in such cases, though the relative merits of a dry desert over a humid jungle land are not always predictable. Diabetes and thyrotoxicosis are usually a contra-indication, unless mild and very well controlled. Depression, particularly in parochial-bred wives, is a very poor risk, as is alcoholism.
3. Medical Services Available This is usually a much more significant factor in selection. Many medical conditions, with a good prognosis, are not a bar to life overseas, provided the medical services available are adequate to continue proper surveillance and react adequately to any emergency that may arise. Examples of such borderline cases are diabetes, hypertension, chronic neurological conditions, chronic gastro-intestinal disease such as dyspepsia, malabsorption syndrome and quiescent Crohn’s disease, and apparently-cured malignant disease. A sometimes forgotten group is that of merchant seamen who are exposed to a peculiarly isolated environment, where they may be dangerously out of reach from expert medical care for much of their working lives. Precise notes for guidance are published by the General Council for British Shipping.3 One particular condition which is often underrated by general practitioners and some specialists, is active peptic ulceration, where sudden haemorrhage or perforation could prove rapidly fatal in the middle of the Pacific Ocean. Another condition which usually precludes return to deep sea life is myocardial infarction. Even where a good recovery is made, the increased chance of further thrombosis occurring far from medical assistance, particularly if anginal pains are occurring, render a return to deep sea service unwise. 4. Mental Strains of Overseas Service The stresses and strains inherent in living and working abroad in an alien environment must not be underrated, and indeed only an experienced observer who has lived overseas and observed his expatriate colleagues can fully appreciate the subtle pressures that can so easily lead to a breakdown of morale and health. Careful selection of individuals for life overseas must be a routine procedure for both medical departments and personnel functions. Although we have considered the physical factors, which in many cases have improved over the years, changes in the social, cultural and political environments all over the worl have changed rapidly in the recent past, and in many cases for the worse. In many countries, stable colonial regimes existed where the European expatriate enjoyed a unfairly favourable style of life, surrounded by an insulating community of his own kind and a familiar social way of life. Where his employers maintained an
perhaps isolated
expatriate community or camp, an entirely European way of life was preserved, and the Government of the
country made little inroads into his life.
Many individuals in such communities never bothered to explore a fascinating and interesting country to make
any contact with the local inhabitants except to employ servants whom they trained in European ways and dealt with very much on their own terms. Now in many areas, all this is history and today’s world is different. Much as the assistance of servants is welcomed, particularly by wives and couples with young children, this can lead to boredom for a wife who no longer has housework or a job to occupy her time. It may be difficult to obtain a diverting job, for work permits may not be granted to temporary residents unless they have unique skills or experience to offer. Time can hang heavily on a wife’s hands despite attendance at the camp’s coffee, mah jong and gossip circuit or handicraft classes and yoga sessions, and minor irritations and frustrations become magnified in her mind. The husband has at least got his own job every day, and the company of his colleagues similarly occupied. Where a wife is isolated from friends or does not have ready access to her own transport, this can lead to a rapid decline in her happiness and morale and poorly corrected eyesight may preclude the issuing of a driver’s licence in some countries. For those who have never travelled very far previously the sight, sounds and smells of an overseas market, bazaar or ’souk’, can be an
overwhelming experience.
Other potent factors may be separation from her own mother and family, or from her own children at school in their home country. With the spread of independence all over the world, many countries are now notable for a degree of illconcealed hostility to foreigners or in extreme cases, outright resentment of them is manifest. In many countries, particularly with different religious faiths, it is easy to give offence in all innocence and ignorance. For sensitive and considerate individuals the possibility of offending in this manner can be a constant worry, while standards of justice vary considerably, and it is perfectly possible to land in a gaol of mediaeval proportions for a traffic offence that would scarcely merit a licence endorsement in Britain, or be summarily ejected from the country. In screening applicants, one is looking for well balanced individuals with a sense of proportion, sensitivity to other people’s points of view and patient understanding. Perhaps the most valuable gift for survival in alien environments is a sense of humour under all circumstances, and in certain situations slightly &dquo;mad&dquo; individuals do very well, but only those with a very special type of eccentricity and not the medical brand of
psychoneurosis. As adaptability to a changed environment, including mental and physical resilience, is a pre-requisite, one has reservations about allowing applicants who are over forty years old to work in the Tropics or other strange
countries for the first time in their lives. Previous successful service is a good guide for allowing people to continue in overseas postings indefinitely, provided they are fit in all respects. Nevertheless, one has observed a tendency in middle age for ideas to become fixed and particularly employees who have been in one posting for many years may become resentful of the changes going on round them. As more influence passes to Goverment activities and more regional staff assume senior positions in their company they miss the &dquo;good old days&dquo; and deplore the speed of regionalization policies. Often the most practical and kind move for all is to cross-post them to a fresh overseas assignment or return them to their home country. Any previous history of mental instability, neurosis or psychosis needing treatment, should be regarded
Downloaded from rsh.sagepub.com at QUINNIPIAC UNIV on March 22, 2015
224 with the greatest reservation. Overseas experience has shown that individuals with previous histories of depressive or schizophrenic tendencies, however well cured they may appear to be, tend to do badly when moved out of their normal home environment. Even some specialist psychiatrists are apt to consider that the refreshing challenge of a new job, perhaps with promotion, a more attractice salary and tropical sunshine will be a tonic to such candidates. Unfortunately, the reverse is more frequently the case, and a breakdown of mental health often soon follows arrival overseas. Provision of Health Services As noted previously, the quality of medical services varies from country to country and within a country. For companies with activities overseas, constant account must be taken of the availability and standard of medical services in its various areas of operation. Adequate services are a positive requirement to ensure the efficiency of the business, quite apart from humanitarian reasons. The availability of good medial treatment is a strongly positive morale factor in attracting staff to otherwise isolated locations. This is particularly so when a company wishes to attract and keep specialist expatriate staff, combined with provision of schools for children up to 10 or 12 years, good company housing and a personnel department which can help to smooth the problems of a newly arriving family adapting to a strange country. Such provisions are the &dquo;silent&dquo; part of an expatriate’s contract of service. Where operations are on a small scale, as in a marketing organization, employees will use existing medical services, often engaging a local doctor of repute as a part-time medical adviser and making arrangements with a local private or government hospital. Where activities are on a larger scale such as a steel
plant, pharmaceutical factory, major oilfield, refinery petro-chemical complex, the company may provide medical services of its.own, ranging from a simple occupational health clinic with nursing and ancillary staff and a part-time medical adviser, up to hospitals with specialist physicians, surgeons and other full time or
medical officers, and branch clinics in the main areas of activity. Companies providing such a comprehensive health service do so because of a need to have an occupational health service for its employees and to provide total medical care for the employees and their families who may be living in an isolated and undeveloped area. Naturally, such a wide ranging service is an expensive burden on any commercial organization which does not wish to compete with the wider obligations of a state’s medical services to its’own citizens and other temporary residents. Where full time company medical officers are emregular communication with headquarters keeps senior medical advisers informed of standards of medical services in the immediate area. In order to keep continually informed about standards elsewhere, it is common policy for headquarters medical advisers to make regular visits to various parts of the world. On these visits, local doctors are met and various hospitals visited in order to obtain first hand judgment of the quality of medical attention available to staff and families. It is sometimes discreetly possible to assist the for example by advising Managestandard slightly ment of the local company to donate an item of badly needed medical equipment to a selected hospital or clinic, or make a cash donation.
ployed,
-
Medical Evaluation and Treatment in Home Country Where extensive medical or surgical investigations and
treatment are required, it is common policy for employers to recommend that this be done in the patient’s
home country wherever this may be. The timing of this obviously depends upon the severity and urgency of the condition. Prolonged periods of sickness or post operative convalescence are not to be encouraged in a country strange to the patient. In addition, as mentioned previously, illness in a strange country can provoke unreasoning apprehension in the patient or especially in the spouse or parents, and it is often much better for everyone’s peace of mind to evacuate the patient at an early stage despite the adequacy of medical facilities on the spot. Cold surgery and routine investigations are usually arranged during expatriate families’ home leave. In view of the need to obtain specialist appointments and treatment without delay, it is common for many international organizations to provide private medical insurance for all its international staff, often in a bulk scheme, with one of the major insurance schemes under
special
terms.
Where
more urgent medical problems crop up, employees or dependants are flown to their home country.
In many cases, medical escorts are necessary to accompany patients. This is particularly necessary. for psychoneurotic problems, even quite mild cases, or alcoholics, whose behaviour during aeroplane journey may be quite unpredictable. Large organizations often supply their own nursing sister or medical officer for this purpose, but where this is not possible, specialist organizations exist to help with such cases. Three such examples in the London area are :1. Transcare Limited. 2. St. John Ambulance Aeromedical Section. 3. Europ Assistance Limited. In really calamitous, but fortunately rare situations, it is possible for them to obtain a charter aircraft with a surgical or medical team with full equipment, and be airborne to any part of the world within a very short time indeed. A variety of aircraft may be used, ranging from an HS125 or BAC111 up to a Comet or Boeing 707, depending upon the distance. Naturally such a remarkable service costs money, and the usual mode of evacuation for even comparatively acute cases is by scheduled airline services with medical escort where necessary. For medical evacuation around Europe fast &dquo;low profile&dquo; ambulances may be used, such as Citroens of Pontiacs by one company. Although expensive evacuation by private transport is seldom resorted to, it is reassuring for indivuals serving away from their home country to be aware of the existence of such facilities. A very real and growing hazard all over the world is the possibility of severe injury in a road accident. The knowledge that promp evacuation to their accustomed surroundings for long-term treatment is a source of comfort to all. For employees working in their home country all over the world, industrial organizations are concerned to see that they normally receive the best of medical treatment locally available. In certain cases, where highly specialized treatment is not available, companies assist their employees in obtaining suitable treatment in another country where this may be obtained. REFERENCES 1 TURNER, A. C. 1975 Travel Medicine, p. 161. 2 CLOTHIER, J. G. November 1973 Minutes of International Association of Physiciansfor the Overseas Services. 3 General of British Shipping, August 1976 Medical and Visual Standards. These papers were presented at a Conference of the Society held in London on 31 March 1977.
Council
’
Downloaded from rsh.sagepub.com at QUINNIPIAC UNIV on March 22, 2015
.
t.
IMPLICATIONS TO INDUSTRIAL ORGANIZATIONS
N. W.
ASHWORTH, M.A., M.B., B.CHIR., D.I.H., Senior Medical Adviser, Shell International Petroleum Co. Ltd. ALTHOUGH worldwide colonial connections and have dwindled considerably since the JL last war, great numbers travel regularly overseas on behalf of employers, or live abroad as expatriate employees of International Companies or advisers to overseas Governments or commercial enterprises. Conversely, with growing participation of foreign nationals in their own affairs, regional employees of International Companies and their own Government agencies are being sent overseas for periods of residence on training assignments. As an example of this, at the present moment there are approximately 10,000 expatriates working in Lagos, and in one oil company’s operations in Turkey, staff of 18 different nationalities are employed. Many Britons are seeking variety and higher material rewards abroad, and to maintain overseas earnings, successive Governments urge us to promote our export drive. &dquo;Export or Die&dquo; has been a political catchphrase. In health care for itinerant employees we must ensure that the paraphrase &dquo;Export and die&dquo; does not result.
obligations
HEALTH SELECTION AND EDUCATION FOR TRAVELLERS overseas on short trips, and especially for employees and families assigned abroad for contracts of several years, it is obviously good sense, for all parties, to screen carefully their state of health. The physical and mental strains associated with life in an alien country vary greatly, depending upon the climatic, political, cultural and social environment. A varying standard of medical services is available to treat any breakdown in health, both from country to country and often in different areas of one country. When suffering ill health in a strange land, the natural anxieties attendant upon ill health are compounded by the need to seek medical treatment from a foreign medical service possibly with language difficulties and misunderstandings, and a different style of dispensing medical attention and handling patients. In practical experience, one usually finds a male employee, on a bachelor posting. overseas, is quite willing to take his chances with local medical care, particularly if he is well checked before his overseas assignment. When he takes his wife, and particularly young children, a heightened anxiety about standards of medical care available immediately becomes apparent. This is understandable, as young children are likely to develop sudden, unexplained illness such as high fevers. Such episodes occurring where there is inadequate or tardy medical opinion available can be the last straw for an inexperienced and apprehensive young expatriate family, and may precipitate a resignation by the employee and return to the known conditions in his own country.
In the author’s particular organization, it is routine policy to examine international staff and dependants every two years. Where a change of posting occurs within this interval, complete examination is carried out if one year has elapsed since the previous check, where less than this, a medical interview is conducted with the he is questioned about possible medical employee when problems which may have arisen with himself or his family. Such examinations and interviews are best carried out by medical advisers with experience of living and practising in various overseas terriroties, and particular experience of the physical and social conditions that candidates are being assigned to. A first-hand knowledge of such conditions and of the differing environments is an pattern of disease in different invaluable asset that can be added to the service one provides to one’s associates. A doctor with such experience not only has a better understanding of the style of life his patients are going to, but also will be in greater accord with them and be more credible. In addition, a first-hand knowledge of medical facilities available in various countries and their capabilities, whether private practitioners and clinics, state medical services, or occasionally Company hospitals and clinics, will help to avoid wishing an unreasonable medical burden on these medical services often hard pressed with their own problems. Finally, a serious or long-term breakdown in health of the employee or family will inevitably cause upset and collapse of morale for all, and considerable expense. Such an event will necessitate evacuation of the whole family for definitive investigation and treatment of the sick member. Often, the expenses for such -
event are willingly met by employing organizations. Naturally, they are keen for their employees to be carefully screened, to avert such an event, for it will result in disruption of career planning for the individual involved and also his employing company. While an alternative space is being found in the organization at an
short notice, a man’s career progress can be held up for much as two years. It must be emphasized that the above consequences will usually follow when an accompanying wife’s health breaks down, for prolonged separation from an ill spouse is not usually acceptable to employees and indeed is not encouraged by enlightened employers. Many changes in overseas conditions have occurred in the twenty-five years and physical conditions of life have generally improved considerably. The almost universal introduction of air conditioning to the living and working environment in hostile climates, together with much better quality and more varied fresh and chilled foods available in most countries, and improved communications and transport, have combined to make as
last
Downloaded from rsh.sagepub.com at QUINNIPIAC UNIV on March 22, 2015
222
healthy for all. Notwithstanding physical hazards still exist and can provide a nasty surprise for the unwary or imprudent. Not all employees will enjoy comfort of air life abroad
more
agreeable
and
these advances,
conditioned offices to work in, and may have to cope with the adverse climate of a brilliantly hot desert where temperatures up to 55°C occur and sand penetrates into everything, a steaming hot jungle with 100 per cent humidity where clothing and belongings go mouldy, or the fierce cold of the Arctic. Other physical hazards include sharks and sea snakes, whether one is an offshore diver or merely relaxing in the sea. Snakes, scorpions and other hostile species can be a background worry, despite the small number of encounters that in practice occur. More serious and real medical hazards areposed by such widespread diseases as malaria, which is increasing at present, a variety of gastrointestinal diseases and infestations, filariasis, bilharzial infestation and sleeping sickness. More recently, Lassa Fever and Marburg’s or Green Monkey disease, have produced a degree of apprehension out of proportion to its real prevalence and the actual chances of overseas travellers or residents contracting the disease. A sensible, well informed approach to health in overseas locations is essential and adequate education of employees will pay dividends for any organization with staff going overseas. At any medical examination or interview the opportunity should be taken to give individual counselling in these matters and allow individuals to clear any doubts they may have with an experienced medical adviser. Many organizations supplement this with booklets about various areas containing general hints on health, and with special information courses for its employees and their wives, to impart background information on the area to which they are assigned. In many cases, larger companies will run courses themselves, or alternatively such organizations as the Centre for International Briefing at Farnham Castle supply this need. Topics covered will be the language, culture, politics, history and customs of the Area, as well as general health advice. Comprehensive advice on immunization and health protection is an essential function of employers who are nowadays expected to provide such services before exposing their employees and dependants to predictable health hazards. Most individuals readily accept
protection against Typhoid/Paratyphoid and
Smallpox,
Cholera,
Yellow Fever, but complamet with is often concerning immunization cency against tetanus and poliomyelitis. This must be kept up, as tetanus is worldwide and poliomyelitis is endemic in many overseas territories. Routine administration of human immunoglobulin against infective hepatitis is advocated by many for travellers visiting many countries and for short assignments in certain areas. For longer stays abroad, administrative difficulties occasionally prevent follow up or individuals may not be keen to continue with comparatively large injections every six months. Similarly, with the advent of better anti rabies vaccines, immunization for those living in areas of high endemicity, or in regular contact with warm-blooded mammals, may become routine. Malaria prophylaxis is essential for those posted to malarial zones or even travelling briefly through such zones. In practice, scepticism is sometimes found in expatriates living in malarial areas, who for a variety of reasons, usually specious, do not see the need to take such pills. It is the more necessary for employing organizations continually to remind their members of the danger of malaria, and the need to adhere scrupul-
ously to the advised prophylactic regime. In some companies it is policy to circulate letters to employees, at least annually, reminding them of the reality and hazards of malaria, particularly the Plasmodium Falciparum strain the so called malignant variety and the need to take appropriate measures. They are also reminded of the hazards to schoolchildren flying out to the Tropics for their holidays, and the need to send them back to school in Europe with a month’s supply of pills even if they have only spent one day or an hour in transit through an infected area, and a note to the Scool Matron with instructions for continuation of prophylaxis, reminding them of the possibility of malaria developing despite all precautions. Unfortunately, no single drug seems yet to be the ideal preventive treatment for all four species of malaria, and all parts of the World. The author’s particular Company has settled on a policy of advising Proguanil, of &dquo;Paludrine&dquo;, as its single, worldwide prohylaxis. One tablet daily is given to the average adult, and an appropriate dose for children, -
-
and in certain areas, where infestation with P. Fal-
ciparum is particularly rife, or reports of drug resistance occur, this dosage is doubled. A very good resume of considerations of fitness for travel and medical assessment for living in warm climates is given in Dr. Anthony C. Turner’s book Travel
Medicine I, and a detailed consideration of these criteria is
beyond the scope of this paper. Any assessment of individuals’ fitness for life overseas must take into account the following factors :1. Fitness for the Journey In practice, this is rarely an obstacle except in the case of evacuation to home country following ill health or accident. For short term business travellers in particular, due account must be paid to the abnormal environment of air travel, with a mild degree of decompression usually equivalent to an altitude of 5,000 to 8,000 feet, relative dehydration of the cabin’s atmosphere, the fatiguing effects of crossing several time zones and the tiring experience of physical confinement for several hours. Most companies now realize the value of advising a complete rest for 24 hours after a journey involving 4 or 5 hours time change, though such sound and practical advice is often ignored by high-pressure tycoons spurred on more by business motivation than by elementary prudence and concern for their own health and the quality of advice they may contribute in their state of circadian disarray. Also, in an effort to increase the efficiency of their more senior employees, the discomforts of long flights are mitigated by the company sending their representatives by first-class travel. Some companies also grant this facility to all individuals of unusual dimensions, for example all employees of 6 feet 5 inches or more in stature. z
2.
Simple Physical Effects of Climatic
Environment
Often, when considering overseas assignments, tropical conditions are thought of, as most developing countries
are situated in the Tropics. However, other climatic variations must be remembered including hazards of extreme cold. In a paper to the International Association of Physicians for the Overseas Services in 1974, Dr. J. G. Clothier described the extreme and dramatic hazards for people working in the oil industry on the shores of the Arctic.2In practice, simple physical effects of climatic variation are seldom a practical bar to travel or
employment
Downloaded from rsh.sagepub.com at QUINNIPIAC UNIV on March 22, 2015
overseas.
223 Some examples are certain infected skin conditions, which are exacerbated by hot sunlight and excessive sweating. Skin cancers may be a reason to advise against living in areas with high ultra violet irradiation, particularly for those with notably fair complexions. Certain cardiovascular disease cases are poor risks for overseas service; uncontrolled hypertension or cardiac failure and recent myocardial infarcation are examples. Recent tuberculous infection is usually a contraindication to transfer, while asthma needs very careful evaluation. Certain notoriously smoggy areas such as the the Tokyo-Yokohama area have a generally adverse effect in such cases, though the relative merits of a dry desert over a humid jungle land are not always predictable. Diabetes and thyrotoxicosis are usually a contra-indication, unless mild and very well controlled. Depression, particularly in parochial-bred wives, is a very poor risk, as is alcoholism.
3. Medical Services Available This is usually a much more significant factor in selection. Many medical conditions, with a good prognosis, are not a bar to life overseas, provided the medical services available are adequate to continue proper surveillance and react adequately to any emergency that may arise. Examples of such borderline cases are diabetes, hypertension, chronic neurological conditions, chronic gastro-intestinal disease such as dyspepsia, malabsorption syndrome and quiescent Crohn’s disease, and apparently-cured malignant disease. A sometimes forgotten group is that of merchant seamen who are exposed to a peculiarly isolated environment, where they may be dangerously out of reach from expert medical care for much of their working lives. Precise notes for guidance are published by the General Council for British Shipping.3 One particular condition which is often underrated by general practitioners and some specialists, is active peptic ulceration, where sudden haemorrhage or perforation could prove rapidly fatal in the middle of the Pacific Ocean. Another condition which usually precludes return to deep sea life is myocardial infarction. Even where a good recovery is made, the increased chance of further thrombosis occurring far from medical assistance, particularly if anginal pains are occurring, render a return to deep sea service unwise. 4. Mental Strains of Overseas Service The stresses and strains inherent in living and working abroad in an alien environment must not be underrated, and indeed only an experienced observer who has lived overseas and observed his expatriate colleagues can fully appreciate the subtle pressures that can so easily lead to a breakdown of morale and health. Careful selection of individuals for life overseas must be a routine procedure for both medical departments and personnel functions. Although we have considered the physical factors, which in many cases have improved over the years, changes in the social, cultural and political environments all over the worl have changed rapidly in the recent past, and in many cases for the worse. In many countries, stable colonial regimes existed where the European expatriate enjoyed a unfairly favourable style of life, surrounded by an insulating community of his own kind and a familiar social way of life. Where his employers maintained an
perhaps isolated
expatriate community or camp, an entirely European way of life was preserved, and the Government of the
country made little inroads into his life.
Many individuals in such communities never bothered to explore a fascinating and interesting country to make
any contact with the local inhabitants except to employ servants whom they trained in European ways and dealt with very much on their own terms. Now in many areas, all this is history and today’s world is different. Much as the assistance of servants is welcomed, particularly by wives and couples with young children, this can lead to boredom for a wife who no longer has housework or a job to occupy her time. It may be difficult to obtain a diverting job, for work permits may not be granted to temporary residents unless they have unique skills or experience to offer. Time can hang heavily on a wife’s hands despite attendance at the camp’s coffee, mah jong and gossip circuit or handicraft classes and yoga sessions, and minor irritations and frustrations become magnified in her mind. The husband has at least got his own job every day, and the company of his colleagues similarly occupied. Where a wife is isolated from friends or does not have ready access to her own transport, this can lead to a rapid decline in her happiness and morale and poorly corrected eyesight may preclude the issuing of a driver’s licence in some countries. For those who have never travelled very far previously the sight, sounds and smells of an overseas market, bazaar or ’souk’, can be an
overwhelming experience.
Other potent factors may be separation from her own mother and family, or from her own children at school in their home country. With the spread of independence all over the world, many countries are now notable for a degree of illconcealed hostility to foreigners or in extreme cases, outright resentment of them is manifest. In many countries, particularly with different religious faiths, it is easy to give offence in all innocence and ignorance. For sensitive and considerate individuals the possibility of offending in this manner can be a constant worry, while standards of justice vary considerably, and it is perfectly possible to land in a gaol of mediaeval proportions for a traffic offence that would scarcely merit a licence endorsement in Britain, or be summarily ejected from the country. In screening applicants, one is looking for well balanced individuals with a sense of proportion, sensitivity to other people’s points of view and patient understanding. Perhaps the most valuable gift for survival in alien environments is a sense of humour under all circumstances, and in certain situations slightly &dquo;mad&dquo; individuals do very well, but only those with a very special type of eccentricity and not the medical brand of
psychoneurosis. As adaptability to a changed environment, including mental and physical resilience, is a pre-requisite, one has reservations about allowing applicants who are over forty years old to work in the Tropics or other strange
countries for the first time in their lives. Previous successful service is a good guide for allowing people to continue in overseas postings indefinitely, provided they are fit in all respects. Nevertheless, one has observed a tendency in middle age for ideas to become fixed and particularly employees who have been in one posting for many years may become resentful of the changes going on round them. As more influence passes to Goverment activities and more regional staff assume senior positions in their company they miss the &dquo;good old days&dquo; and deplore the speed of regionalization policies. Often the most practical and kind move for all is to cross-post them to a fresh overseas assignment or return them to their home country. Any previous history of mental instability, neurosis or psychosis needing treatment, should be regarded
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224 with the greatest reservation. Overseas experience has shown that individuals with previous histories of depressive or schizophrenic tendencies, however well cured they may appear to be, tend to do badly when moved out of their normal home environment. Even some specialist psychiatrists are apt to consider that the refreshing challenge of a new job, perhaps with promotion, a more attractice salary and tropical sunshine will be a tonic to such candidates. Unfortunately, the reverse is more frequently the case, and a breakdown of mental health often soon follows arrival overseas. Provision of Health Services As noted previously, the quality of medical services varies from country to country and within a country. For companies with activities overseas, constant account must be taken of the availability and standard of medical services in its various areas of operation. Adequate services are a positive requirement to ensure the efficiency of the business, quite apart from humanitarian reasons. The availability of good medial treatment is a strongly positive morale factor in attracting staff to otherwise isolated locations. This is particularly so when a company wishes to attract and keep specialist expatriate staff, combined with provision of schools for children up to 10 or 12 years, good company housing and a personnel department which can help to smooth the problems of a newly arriving family adapting to a strange country. Such provisions are the &dquo;silent&dquo; part of an expatriate’s contract of service. Where operations are on a small scale, as in a marketing organization, employees will use existing medical services, often engaging a local doctor of repute as a part-time medical adviser and making arrangements with a local private or government hospital. Where activities are on a larger scale such as a steel
plant, pharmaceutical factory, major oilfield, refinery petro-chemical complex, the company may provide medical services of its.own, ranging from a simple occupational health clinic with nursing and ancillary staff and a part-time medical adviser, up to hospitals with specialist physicians, surgeons and other full time or
medical officers, and branch clinics in the main areas of activity. Companies providing such a comprehensive health service do so because of a need to have an occupational health service for its employees and to provide total medical care for the employees and their families who may be living in an isolated and undeveloped area. Naturally, such a wide ranging service is an expensive burden on any commercial organization which does not wish to compete with the wider obligations of a state’s medical services to its’own citizens and other temporary residents. Where full time company medical officers are emregular communication with headquarters keeps senior medical advisers informed of standards of medical services in the immediate area. In order to keep continually informed about standards elsewhere, it is common policy for headquarters medical advisers to make regular visits to various parts of the world. On these visits, local doctors are met and various hospitals visited in order to obtain first hand judgment of the quality of medical attention available to staff and families. It is sometimes discreetly possible to assist the for example by advising Managestandard slightly ment of the local company to donate an item of badly needed medical equipment to a selected hospital or clinic, or make a cash donation.
ployed,
-
Medical Evaluation and Treatment in Home Country Where extensive medical or surgical investigations and
treatment are required, it is common policy for employers to recommend that this be done in the patient’s
home country wherever this may be. The timing of this obviously depends upon the severity and urgency of the condition. Prolonged periods of sickness or post operative convalescence are not to be encouraged in a country strange to the patient. In addition, as mentioned previously, illness in a strange country can provoke unreasoning apprehension in the patient or especially in the spouse or parents, and it is often much better for everyone’s peace of mind to evacuate the patient at an early stage despite the adequacy of medical facilities on the spot. Cold surgery and routine investigations are usually arranged during expatriate families’ home leave. In view of the need to obtain specialist appointments and treatment without delay, it is common for many international organizations to provide private medical insurance for all its international staff, often in a bulk scheme, with one of the major insurance schemes under
special
terms.
Where
more urgent medical problems crop up, employees or dependants are flown to their home country.
In many cases, medical escorts are necessary to accompany patients. This is particularly necessary. for psychoneurotic problems, even quite mild cases, or alcoholics, whose behaviour during aeroplane journey may be quite unpredictable. Large organizations often supply their own nursing sister or medical officer for this purpose, but where this is not possible, specialist organizations exist to help with such cases. Three such examples in the London area are :1. Transcare Limited. 2. St. John Ambulance Aeromedical Section. 3. Europ Assistance Limited. In really calamitous, but fortunately rare situations, it is possible for them to obtain a charter aircraft with a surgical or medical team with full equipment, and be airborne to any part of the world within a very short time indeed. A variety of aircraft may be used, ranging from an HS125 or BAC111 up to a Comet or Boeing 707, depending upon the distance. Naturally such a remarkable service costs money, and the usual mode of evacuation for even comparatively acute cases is by scheduled airline services with medical escort where necessary. For medical evacuation around Europe fast &dquo;low profile&dquo; ambulances may be used, such as Citroens of Pontiacs by one company. Although expensive evacuation by private transport is seldom resorted to, it is reassuring for indivuals serving away from their home country to be aware of the existence of such facilities. A very real and growing hazard all over the world is the possibility of severe injury in a road accident. The knowledge that promp evacuation to their accustomed surroundings for long-term treatment is a source of comfort to all. For employees working in their home country all over the world, industrial organizations are concerned to see that they normally receive the best of medical treatment locally available. In certain cases, where highly specialized treatment is not available, companies assist their employees in obtaining suitable treatment in another country where this may be obtained. REFERENCES 1 TURNER, A. C. 1975 Travel Medicine, p. 161. 2 CLOTHIER, J. G. November 1973 Minutes of International Association of Physiciansfor the Overseas Services. 3 General of British Shipping, August 1976 Medical and Visual Standards. These papers were presented at a Conference of the Society held in London on 31 March 1977.
Council
’
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.
t.
