By Yorghos Apostolopoulos and Sevil Sönmez
Mass charter tourism is the cornerstone of development plans in the Caribbean. Unparalleled tourism investment in the post-World War II era has boosted a tourist influx of unprecedented dimensions, the world's largest peacetime population movement, especially in developing insular regions. The heavy influx of tourists has contributed to significant economic gains in Caribbean nations. However, it has simultaneously inflicted a plethora of long-term adverse consequences, including the emergence and diffusion of infectious diseases. Paradoxically, while the sustainable development of the Caribbean requires the control of infections and diseases, travel and tourism actually produce the facilitating conditions for their very emergence.
Tourism, the dominant economic activity of the Caribbean islands, reaches higher than 90% of Gross Domestic Product in many islands. At the same time, this vital source of income has also been identified as a major threat to the region's sociocultural, ecological, and public health sustainability. These include spatial and socioeconomic polarization, uneven development, ecological degradation, domination of regional political economies, management repatriation, rising alienation among locals, and structural under-development. Such negative externalities of tourism have eclipsed the potential for equitable social, sectoral, and regional benefits, especially considering that mass tourism was expected to demonstrate the greatest positive impact. Further, this unprecedented growth has resulted in a surplus of accommodations and its subsequent consequences, inflationary pressures causing dramatic rises in the cost of living, labor and other resource shortages, and a failure to integrate tourism with other sectors.
The conventional mass tourism model must undergo a significant overhaul to avoid undermining local communities, ecological and social systems. This means encouraging different types of tourists and tourism, spreading tourism over more diverse destinations, and thinking about products in markets, in short, profound structural changes in the tourist industry. These modifications must include interregional differentiation, diverse regional tourism production, and maximized economic benefits in both the informal and formal sectors over an entire region. All this can be accomplished by initiating effective interlinkages between tourism and other economic sectors, by assuring equity and encouraging local involvement, by incorporating environmental considerations into policy making and tourist product development, and by assuring continuity and adjustability of the region's tourism development within its wider environment. Further, considering the tourism industry's vulnerability to uncontrolled internal and external shocks (i.e., recession, natural disasters, geopolitical conflicts, epidemic disease), the welfare of the littoral Caribbean may be undermined and ultimately constrained by neglect of the critical importance of social and geographic ecology.
HEALTH REPERCUSSIONS OF CARIBBEAN TOURISM
While microbial adaptation and change most often account for the origin of diseases, international travel has been linked with an explosion of disease propagation in several geographic regions. When people travel, not only do they carry their genetic makeup, disease pathogens and vectors, and accumulated immunologic experience, but they also transport their capacity to introduce diseases into new regions. Like other exchangeable goods, the diffusion of disease through traveling human populations traces the structure of social networks, as various diseases travel along different structural routes.
The Caribbean already suffers from problems associated with underdevelopment and endemic and climate risks. However, the annual influx of millions of mass tourists to the Caribbean constitutes an added pathway for the diffusion of infections and diseases. It also sets the stage for intermingling diverse genetic pools and cultures. The public health repercussions affect the host population, as well as the traveler, in ways previously unknown and unanticipated. The tourist brings these public health repercussions back home, and both ecosystems receive their impact. The global leisure revolution, ongoing improvements in transport media, and movement between diverse climatic zones (exemplified by global warming and climate change) have exacerbated the vulnerability of travelers to infectious diseases. Beyond the illnesses induced by travel itself, the exposure to unfamiliar infectious agents and demonstration of risky behaviors heightened by the vacation setting and culture, have the potential to cause enormous health strains on the parties involved.
Travel health risks in the Caribbean, ranging from malaria and dengue fever to HBV and dysentery, differ by types of travel. However, mass tourists are the travelers most at risk for infection. Furthermore, the magnitude of health consequences of mass tourism largely depends upon the volume and scope of tourists, as well as health determinants related to the process of travel. The tourist influx bridging disparate population health determinants often crosses gaps in socioeconomic development and public health practices with analogous consequences.
As is the case in most littoral areas, risky behavioral patterns involving substance misuse and casual/unprotected sexual encounters constitute a prevalent hazard in the Caribbean islands particularly due to the pervasiveness of "sun, sea, sand, and sex" tourists. Moreover, the tourist-based commercial sex industry, fueled by the eagerness of certain travelers to seek out commercial sex opportunities while on a Caribbean vacation provides prostitutes with ample opportunities to give sexually-transmitted infections (STIs) to travelers in the absence of state control and regulation. Further, similarly risky encounters occur between "beach boys" and white foreign women, between locals and "exotic" visitors, and between pedophiles and victims of child sex tourism. In the Caribbean, as in many other developing tourist regions, informal sector tourism is inseparable from the sexual exploitation of women and children. Sex tourism is based on networks that provide services such as tourist guides, prostitutes, brothels, and massage parlors and often serve foreign sex tourists as well as local customers. Minors in particular are attracted to working in sex tourism by the lure of foreign tourists' wealth and consumerism. Sex tourism, homophobia, and poverty have been blamed for the AIDS increase in the Caribbean, which has the second highest rate of HIV infection after Africa. Surprisingly, the Caribbean along with Latin America continues to be perceived as an attractive destination by sex tourists.
Preconceived images of "exotic" local women have fueled the idea that they are full of sexual energy or that they only think about sex. These images are often promoted as part of the amenities of a tourist holiday package by some islands, such as the Dominican Republic. On others, such as Haiti, sex between adult male tourists from the U.S. and local children has remained a part of the informal commercial sex industry for many years. Of course, while tourism is not the cause of minors?' sexual exploitation, it does provide easy access to vulnerable children. Therefore, the acute importance of regulation and health surveillance of the commercial sex industry is self-evident, particularly as it intersects with travelers.
HEALTH POLICY FOR A GLOBALIZED INFLUX
The globalization process has dramatically transformed global tourist patterns. As there are clear indications that human mobility will further intensify over the coming years, regardless of the setbacks experienced by the tourism industry resulting from the September 11 terrorist attack in the U.S., there are immense public health ramifications. Tourist health is practically treated as a hidden dimension of tourism and consequently neglected. Yet, both tourists in the Caribbean and host populations are increasingly exposed to new health problems as the circulation of pathogens and vectors increases due to intersecting epidemiological and sociocultural boundaries. Discrepancies in the level of knowledge and types of beliefs, attitudes toward diseases and health, and expectations for and access to health services or information are likely to exist between travelers' home communities and the destinations they visit. Assessing and monitoring factors that affect health and health services for international tourists are crucial for anticipating and proposing changes and adaptations to tourists' health needs. A clear understanding of the related causes and risk factors is critical for targeting adapted preventive interventions. The growing awareness of the dangers of HIV/AIDS and other STIs make this even more imperative, especially since such serious health risks can create irreversible problems for the Caribbean's predominantly "4S" tourist market.
The health risks of travelers are related not solely to the destination and direction of travel but also to the movements of tourists across epidemiological, behavioral, and geographic boundaries. The multi-directionality of tourist flows in the Caribbean and their demographic composition can essentially determine the health characteristics of populations. Since tourism is of such importance to the Caribbean, the promotion of travel health represents a crucial strategy because subsequent public policies, if properly initiated, could make significant contributions to the maintenance and growth of international economies. While travel health promotion may have the correct intentions, its shortcomings are often due to unplanned and uncoordinated activities within the amorphous, acephalous, and fragmented tourist industry, to the narrow focus of much contemporary medical education, to widespread ignorance of medical (disease) geography, and to the associated risks of disease importation and spread from tourist migration.
Because of increasing global tourism and emerging and re-emerging infections, the World Health Organization and World Tourism Organization have been urged to cooperate on a strategic initiative to provide guidelines for future action. The global public health ramifications of tourism can only be mitigated by the synergistic efforts of these international organizations. The emphasis of the initiative rests on the importance of working with primary stakeholders involved in and influenced by global tourism patterns. The ?"healthy travel and tourism" campaign has resulted. The campaign aims to define constructive action priorities to avoid health problems, to promote health among both travelers and host communities, and to establish healthy tourism networks among private sector representatives (such as tour operators and travel agencies) and host country authorities. Travel health promotion as well as mitigation planning, ongoing disease prevention, hazard mapping and surveillance, and risk assessment bolstered by sociomedical research are critical for a sustainable tourism sector in the Caribbean.
Yorghos Apostolopoulos is a Research Associate Professor of Sociology and Sevil Sönmez is an Associate Professor of Tourism Management, both at Arizona State University, Tempe, Arizona. Their work delves into development, health, population/tourism, and the epidemiology of migration.