Impaired travellers: the unseen illnesses

ITIJ 191, December 2016

HIV, diabetes, depression – while these chronic diseases have episodes where the sufferer feels extremely unwell, for many they can be managed with the right medication. Travelling, though, presents a different set of challenges, from increased stress exacerbating a condition, to the practicalities of a lost suitcase – meaning no medication. Mandy Langfield considers the problems these travellers face, and what moves the travel insurance industry has made to respond.

In the UK, one in four people will suffer from a mental illness at some point in their lives. In the US, 18 per cent of the population suffers from some form of anxiety or depression. According to the Anxiety and Depression Association of America, people with an anxiety disorder are three to five times more likely to regularly visit a doctor than someone without, and six times more likely to be hospitalised. While holidays are supposed to be relaxing, in actual fact the process of going on holiday can exacerbate some people’s anxieties – ‘Will I get to the airport on time? Will there be big queues at security? What if the plane is delayed?’. There are a lot of opportunities for things to go wrong, and for people who need routine in order to stay calm, holidays can throw some serious curveballs.
This is particularly pertinent when it comes to business travellers, whether they are on a short assignment or are a long-term expat. Moving to a foreign country can be an incredibly stressful experience, and research from International SOS has shown that a significant number of assignments are curtailed due to the mental health of the employee or a member of their family. Depression can lurk in the background, but may not manifest itself until the stress of being overseas presents itself. 
The travel insurance available for mental health conditions remains patchy around the world, with most standard policies excluding cover for such health issues. This may change in the future – for example, in February of this year an Australian court ruled that insurer QBE unlawfully discriminated against a female traveller suffering from depression by denying her claim for a cancelled holiday. QBE warned that if the company is obliged to cover mental health illness in its policies, then it is likely that premiums would have to go up. For travellers with a condition that needs covering, however, a small increase in premium would likely be worth every penny for the peace of mind it would bring. The British travel insurance industry is also making strides in meeting the needs of travellers with mental health problems, as more insurers add medical screening to their policies that will perform a reasonable risk assessment of a traveller’s particular condition and offer relevant cover for a higher premium.
The travel insurance available for mental health conditions remains patchy around the world
Another ‘unseen’ illness that can be seriously affected by travel is diabetes, which may require medication such as insulin. According to International SOS, failure to manage diabetes can pose a greater risk to a traveller than an infectious disease. The World Health Organization estimates that diabetes affects nine per cent of people over the age of 18 worldwide. In 2014, approximately 387 million adults had diabetes, and by 2035 this number is expected to reach 592 million, according to the International Diabetes Federation. 
ITIJ spoke to Dr Katie Geary, medical director at International SOS, whose speciality is disease control and pandemics. She manages a team of doctors and nurses who deliver healthcare and medical assistance to client organisations and individual members globally. When asked what the company can do to assist travellers who are abroad and have lost, run out of, or had their medication stolen, Dr Geary said: “We have several options depending upon the country, the medication required, and the duration of travel. Our first option is to try and source the same drug. We maintain a global database of credentialed healthcare providers. We use the database to locate a local, appropriate healthcare provider and arrange an appointment so they can prescribe the drug amount and dose required. By using our providers, we can be sure the medication will not be counterfeit and the prescription will be appropriate.”
Travelling across time zones can complicate schedules for taking medications, and travellers also need to be careful not to lose or run out of necessary medications. Finding replacements can be inconvenient or even hazardous; in some countries in the developing world, for instance, between 10 and 30 per cent of medications are counterfeit, according to the US Centers for Disease Control and Prevention (CDC).
“Occasionally, there are issues where a medication is not available in a country,” said Dr Geary, “either because it is not licensed for import or because it is not approved for distribution in the country. If the drug is not available but approved for use in country and the person will be travelling in the area for an extended period of time, we can work with our medical suppliers and a local credentialed clinic and import the required medication.” Finally, she said, ‘on the rare occasion where no appropriate alternative is available, and the medication is mandatory, we would take the traveller to the medication’.
HIV is treatable on a long-term basis, so any perceived concerns underwriters have have been overblown
Thirty-seven million people around the world have HIV. The Global Database on HIV-specific Travel & Residence Restrictions presents some interesting and occasionally shocking information about the problems that HIV positive travellers may face, not least of which are restrictions on where they can and can’t visit. The website states: “For many people, travel is an important aspect of life. Some choose to benefit from the positive quality-of-life effects which come from participating in leisure travel. Others have to stay in foreign countries for long periods due to personal or professional reasons.” While there has been progress made by many countries, including China and the US, which have both lifted bans on HIV positive travellers entering, restrictions still remain. In 2015, Singapore lifted its two-decade-long ban on HIV positive travellers entering the country, but such visitors can only stay for a maximum of three months. Australia and New Zealand both have similar restrictions on long-term visitors.
Travellers with HIV need to take care when planning travel and determining the medication they need to take with them. As Dr Geary explained to ITIJ: “The medication taken to treat HIV may have significant side effects. In addition, [it] can be difficult to source in many parts of the world. Particular attention needs to be spent ensuring adequate supplies are taken for the duration of the trip. All travel should be undertaken, at least initially after treatment begins, with the support and advice of the traveller’s home treating specialist.” Additionally, she added, while ‘HIV does not in itself preclude travel in all its existing forms … it does require more planning and time spent assessing every aspect of the proposed travel’. “The impact of HIV is predominantly on the immune system,” she said, “and this may have an impact on the vaccinations that can be safely administered for non-essential travel.”
Obtaining reasonably priced and comprehensive travel insurance for HIV can be difficult, much as it can be for any serious pre-existing condition, but a lack of understanding surrounding HIV as an illness can make it even more difficult. Fiona Macrae, head of client engagement for UK-based Travel Insurance Facilities Group, said that in order to develop the medical screening questions used in the company’s Protectif system, they listened to ‘charities and customers’. “Protectif has been developed to ensure that we ask the most relevant questions to the customer in a sensitive way and in a language the customers understand, regardless of the condition screened – sensitivity and understanding are paramount,” she told ITIJ. “This has led us to implement both sets of feedback into the criteria, allowing Protectif to be a dynamic rating system. Protectif always asks the customer for the details of their medication first, and then links it to the condition the medication is taken for, which helps to be more accurate in the collection of information from customers.”
When HIV was first diagnosed as a potential epidemic in the early 1980s, the public reaction quickly amplified the disease into a global moral panic, which consequently made the insurance industry view HIV, and later AIDS, as a catastrophic risk, according to Macrae. Tristan Rothwell of World First Travel Insurance – which was one of the first companies in the UK to provide travel cover for HIV positive clients – shares this view. He said of his company’s policy: “It was the brainchild of my mother and founder of Rothwell and Towler, our parent company. My parents knew a lot of gay people and they were finding they couldn’t get travel insurance, or any insurance for that matter – this was back when HIV and AIDS were still very misunderstood, so we arranged the first policy of its kind back in the very early 1990s. The questions were formulated by working with HIV specialists and insurance companies.”
Once the stability of the medical condition is established, due to the advances in research into antiviral drugs, HIV is treatable on a long-term basis, so any perceived concerns underwriters have have been overblown, continued Fiona Macrae. “The biggest threat to underwriters,” she explained, “which applies to all risks underwritten for pre-existing conditions, is that the customer does not give full and honest disclosure of their condition. HIV should be rated like all other managed diseases and the only worry for a traveller should be if they lose their medication or are travelling in a location where the medical facilities are sub-standard.