Waterways at the Centre of the Earth – From Panama to Darien

TMA Member Goondiwindi : Dr Rowena Sheppard

The 77 kilometre long engineering feat known as the Panama Canal, is truly awe inspiring – a testimony to foresight and imagination, and to man’s ability to literally move mountains and to overcome the diverse obstacles of politics, finance, weather, landslides and tropical disease. The story of the canal, is also the story of yellow fever to which over 22,000 canal workers succumbed. Through the astute observations and efforts by Dr William Gorgas our first understanding of mosquitoes as a vector of diseases came into being. Even today Yellow Fever has case fatality rates of up to 50% in some parts of the world, but the canal itself has been declared Yellow Fever free.

It is astounding to see a 50,000 tonne steel ship rise above you as water fills the lock ahead, to watch the sun rise over the Caribbean and set over the Pacific. A maze of quaint “mechanical mules” haul the ships along through the locks, keeping them within feet of the sides, co-ordinated by a thousand eyes and voices, mingling with the groan of metal and the sounds of the jungle just beyond. A bustling and booming Panama city abuts the western verge of the canal.


Less than 400 km South of the highly trafficked Panama canal, lies one of the worlds most inaccessible waterways, in the hot humid, and heavily forested Darien jungle, a travellers journey backwards in time, in dugout canoes, into the sparsely villaged homelands of the Embera Indians.

Panama’s legendary Darien jungle and the 50 km wide delta of the Atrato river has defeated the Pan-American Highway and numerous attempts to tame and “civilize” its pristine wilds. This has largely protected the natural and cultural heritage in the area.

The Darien jungle has never taken kindly to drop-ins. In 1699, 900 Scottish settlers rushed headlong into the jungle. Indians or malaria killed most within months. In 1854, an American expedition began hacking through the tangle of deadly snakes and Gordian roots in search of a canal route. They wound up lost and so hungry they ate their dead. The Darien province can still play host to malaria and yellow fever, though the incidences are now much lower than that faced by our forebears.

Given this history, it is perhaps unsurprising that fewer than 700 DEET soaked tourists visit Darien province’s rain forests each year, bringing meager income to the locals. One is statistically more likely to meet a mercenary, narcotic trafficker or a logger than a camera toting tourist, but I was fortunate to be in the latter group and to be introduced to its gentle and still naïve peoples. Let us hope the eco-tourists prevail to help preserve this “soul” of Panama.

… Prepared by Dr Rowena Sheppard, Goondiwindi TMA

Goondiwindi TMA Clinic

Cressy Clinic is a truly country practice, situated 5 km out of Goondiwindi, across a couple of grids, and often with a few roos outside in the paddock!

Dr Rowena Sheppard has been a general practitioner in Goondiwindi for 23 years, with one of her many hats being the ability to provide accessible travel related medical services to the local community.

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South African Holiday

TMA Member – Geelong Dr Paul Davey


Dr Paul Davey the medical director of The Travel Medicine Alliance Clinic Travel Health Geelong has recently travelled to South Africa riding a motor bike for three weeks around this amazing country. Here are his thoughts regarding the safety of this destination.

South Africa is a wonderful place for an adventure and a holiday. I decided to travel there after talking to some clients who had recently returned. They had loved their trip but then made the observation that they were glad they had travelled now as they weren’t sure of what was going to happen to the country, and to its political stability when Nelson Mandela dies. I have for a long time advised my traveler clients that if they want to travel and the opportunity to go is present then go. If a trip is delayed obstacles can arise and we may never end up going. I decided I should follow my own advice and booked the trip.

Safety in South Africa

Lots of people who haven’t been to South Africa expressed concern re the safety of travelling in South Africa. We checked this out with the tour operators who gave very sensible advice.

“Most of the crime that occurs in South Africa takes place in the poor township areas and mainly affects the local people. We recognize that personal safety is an issue. In the big cities precautions are needed and we suggest the following: Don’t flaunt wealth; Don’t walk around the cities at night; Travel by taxi to destinations at night. With caution you can stop bad experiences happening.”

We had a wonderful time in South Africa, and following the above advice and being cautious meant that on no occasion did we feel that our safety was threatened. In the smaller rural towns we perceived no risk at all. The people were amazingly friendly and every South African we met loved their country.

General Advice

Dr Paul Davey has offered two general travel advice suggestions following on from his African Travel.

Seek Expert Travel Medical Advice


Whilst at a private game park in the Kruger National Park region, we met an Australian couple arriving late in the afternoon. They looked exhausted and I asked if they had come far and they explained how they had been staying only about 40 km away but had had to travel 600kms that day. As they were leaving in the morning for the short drive they had mentioned how after visiting the game park they were travelling on to Victoria Falls. They were then asked if they had been vaccinated against Yellow Fever. They hadn’t and when told that they wouldn’t be permitted back into South Africa unless they were vaccinated they had to make a 300 km trip to a medical centre where they could receive this vaccination. Before leaving Australia they had been to their local doctor and had asked regarding the need for this vaccination. Their doctor had checked regarding this and advised them that it wasn’t required. Unfortunately for them the immigration requirement by the South African government changed last year and it is now a compulsory vaccination against Yellow Fever if returning from Victoria Falls.

Travel Insurance is a MUST

During a motor bike trip our lead rider crashed into a truck whilst travelling at 120km/hour. Following this accident and whilst attending to the rider I attended a small medical clinic in Swaziland and then a larger clinic in South Africa before he was evacuated back to Pretoria. Our friend required road ambulance and air ambulance transfer and then open heart surgery to treat his injuries. The local facilities were basic at the level of a school first aid clinic. Transport to first class facilities was essential. The cost of the evacuation and treatment would have been astronomical. Travel Insurance in general and also specific insurance designed to cover the costs associated with increased risk activities be they motor bike riding, or mountain climbing or snow skiing or boarding is essential for all overseas travel.

… Prepared by Dr Paul Davey, Geelong TMA

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Kayaking in Remote Solomons 
- Morovo Lagoon

Prepared by TMA Member Maitland

Public Health Physicians also need travel health advice. Another satisfied (and healthy) Chromis customer. And the beautiful fish is our symbol. Check our website www.chromis.com.au for more information on us and our services.

As we set out that first day, my daughter was convinced we were in a travel commercial. Under blue skies we paddled through clear warm tropical waters with spectacular views of the coral and sea life below. There were mangroves and palms to the waters edge, an occasional idyllic sandy beach and hardly a soul around. And even when the heavens opened that afternoon, we were delighted. Paddling in warm rain!

We camped in tents on a tiny uninhabited island that first night then visited local lodges for the next two. We explored islands and villages, clambered to a waterfall, shared an impromptu evening of music and had a brief insight into local culture and history. This is a beautiful and undeveloped region and kayaks are such a gentle, peaceful way to explore it.

Back at Uepi we sadly returned our boats and settled in for days of exploring the local reefs. The dive from the resort jetty was amazing; school fish, giant clams, reef sharks and a scorpion fish. And then there were scores of other snorkelling sites a short boat ride away; big drop offs, coral gardens, sea snakes and crayfish and an extraordinary diverse range of fish. On one special pre-breakfast snorkel our family had exclusive water time with a school of Manta Rays.

By good fortune our visit coincided with the Festival of Pacific Arts and Honiara was host to a superb mix of neighbouring peoples. For a few fascinating nights we soaked up the singing and dancing, traditional arts, short film festival, photo exhibition, and fireworks. Good fun.

We loved the Solomons and would happily return. We took the usual enteric precautions, took antimalarials and stayed well.”

… Prepared by patient of Chromis Travel Medicine Service 

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Acute Mountain Sickness (AMS)

… Prepared by TMA Member Maitland: Dr Puru Sagar Chromis

A survey among travelers departing from Cuzco International airport in Peru showed that almost half of all travelers (48.5%) interviewed reported symptoms of altitude sickness, and 17% had severe AMS. One in five travelers with AMS was forced to alter their travel plans. Three people were admitted to hospital and one was urgently evacuated.

Only one-sixth (16.6%) of the group used Acetazolamide (Diamox) for prevention of AMS, but more than 60% used coca leaf products.

Unfortunately, the use of coca-leaf products (usually tea) was found to be associated with a greater risk of developing AMS in this study. Use of coca-leaf can have other negative side-effects (changes in circulation and cardiac arrhythmias) as well as a positive urine drug screen to cocaine.

Other recent reviews have found that Diamox 250 mg half tab twice daily reduced the risk of developing AMS by about 48%. There was no benefit in taking higher doses. Diamox is strongly recommended for travelers flying into Cuzco (elevation 3,225 m) and is often required at lower altitudes (around 2,000 m).

These scientific studies underline the need to obtain accurate and up-to-date advice from an experienced travel medicine practitioner before undertaking trips to altitude. Prevention is really worthwhile.

The Travelling Well iPad app or iBook from Dr Deb the Travel Doctor has very useful information on preventing and recognizing altitude illness.


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No vaccines will prevent this one though being knowledgeable of your accommodation and environment might help. This rare, but rather topical virus is carried by rodents and can be passed on via contact with their excrement. It occurs in both North and South America and East Asia and was first isolated in 1978 in Korea.

No known illness has occurred in Australia though antibodies have been found in rodents in this country. The virus causes both respiratory disease (hantavirus pulmonary syndrome [HPS] and haemorrhagic renal problems [HFRS] with about 30% of those inflicted dying of the disease. Interestingly, it was investigated as a biological warfare agent by the US government – though this doesn’t happen nowadays. Imagine being attacked by weponised mouse urine!

A major outbreak has occurred in the United States over the last few months and new cases are still being discovered. There have been nine confirmed cases with three deaths in travellers to the ever popular Yosemite National Park. Most of the cases relate to a cluster of illnesses around the Signature Tent Cabins in Curry Village. Park records have shown that at least nine Australians could have been exposed in the period between June 10 and August 24 and urged to seek medical review if they become unwell. More info.

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Viral Hepatitis

A recent major conference in New Zealand has released a statement on this significant disease and its impact for the Australian and New Zealand populations. By world standards we are low risk for viral hepatitis HOWEVER about half a million people are living with the consequences of the disease in the two above mentioned countries and fifty new cases diagnosed every day. So while it is important to consider hepatitis vaccination for travel, it’s also important to consider without intent to travel. The vaccine is cheap, safe and effective. All Australian children are offered a childhood vaccination program for hepatitis B but there are a lot of adults who need to catch up.

Getting Hepatitis B vaccinations and still smiling.

The Auckland Statement is an urgent call to action for our governments and the community at large to come together and curb avoidable deaths caused by viral hepatitis — including through setting targets for reducing transmission, increasing testing, and enhancing access to specific treatments. More info.

… Written by Dr John Kenafake, Sunshine Coast TMA

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True Travel Adventure of a Mid Sixties Lady


“Just do it”, ”Life be in it” and “seize the day” are common enough motivational and marketing phases so it’s refreshing when you meet ‘the real deal’.

J.M. is a mid sixties female patient of mine with significant asthma. You could imagine her in the CWA or playing bingo at the local RSL. Scratch the surface and you find a hard core travel pedigree that would make a 1970s adventure surfer blush with envy. A couple of years ago she spent 3 months in West Africa travelling through some of the poorest and ‘wildest’ countries in the world. Solo and overland using local transport she travelled across Senegal, Benin, Togo, Burkina Faso and Mali. Places that have most of us reaching for a map just to locate. Inhospitable deserts and lush jungles revealed their secret gems to her such as the amazing mud mosque of Djenne, built in 1907. See right.

As I lived her tales vicariously, sitting my clinic in Maroochydore I was in awe of her river boat [known as a passasse  trip up the Niger River, Mali to the legendary Timbuktu [or Tomobouctou – it sounds great in French].

No European returned alive from Timbuktu until 1868. A similar trip was once described as ‘for those who like their pleasures lonely and their comforts few’.

Now as far as ‘out there’ trips go it’s hard to top the Sahara and West Africa but, of course ,she did .2012 saw her overland from Georgia [where’s that map], Armenia, Iran, Pakistan, China and Mongolia. This carves a huge slice through the Middle East and Asia.

Of course, travel like this is not without drama. At the Iran-Pakistan border she has to have an army escort and travelled on a bus filled with fifty Bangladeshi refugees. No food or water was provided for them for the 18 hour 600 km ‘journey from hell’ so she was able to buy bread and distribute it through the bus. They, and she, survived and she travelled on along the Karakoram Highway-the highest paved road in the world from Abbottabad, Pakistan to Xinjiang in China. This highway is known as ‘the Friendship Highway’ in China and is also known as the ‘ninth wonder of the world’.

Friendship Highway. Earthquakes and floods had cut the road and she needed a 
three hour boat trip to link up road sections

Boating in the mountains.

Aggressive border guards and lack of facilities [worse than the Sahara] were balanced by warm, friendly locals happy to help her out or put her up for the night if needed. This proved, once again, regardless of politics, people are generally kind the world over-especially for the PREPARED TRAVELLER.

J.M. is 2nd from the left with an escort of border guards.

Speaking of being prepared please read this post by a travel nurse in Uganda on the International Travel Medicine website.

“In travel medicine we talk of “risk assessment” but we must also clearly ask patients/travellers what level of “risk acceptance” that they are prepared for. Even in Uganda, many new expats seem to think that all magic will happen if they are sick/injured and they will be whisked away to a fully equipped and staffed “developed world type” ER – which of course is usually not the case. When orienting new expats to the health issues in Uganda – I always stress, with a lot of emphasis, if you have a car accident here, be prepared that there is no 911! The first people on the scene will take your wallet, watch, computer, and iPhone. The next people will be the good Samaritans and they will do their best to put you in the back of a pick-up or taxi and take you to the nearest (which is not usually the best) clinic. Travellers and expats to remote areas and developing nations must understand that they do take significant risks with their lives/health and they should be prepared if the worst happens”. Cindy Rugsten RN BN DTM AFTM RCPS (Glasgow) Travel Medicine Nurse Specialist

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South Pacific – Other precautions

Dr Colleen Lau
Food and Water-borne Diseases

The same precautions with food and water for developing countries apply in the Pacific Islands: Cook it, peel it, boil it, or forget it! However, it is not always easy to follow these rules at all times during travel. Depending on your trip, your travel doctor might recommend vaccinations for Hepatitis A, typhoid, and travellers’ diarrhoea. It is always a good idea to have a simple medical kit with medications for treating traveller’s diarrhoea, and correct treatment could mean that you are better in a few hours rather than being sick for days or even weeks.

Kayaking in Pago Pago Harbour, American Samoa – Chosen by Lonely Planet as one of the top 15 experiences in the Pacific Islands!
Blood-borne and Sexually Transmitted Infections

Hepatitis B is common in the Pacific Islands, and an estimated 25 to 30% of the local population have chronic Hepatitis B infection. Travellers should consider Hepatitis B vaccination if they plan to live or work in the Pacific, or expect to have close contact with the local population. All Australian children are now routinely vaccinated for Hepatitis B. Sexually transmitted infections are common, and HIV is also becoming a problem.


There is no risk of rabies on the Pacific Islands, but dog bites are common on some islands, and American Samoa has the unenviable reputation of having the highest incidence of dog bites in the world! Scuba diving is a popular activity, but there are few decompression chambers in the Pacific in case of mishaps. The Divers Alert Network provides information and insurance for scuba divers. Ciguatera fish poisoning is caused by marine microalgae in the tropics, and can cause nausea, vomiting, abdominal pain, diarrhoea, muscle cramps, paraesthesia, and a reversal of hot and cold sensation. It is riskier to eat large fish because they accumulate for toxin by eating smaller fish. As a general rule, if the fish fits onto a dinner plate, Ciguatera is unlikely to be a problem. It is best to avoid eating large reef fish such as barracuda and grouper. More information on ciguatera can be found in the June 2009 edition of the TMA Newsletter.

Natural hazards such as cyclones, earthquakes, and volcanic eruptions are part of everyday life, but serious disasters are relatively rare. Indeed, volcanic activity is responsible for creating many stunning and incredible landscapes throughout the Pacific, including extinct craters filled with rainforests and bats, tiny islands with sharp jagged peaks piercing the sky, abandoned villages half buried by old lava, and active volcanoes that are still erupting today.

Tinakula, Temotu Province, Solomon Islands. On a rest day from fieldwork, the local team on the Solomon Islands showed me their active volcano, which was about an hour’s boat ride from where we were working. Tinakula is only 3.5km wide, but rises 850m above the ocean, and has been uninhabited for decades because of eruptions. Even from a far distance, it is clear that Tinakula is highly active, with smoke pouring out from the top of its cone. But the true forces of nature could only be appreciated from up close, where rumblings from the volcano could also be heard and felt, and hot rocks seen spurting into the sky, and then tumbling down the hill into the ocean with a big steaming splash.

… Prepared by Dr Colleen Lau, TMA Perth and Brisbane

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South Pacific – Leptospirosis

Dr Colleen Lau

Leptospirosis is a bacterial infection that is often misdiagnosed as dengue because symptoms can be very similar. The bacteria are carried by animals (including rodents, pets, livestock, and wildlife), and excreted in their urine. Humans can become infected by direct contact with animals, or contact with water and soil that has been contaminated by animal urine. The risk of infection is especially high after flooding, because floodwaters can spread the bacteria, and wash them into rivers and streams. During flooding, people often have to wade in water and therefore have cuts, wounds, and waterlogged skin, all of which increase the risk of infection. In the Pacific Islands, recent outbreaks have occurred after cyclones and flooding on some islands including Fiji and New Caledonia. People participating in outdoor activities are also at risk because of contact with fresh water and soil. The risk of infection can be reduced by wearing protective clothing and boots, cleaning and covering wounds, and avoiding swimming in freshwater streams and rivers after heavy rainfall. The bacteria do not survive in seawater, so there is no risk of leptospirosis from swimming in the ocean.

Leptospirosis research team at work in American Samoa. Left: Unloading fieldwork gear on the remote Manu’a Islands in the far east of American Samoa. Right: Collecting blood samples and questionnaire data. Our study collected data from over 800 people from 5 islands in American Samoa, and found that about 15% of people have had previous leptospirosis infections. The study investigated environmental factors that increased the risk of leptospirosis transmission, produced maps to predict high-risk areas, and provided information to improve public health interventions.

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Island Hopping in the South Pacific

Dr Colleen Lau is one of the founding travel doctors of the TMA Perth Clinic, and also works at the TMA Brisbane Clinic. Over the past 3 years, she has travelled around the South Pacific for tropical medicine research projects and consultancies, and has just completed a PhD in infectious disease epidemiology at the University of Queensland. In this article, Colleen provides us with information on health hazards in the South Pacific, and some snapshots from her research trips in American Samoa, Vanuatu, and the Solomon Islands.

Travel Health Precautions for the South Pacific

If you expect to find remote islands, underwater adventures, friendly smiling faces, flower garlands, tropical sunsets, coconut trees, and cocktails in the South Pacific, you will not be disappointed. On a world map, the islands look like tiny dots in the vast ocean. Close up, they are home to incredible diversity in culture, history, language, landscape, economy, and wealth. Consequently, sanitation, hygiene, and the quality and availability of health care also vary dramatically between the island nations. Although the Pacific Islands conjure images of tropical paradise, most of them are developing nations, and there are health issues that travellers should be aware of. Prevention is always better than cure, and the risk of many of the health hazards can be significantly reduced by simple precautions.

Rainmaker Mountain, American Samoa. After a 2-hour uphill hike, the view from the top of Mount Alava is breathtaking. Everything is lush and green, because American Samoa is one of the wettest inhabited places in the world, with an annual rainfall of over 3000mm. For my leptospirosis research project, I spent 3 months there during the ‘dry’ season, and it rained every single day!
Mosquito-borne Diseases
  • Dengue occurs throughout the South Pacific. In most tropical areas around the world including the Pacific, the frequency and size of dengue outbreaks have increased in recent years due to a combination of demographic, environmental and climatic factors. In one of my studies from American Samoa, about 95% of adults had antibodies to dengue viruses, indicating that they had been infected some time in the past. Dengue can cause fevers, a rash, sore bones/joints/muscles, headache, and a flu-like illness. A very promising dengue vaccine is currently being tested, and will hopefully be available in a few years’ time.
  • Malaria is found in Vanuatu and the Solomon Islands, but there is no risk in Fiji, Samoa, American Samoa, Tonga, French Polynesia, Cook Islands, or the Micronesian Islands. In Vanuatu, malaria is found in virtually the whole country, but is low risk in Port Vila and Tafea Province (including Tanna Island, where the famous active volcano Mt Yasur is located). Malaria is also found throughout the Solomon Islands, but is low risk in Temotu Province in the far south. In Tanna and Temotu, an AusAID-funded Malaria Elimination Program has significantly reduced the number of malaria cases. If travelling to Vanuatu and the Solomon Islands, you should speak to your travel doctor about antimalarial medications. Malaria is a potentially fatal infection, but is treatable if diagnosed early. If you develop any fevers during or after travelling to the tropics, see a doctor as soon as possible.
  • Chikungunya virus has spread over the past few years from East Africa to the Indian Ocean Islands and Asia, and local transmission was recently identified in New Caledonia and Papua New Guinea. There is therefore a risk that the virus will continue to spread to surrounding countries including Australia and the Pacific Islands. The infection can cause quite disabling symptoms including fever, rash, joint pain and stiffness, and severe tiredness. A large Ross River virus outbreak swept through the Pacific Islands in 1979/1980, but there have been few reports of infection since then.

    When travelling in the South Pacific, it is therefore very important to take precautions against mosquito bites by using DEET-containing repellents, wearing protective clothing, and using mosquito nets or screened accommodation. Perfumes can attract mosquitoes and should be avoided.

Village health post (left) and Tanna Hospital (right), Tanna Island, Vanuatu. Health care and medical supplies are limited, especially in the more remote islands. It is always best to carry a few basic supplies, and the most common items that travellers need are medications for diarrhoea, colds and flus, and pain-killers, and simple dressings for minor wounds and injuries.

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Travel Health Information

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