American travelers often focus on avoiding diseases or violence in foreign lands, but a new study shows they may overlook a larger health threat: road accidents.
Between 2003 and 2009, more Americans died abroad from crashes involving cars or motorcycles than from homicide or terrorist events, the researchers write in the journal Injury Prevention.
Money spent on public health interventions related to homicides "has apparently been spent successfully," Dr. David Bishai told Reuters Health.
Bishai, a professor at Johns Hopkins Bloomberg School of Public Health in Maryland, led the new study.
But, "there is a gap in funding now," he said. "What gets travelers abroad isn't so much infectious disease or homicide - it's road safety."
Health risks during international travel can be tricky to measure and the U.S. Department of State spends $51.6 billion annually to protect U.S. citizens both abroad and at home, according to the report.
In the past, researchers have struggled to put the number of deaths abroad in a fair context. For example, a simple total of American deaths in a country does not reflect how often travelers visit the area.
With this in mind, Bishai and his team measured deaths-per-one-million-visits to a country by American travelers. U.S. State Department data showed a total of 5,417 unnatural deaths among Americans abroad during the six-year study period.
Previous estimates have put an American's average stay abroad at roughly 20 nights.
Homicides occurred most often in the Philippines, at a rate of 21 per million visits. Seven Americans were murdered in that country in 2007 and 11 in 2008. The remaining top-five countries for intentional deaths were Columbia, with 13.7 intentional deaths per million American visits; the Dominican Republic, with 11 deaths per million; and Thailand and Morocco, each with about 5.5 intentional deaths per million visits.
But with the exception of the Philippines, more Americans died from road crashes in all of the 160 countries surveyed than from homicides.
Thailand topped the list of traffic fatalities with 16.5 deaths per million visits, followed by Vietnam, with 15 fatal road accidents per million visits. A majority of those deaths involved motorcycles or scooters.
"People will go to Vietnam and ride on a motorcycle because it's the way to get around," Bishai said.
The other countries in the top five for fatal road accidents were: Morocco, with 12 deaths per million visits; South Africa, with 11 deaths per million visits, and Indonesia, with 10 deaths per million visits.
"We know that the distribution of road traffic fatalities varies dramatically across different parts of the world," Huseyin Naci told Reuters Health in an email.
"While pedestrian deaths are more common in many parts of Africa, motorcycle and bicycle deaths occur more frequently in southeast Asia," he said.
Naci who researches health and policy at the London School of Economics and Political Science, was not involved in the current study.
"One limitation of the study, which the authors acknowledge, is that we still do not know the characteristics of people who travel to different countries," Naci said.
The U.S. Commerce Department provided the researchers with the number of outgoing trips, but Bishai agreed that "to do a better study, we would need finer measurements of the number of days of exposure in these countries."
"We need more tourist-related research that gives us a better idea of exposure to road travel," said Dr. Stephen Hargarten, director of the Injury Research Center at Medical College of Wisconsin in Milwaukee.
Hargarten, who was not involved in the new research, pointed to the promise of smartphones, which U.S. travelers could use in research to report more accurate locations and lengths of stays.
No matter where travelers are going, there are a few general rules to follow, Hargarten said. For one, mass transportation options like train or bus travel tend to be safer ways of traveling.
He added: "Wear your seatbelt, wear a helmet, avoid travel with unscheduled aircraft."
For travelers going to Thailand or Vietnam, "you are going to these destinations, then you can lower your risk drastically by just not getting on a motorcycle or scooter," Bishai said.
He advised caution when traveling by taxi, too. Even if a taxi driver appears to be alert and safe, "pretend you are being driven by a high-risk driver," because the environment and other drivers may not be as safe, Bishai said.