Closing Remarks - April 28, 2000

Bernhard H. Liese MD, MPH, Senior Advisor, Human Development, Africa Region, The World Bank (Former Medical Director, World Bank)

James Striker, PhD, Clinical Psychologist, Joint Bank-Fund Health Services Department

DR. LIESE: This has been a tour de force through the pretty uncharted and large territory of travel medicine/occupational medicine, or occupational medicine/travel medicine. We looked from the psychological side to the physiological side, from the individual to the workplace. So there was quite a breadth in the presentations which have been shared with us.

I think the clearest for me were many of the presentations which dealt with the physiological side, if I may say so, of travelers. We had superb examples of, for example, studies on DVT from various perspectives. Lennart and Patrick did very nice presentations on that. We understand what we are talking about.

Michael showed us the data on radiation exposure in British Airways in planes, very hard data, very clear data. We have talked about air quality for cabin code and things, very hard data, physiological data which are available. That is one side.

The work on circadian rhythms and sleep deprivation to me appeared equally hard and scientific in context. I believe that Mark Rosekind and Professor Lemmer have really outlined what happens. And while much of the work on circadian rhythms and sleep deprivation which is published is in the area of safety, concerning pilots, for example, not in the area of productivity, I do think there is a lot of evidence there which could be used.

At least from these presentations I went away with a clear understanding why I am grumpy when I return home after a long mission. First, I feel better that everybody seems to be grumpy, according to the data, and now I learned why I am grumpy. And I told that yesterday evening to my wife in self-defense, and she immediately said, "No, not everybody's grumpy. You are grumpy."

[LAUGHTER]

So there are data which one can put together, and in the physiological area, there is quite a body of evidence around.

We know as well a lot about risks. I think Jay Keystone's superb Tour de force, if I will put it that way, "don't get bit, don't get hit, don't get lit", and so on—don't eat—shows very clearly what we know and how far the field has been advanced. Then new opportunities for malaria prophylaxis, there are twin vaccines for hepatitis and so on. I don't want to go through it all.

Ken looked at risk from the perspective of an epidemiologist, which is closer to my own profession, closer at heart, talking about cumulative incidence, about probability and risk, defining really what is the scientific conceptual foundation when we talk about risks, and the changes in the risk perceptions, how personalities, how groups shape these risk perceptions. I think this is an extraordinarily important dimension. And it painfully made clear how little of some of these risk perceptions can be generalized.

We looked as well at the organizational aspects from the perspective of different organizations, large ones and small ones, you know, from the gigantic GE's perspective, from the specialized perspective of the United Nations peacekeeping operations, and we saw that many of the occupational health directors or occupational health physicians struggled with very similar issues. And many of us have developed very similar kinds of approaches, net-based solutions, information. But we struggle with very similar issues.

Some of the answers or the little hints how you could do certain things have been traded in the seminars, and I'm sure that many of us feel or quite a few of us feel that there could have been more interchange in terms of practical solutions. At least that is often what I feel, because one would like to learn a lot and steal it and implement it at home. I hope that some of that has happened. If it hasn't happened enough, then I apologize for it.

We learned some other very, very interesting things. For example, I learned that melatonin, which I thought was a drug which has a certain specific content, in this country is unregulated, and if you purchase melatonin over the counter, then you might have an active ingredient between zero to 98 percent, and you don't know what you get. Therefore, the studies which we are talking about are for me meaningless. Very interesting observation.

The most uncharted area which we talked about were the psychosocial dimensions of stress, of travel. Here we know relatively little. I mean, it became painfully obvious how little we knew. There are a couple of studies, and I think Lennart just has done extraordinary good work to show us what we know. There is a little bit of what we have done, and then there is a lot of what I would call studies but they are more surveys in which people share perceptions.

I found the presentation of our colleagues who did the spouse study, by Helen Frick, very interesting. It still sticks in my mind that some of the kids or one of the kids called the airplane "Papa." That is something which I will remember.

And thinking back, the perception that many people worried that important events like birthdays and so on were missed at home while we were on travel, these perceptions of the family, they are very interesting. I find them as well very disturbing.

There are as well differences seen in the perception of the traveler himself whose kind of stress level, if you may call it so, increases with the frequency of travel, is not shared at all by the spouse at home whose stress level increases with the duration of absence. So some of the issues are appearing, and it seems clear that there is something to the notion of psychosocial effects of travel on the individual, and that is something which one could at least try to chart on the family.

On the workplace, we know very little. But then if you actually apply some of the knowledge which we have from circadian rhythms and some of the overheads which Mark Rosekind showed, we see, as I said before, why we are grumpy when we return from mission, that 100 percent of people are grumpy and that for 20 percent there is a change in judgment, and so on and so on. Well, I think that is an area which we could pursue further— and I have to say research could chart that field which is pretty much uncharted.

Jack Ivancevich said yesterday very clearly that our discussion about the psychosocial dimension of travel wasn't grounded in any empirical evidence, really, that we didn't have a model and we needed to develop a model to describe these issues. And I couldn't agree more. There is no model, there is no theory. I think it needs to be developed. It can only be developed with a multidisciplinary approach. There is no alternative to that one because you have to look from different angles at it.

It seems to me that the entire field is like a mosaic or a puzzle where we see certain pieces slowly emerging, but we need to put them together some way. We need to have a framework, a common understanding of how we talk about it, and where we steer the research.

One of the tremendous difficulties I see in doing that is, first, that much of this research has to be undertaken in organizations. It's not that you can take individual travelers. You will have to go into organizations. Much of this phenomenon is related actually to organizational culture and to organizational processes, as Jack said yesterday as well. And organizations are sometimes very protective about their own data. It's a big challenge which we have ahead of us.

There is also the need sometimes in the psychological field, at least—and I don't want to be disrespectful— but to look at new measurements, because some of the tested measurements which are around, some are very good. But if you were to take a survey or something like this and apply it five times in a year, the person would not get more or less neurotic. You know, once you have it, fill it out, you won't do it a second time. In other words, there are many validated questionnaires, but there are adjustments which need to be made there. There is quite a bit of spade work which needs to be done there. So we need to resolve the methodological problems as well.

Where do we go from here? I think there are two suggestions which have been made which I at least would wholeheartedly support. The first one was to establish a network, a network or a coalition, a network which would allow many of the colleagues in the room and other ones to share ideas and to see how we actually can move ahead. Research networks are always very powerful entities because they are complementary and they allow people to learn from each other and to build really on evidence which is accumulated, because it is the richness, it's the discussion with different fields where the perspective changes.

I said before, in this organization you have predominantly economists, and they think in sequential logic. That's the way it is. If you talk to an organization with social scientists, they think in patterns. A very different approach to similar problems. So there are opportunities by looking at this in a multidisciplinary sense and establishing a multidisciplinary network. Maybe Lennart and Jim and Mike could give some thought to that, whether it is feasible. Maybe you could do that jointly with a group of colleagues here.

A second recommendation which came forth was maybe after a couple of years to meet again, to take stock of where one has gone, or whether one has gone forward, or whether one is at a standstill, to see where one is, and so these are the two points which I think came out of the discussion at the end in terms of what the future road map is.

I would like to stop here and thank you once more for coming and pass the mike onto Jim.

[APPLAUSE]

DR. STRIKER: Thank you, Bernhard, for an excellent summary of the symposium and some thoughts about how we might move ahead, all of us in this room and hopefully beyond.

I just have a couple of housekeeping things to say and some acknowledgments. The acknowledgments are extremely important because there have been a lot of people that have had to do with making this symposium a reality. But before I get to the acknowledgments, I just wanted to say for all the presenters, when we're finished here in just a few minutes, please don't immediately leave. If you would go across the hall to the other meeting room, we need you in there for a very few minutes. I guarantee you for a very short time.

I would like to begin the acknowledgments by thanking our partners inside and outside of the Bank. We certainly had a lot of them. I will be quick, but I would like to mention everybody.

First of all, I want to thank our internal friends and partners in the General Services Department here, Conference Services, who are responsible for facilities, this whole area, the set-up of everything, making it a comfortable environment, as well as the audio-visual services which I think all the speakers have come to a consensus have been excellent, keeping things moving in a very seamless, smooth way.

I also would like to thank Marriott Food Services who provided breakfast and lunch for us the last couple of days, with good quality as always. Also, American Express, who for the speakers, at least, have done a very good job in organizing and coordinating air flights and transportation for all of the speakers to make sure they arrived, and hopefully arrived when they wanted to. As well the Westin Grand Hotel, which has provided excellent accommodations for all of them.

I would also like to thank Riggs Bank—talk about far behind the scenes. They helped us with how we billed all of you by credit card.

Also, Charlie Kirsch, who has worked with us, our department, for quite a while, working on our internal Web page. He designed the Symposium Web page, which was very nice for us and really gave us a lot of exposure.

Finally, among our partners, probably the most important partner in making this symposium happen was Applied Epidemiology. Ken Mundt and his group have been our epidemiology consultants in our research and in all of our travel research, and had a very important role in the development of the concept and how we could approach a symposium like this.

Now for the Health Services Department side. First of all, there are a lot of people, again, many of our colleagues in the Health Services Department have contributed. You may have seen them out in the hall, walking in the back, registering you when you come in. These are nurses, administrative people, people from our fitness center who have volunteered their time to support this activity, and I think they, too, have helped make things run very smoothly, saved a lot of headaches for some of the rest of us running around doing other things, and hopefully helping all of you out to feel comfortable here. There are too many to name. I won't go through that long list. But we certainly appreciate their work.

Finally, I would like to just make special mention of the members of the team, in addition to Lennart Dimberg and myself, who worked quite hard over the past year putting this together. First is Sandra Ross, our administrator, who is in the back there, if she's willing to stand up briefly.

[APPLAUSE]

And all of you have had contact with her, whether you know it or not, at least through e-mail. She has superb organizational skills and has juggled many responsibilities while doing the rest of her work here in the Health Services Department, always maintaining good humor and a positive approach to things. So we're very grateful, and she has played a very large role in this.

Nicole Marchant. I don't know if she's here in the room. She is executive assistant to our medical director, worked very closely helping make sure the participants made it here on time, coordinating with American Express, and using her long experience in understanding how people work together to help us stay focused in a really positive way.

Also, Ellen Arevalo, who is our budget officer—I cannot forget somebody like that in an enterprise like this—who kept track of billing and costs. Thank you, Ellen, wherever you are. I don't think she's here today. And also as a member of the team, she helped us to keep a good perspective.

Finally, on the team, Cheri Bennett, who is our department's health promotion and communications person, and Cheri I don't think is in the room—oh, yes, she is. Cheri, would you—you must stand up.

[APPLAUSE]

And why is she important on the team? Well, she has coordinated for weeks and weeks with our internal partners to arrange for set-up of all the conference services, make sure that all of our internal communications went very well. A lot of Web page work came through her. She's just been very key behind the scenes, I think, although you've seen her walking around here, to making things run very smoothly again and ensuring that this whole environment that we're in is very comfortable. Thank you, Cheri. That's pretty much the team.

I'd finally like to say— even though he keeps referring to us as his old department and giving us advice about what to do next— the final and probably most important member of the team is Bernhard Liese. He was our leader, as you know, for many years, and it really was his vision and understanding of the links between occupational health and organizational goals that gave us confidence that a symposium like this not only was important and needed, but people would probably show up if we held one. So thank you, Bernhard.

[APPLAUSE]

One last acknowledgment, and that is all of you and your contributions and participation, because that's what the conference was about. Thank you.

Disclaimer: These Proceedings have been produced from transcripts made from audio tapes. Efforts were made to check the accuracy of information with the various authors, but this accuracy is not guaranteed. If there is information that you believe requires correction, please send a message to our e-mail address.