GERM
00:00:09.120 – 00:00:10.960
Aloha. My name is Germ.

WORM
00:00:11.280 – 00:00:12.160
I’m Worm.

GERM
00:00:12.480 – 00:00:24.960
Welcome to episode 68 of the germ and worm travel health podcast. It’s a big planet. See it in Good Health. I’m Dr. Paul Pottinger. You could also call me Germ.

I’m a professor of Infectious diseases at the University of Washington in Seattle.

WORM
00:00:25.200 – 00:00:33.400
I’m Dr. Chris Sanford, also known as Worm, Associate professor in the departments of Family medicine and Global health, also at the University of Washington.

GERM
00:00:33.640 – 00:01:46.210
Well, Chris, here it is. This is an exciting episode for us, number 68, because of two new features, actually.

First of all, we have a wonderful guest, a different Dr. Sanford, a second Sanford doctor, and in fact, I’m going to have you introduce Dr. Tom Stanford when we get to that section. But first, we also have a little innovation and to our listeners, we hope you like this.

This is something we’re going to add to as many of our upcoming episodes as we can, and it’s called why you should go. Chris and I have been so fortunate to travel to many places around the world.

We’re going to give you a quick list of some of those places and reasons why we’ve enjoyed visiting these many different and beautiful parts of the world. We want you to get excited about travel. Do it safely, please. That’s why we’re here.

But also get you inspired about different places to go, places you might not have considered before. So excited to hear about the country of Peru from Chris, who will give us his reasons for visiting Peru today.

Before we get started, our medical disclaimer. This podcast is designed to inform, inspire and entertain, but of course you should not use it as clinical care before you travel.

Please see a qualified healthcare professional for recommendations specific to you and your itinerary. With that said, Chris, tell us please about your reasons for visiting the beautiful nation of Peru.

WORM
00:01:46.850 – 00:06:52.630
We’re starting a new feature for our podcast called why you should go. We talk about a particular country that we love and detail the reasons why we think you should visit. Our inaugural country is Peru.

Peru is a country with everything. Coastal desert, Amazon rainforest, high snow capped mountains, the Incan citadel of Machu Picchu.

People have been living there since at least 12,000 BC. Spanish conquistadors showed up in the 16th century, leading to it becoming a Spanish colony. Independence was declared in the 1820s.

It’s a big country, almost twice the size of Texas. Its population is 34 million, almost a third of whom live in the big coastal capital of Lima. A few pragmatics.

It’s south of the equator, so summer is December through April, winter is June through September. But the climate tends to be consistent year round in most of the country. In the Amazon rainforest, it’s hot and humid year round.

In the Andes, it can be cold year round due to the altitude. And on the coastal desert, it tends to be dry and moderate year round.

Now, a lot of people going to Peru just fly into Lima and then make a beeline for Cuzco and Machu Picchu. And that’s well and fine, but Lima is a bit of a handful. It’s over 10 million people.

And most tourists stay in the Miraflores area, which is an upscale community, sort of the Beverly Hills of Lima. And then Cuzco and Machu Picchu are interesting, but actually my favorite part of Peru is the Amazon rainforest. It’s fascinating.

It’s different, it’s hot, it’s humid. The bugs are big, the bugs are loud, the plants are big.

A fun itinerary is to fly into Iquitos, then take a riverboat an hour or two upriver or downriver on the Amazon and stay in a rural lodge. And this immersion is really the antithesis of living in an American city. Much of the country is relatively empty.

For example, the Loreto Province, which is the biggest province in the country. It’s where Iquitos is in the rainforest.

It’s the size of Germany, which has a population of 82 million, but the entire Loreto Province has a population of 1 million. The biggest city there, Aikidos, has the distinction of being the biggest city in the world that you can’t reach by road.

You have to fly there or get there by boat.

Other interesting places, there’s the Nazca Lines, which are these giant geoglyphs on the coastal desert south of lima, constructed between 500 BC and 500 AD. These are best seen from the sky. There’s a number of lovely colonial towns in the mountains, including Arequipa, about an hour out of Lima by jet.

It’s known as the Ciudad Blanca, the White City, due to the use of white volcanic stone in many of the buildings.

If you like to read fiction set in the place you’re visiting, a fun novel by Maria Vargas Llosa is Aunt Julia and the scriptwriter, published in 1977. Health wise, it’s generally safe. The U.S. department of State travel advisory for Peru is level two.

If you go into the jungle, you need a yellow fever vaccine, plus you want to take malaria prophylaxis. And of course, in the rainforest, using bug repellent is a must. If you’re going to high altitude, say Cuzco, Machu Picchu or Lake Titicaca.

A lot of people find benefit if they take acetazolamide, brand name Diamox. And that can be taken either preventatively or if symptoms of altitude illness occur. Peru is a really big country. A week there is too little.

Again, I would try to see more than just Cusco, Machu Picchu and Lima. It’s easy to travel at any level of budget.

You can travel by private car between luxury hotels or you can stay at hostels and travel by bus for dirt cheap. In my experience. The people are friendly, the food is good, the scenery is amazing. It helps if you speak a little Spanish, but it isn’t mandatory.

My prediction is that if you go once, you’ll want to go again.

I’m delighted to be here today with Dr. Tom Sanford. Tom is a urologist practicing in Honolulu, Hawaii. But we’re not talking about urology today. We are talking about cycling safety.

Because in addition to being a doctor, Tom is a serious athlete. He has completed the Ironman Triathlon on the Big Island.

He swam for all four years competitively at Dartmouth and set a number of school records there. And he is a serious cyclist.

He has published an article that we’ll talk about a little later in jama, the Journal of American Medical association, on cycling safety. And he has completed double centuries, 200 miles in a single day and mountainous terrain, which impresses the heck out of me.

And also, Tom, is it true you once cycled over several days between California and Minneapolis?

Tom Sanford
00:06:53.750 – 00:07:01.750
Quite a bit more than several days. That took me 20 days. But yes, I did some bicycle touring between those two locations.

WORM
00:07:02.230 – 00:07:04.870
That impresses me. Thank you for joining me today.

Tom Sanford
00:07:05.430 – 00:07:06.310
Thank you for having me.

WORM
00:07:06.390 – 00:07:18.310
And full nepotism disclosure here, you may notice that Tom and I have similar last names. Tom is indeed my nephew, but I’m not interviewing him because he’s my nephew. I’m interviewing him because he is a smart doc.

Tom Sanford
00:07:18.710 – 00:07:19.350
Thank you.

WORM
00:07:20.070 – 00:07:28.630
First question, Tom, just in general, somebody’s going abroad, they’re going to be cycling. What are some general tips you would have to keep them safe during that activity?

Tom Sanford
00:07:29.030 – 00:11:20.110
Yeah. Well, I think the first and most important question is where will you cycle? And if there’s a choice in location where you’re planning to go.

So if cycling is going to be an important part of the activities you do when you go abroad and you have a choice about where to go abroad, you can look at some places that are much safer than others. So if you look at the top of the list for safety is Denmark and the Netherlands.

Both of those countries have invested heavily in infrastructure, and a lot of people there ride bicycles. And so there’s a big culture around cycling. So the rates of injury in those countries are much lower than other countries.

So some places don’t have the same level of infrastructure.

For example, Thailand or South Africa, they have much higher rates of both injuries and fatalities per unit traveled compared with a country like the Netherlands or Denmark. So if you have a choice, you, there are places that are much safer if cycling is going to be an important part of what you do when you’re abroad.

But anywhere you go, there are things that you can do to keep yourself safe. So the most important thing is, to the best of your ability, separate yourself as a cyclist from cars.

So a dedicated bicycle path is, is really ideal.

So Even though Washington, D.C. may not be the pinnacle of cycling safety, there’s a, A, a trail there called the Capital Crescent Trail, which runs through a lot of the most important parts of D.C. so if you have a choice to take the Capital Crescent Trail versus ride on straight roads, you’re going to be a lot safer on the Capital Crescent Trail. So the most important thing is to separate yourself from cars and bicycle paths that are created.

Bicycle paths are better than bicycle lanes, but bicycle lanes are better than no bicycle lanes. And if you’re riding on the shoulder, it’s better to have a wider shoulder rather than a shoulder, a smaller shoulder.

So the more you can separate yourself from, from automobiles, the better. Especially when you’re abroad, it’s important to understand the local, not only just the laws, but the culture.

So, you know, and that gets into how safe it is. Like there’s places in, even in the United States where cycling is more dangerous than other places with similar infrastructures.

So you could say why? And we think it’s some of it to do with just the respect for cyclists and the culture around cycling.

And so it’s kind of good to understand what is the culture and what are the laws. Obviously, you do want to know about the traffic signs and follow them when you can.

And it’s good to just be visible, it’s good to just have bright clothing on and, you know, use all the, when you’re signaling yourself in traffic to be big, don’t be small, don’t be subtle, be big, big motion and then predictable. You want to make sure that, that, then that kind of goes along with following the culture and the customs.

If the culture is to point or use specific hand signals, you want to Know that because people will be familiar with the customs wherever they are. And then the most important and then you just got to stay alert.

You know, you just got to realize, especially if you’re cycling around cars, that there is a risk and having a situational awareness will always help you.

WORM
00:11:20.430 – 00:11:37.070
Okay, well, you kind of answered my next question. I was going to ask, as a general rule, is it more safe or more dangerous to cycle abroad? And it appears the answer is it depends.

It’s safer in countries like the Netherlands and Denmark, but is more dangerous in some countries.

Tom Sanford
00:11:38.350 – 00:12:37.295
It really does. It really depends. Having done some actually spend quite a bit of time looking into how dangerous is it to ride a bike.

It’s not such an easy question to answer.

So what you have, the most important thing is not the absolute number of injuries per country because that’s going to depend on whether or not people were riding and how they’re riding.

So obviously if you’re doing Red Bulls rampage mountain bike race, you’re at an increased risk relative to the person who, who’s on a dedicated bike lane just going to work. So getting data on ridership is quite challenging. So the metric that’s most important is either injuries or fatalities per unit traveled.

And that’s usually the most common metric for that is per 100 km is kind of the standard.

WORM
00:12:37.295 – 00:12:37.440
So.

Tom Sanford
00:12:37.670 – 00:12:41.252
So just to give you an example, the US is about 10.

WORM
00:12:41.328 – 00:12:42.470
10 what? Per what?

Tom Sanford
00:12:42.870 – 00:12:52.390
It’s 10 deaths per 100 million kilometers cycled. So that’s, that’s a metric. So the Netherlands are in Denmark are both about one.

WORM
00:12:52.710 – 00:12:55.110
Wow. Really A whole order of magnitude.

Tom Sanford
00:12:55.270 – 00:13:51.320
And I’ve seen, I’ve seen research that say that injuries, because that’s fatalities, injuries are actually 20.

It’s about 25 fold safer to ride in the Denmark or the Netherlands compared with the United States if you look at injuries and injuries are hard to injuries also you have to figure out how to measure them.

So er visits are one way and that’s, that’s kind of the, the way a lot of people use figure out how many injuries people have because the ones that don’t make it to the er, it’s hard to figure out how many sure are there and to document them quantitatively. So the US is not as good as some countries, but it is better than other countries. So I gave the example of South Africa and Brazil.

Brazil is another one. Those are more like in the 30 to 20 to 40 fatalities per 100 million kilometer cycle.

WORM
00:13:51.400 – 00:13:52.440
Significantly higher.

Tom Sanford
00:13:52.680 – 00:14:00.850
Significantly higher. Right. So you know, building infrastructure around cycling can make it Much, much safer.

WORM
00:14:01.250 – 00:14:15.410
That sounds like it.

Now, in terms of equipment that you plan on using, such as a helmet or lights or reflective gear, should one take that with one in, in suitcases or should you plan on getting it at your destination?

Tom Sanford
00:14:15.970 – 00:14:50.980
The safest is always to bring your own because you would hope that there’s helmets available wherever you are.

But especially in a country that’s potentially outside of the Western world, you may not know what the quality of the helmet or protective gear that you’re wearing is. And if it, here’s to standards in the West. So it’s always the safest to bring your own.

But if there are space constraints, if you’re in the west, it’s pretty easy to find something, a helmet to either buy or rent. Whereas in the further off the beaten path you go, the better idea it is to bring your own.

WORM
00:14:51.300 – 00:14:54.580
So you’re thinking Western Europe, you could probably find a lot of stuff there.

Tom Sanford
00:14:54.580 – 00:15:10.900
Oh yeah, yeah. In Western Europe. In the United States, helmets are measured up into a certain category. They’re all about similar safety.

They’ve all been tested to a certain safety standard. Whereas that, that may not be true in, you know, somewhere that’s really rural.

WORM
00:15:11.300 – 00:15:17.220
Okay, so it sounds like if you’re going to a low income country, it’s all the more important to pack pretty much everything you think you would need.

Tom Sanford
00:15:17.760 – 00:15:18.120
Yeah.

WORM
00:15:18.120 – 00:15:31.920
Okay, good, good.

One thing I see, and I live in Seattle, as you know, one thing I see is people riding around on bicycles or other with music, with EarPods, listening to music or who knows what. Is that a good idea?

Tom Sanford
00:15:32.640 – 00:16:06.440
Well, it’s definitely not a good idea.

And if you’re going to ride with an earpiece only one in many places, two is actually illegal in many cases in the United States, two earbuds is not permissible by law. Yeah. So if you’re going to do it, definitely one. And, but you know, some of us have, have done this before.

If you’re going to do it again, you want to do it. We’re in a place that’s a lot safer to ride. You don’t want to do that in the middle of traffic.

That’s, that’s just, you’re just asking, asking for trouble there.

WORM
00:16:06.680 – 00:16:15.580
Okay, good, good. And now you published this article in jama.

Can you talk a little bit about what you found in that in terms of traffic safety, including different age groups?

Tom Sanford
00:16:16.380 – 00:17:43.340
Well, what we were trying to do is to figure out a trend that we found in the United States between 1998 and 2013 where injuries, ER visits went way up in adults, they went down in children and they went er visits due to bicycle injuries, er visits due to bicycle injuries decreased by about 50% and injuries due to, in children they would decrease by about 50% of children they went up by about the same quantity in adults. So the question was what was going on and why was that happening? And we, we think it’s due to ridership changes.

I heard a quote that I thought characterized the issue quite well, which is as cycling decreased as a pastime, it increases popularity as a sport. So less children cycling, for better or for worse, and more adults, and particularly older adults were cycling.

And it seemed like adults above 45 had a much higher rate of getting hospitalized if they were either seen in the er, if they were injured in a bicycle accident, which, you know, it’s not news that older individuals are at higher risk of injury if they get into an accident. But we think it’s basically the result of a change in ridership that we saw that trend.

WORM
00:17:43.740 – 00:17:56.940
Okay, well I’ve seen touring groups advertised for older people, even seniors. So I think would you say it’s reasonable to assume that if that’s a trend in the US it may be a trend in other countries as well?

Tom Sanford
00:17:57.420 – 00:18:53.090
It’s an interesting question because we didn’t, you don’t necessarily see the same trend in Europe, but cycling has been much more popular in Europe than it was in the U.S. the U.S. seemed to kind of find it or become more interested in, in it as a sport relatively recently compared with Europe. In Europe there’s a much more a big cycling culture. So that the trend isn’t worldwide, that seems to be more of a US phenomenon.

But it does seem to be related to what some have called the mammals, the middle aged men in Lycra.

Because you see the, like you mentioned, you see in Seattle or other major cities you see more groups of large groups of people who ride together on the weekends. And a lot of them are in their middle age. You know, they’re somewhere between that 50 and 70 year age range.

WORM
00:18:53.250 – 00:18:55.650
I’m going to tell that acronym to everybody I know.

Tom Sanford
00:18:57.090 – 00:18:57.570
Yes.

WORM
00:18:58.480 – 00:19:21.360
Well, good.

Well, summing up sounds like most important first thing to think about is do you have a dedicated space to cycle in, ideally a bike lane, something set apart from traffic. You also mentioned helmets, reflective gear, lights, not wearing more than one earpiece.

If any other tips just for keeping things safe cycling abroad.

Tom Sanford
00:19:21.760 – 00:20:38.880
So I just want to make a comment about helmets. There was there, there is, there was some criticism of helmets for a while in terms of does it make you safer.

And if it makes you safer, is it, is it good or bad for cycling? So in Australia, they implemented a mandatory helmet law and head injuries went way down.

And if even in countries like Denmark, where cycling is very safe compared with United States, there’s no question that if you have a head injury that’s, that’s puts you in a group that’s much more likely to have a bad outcome.

Now, helmet use in, in, in countries where cycling is safe is actually quite low, but for the people who do fall down and hit their head, it’s not good. So I, I really think that wearing a helmet is probably the best thing you can do that is under our control.

Other than figuring out where to cycle safely, not all of us live in cities where we have dedicated bike lanes. In Honolulu, we don’t have very many good examples of that.

So we use bike lanes, which are, we’re really happy we’re seeing more of those, but not all of us have access to it. So the best thing that you can do for yourself is to wear a helmet. It really does decrease the risk of bad things happening to you.

WORM
00:20:38.880 – 00:20:44.960
Good. Super. Well, Tom, thank you so much. Tom Sanford, Honolulu, Hawaii. Appreciate your insight on this.

Tom Sanford
00:20:46.000 – 00:20:47.440
All right, take care. Thank you.

GERM
00:20:52.160 – 00:21:51.740
Well, thanks so much to both Dr. Sanford’s Chris and Tom for this really interesting interview. I’ve learned a lot about cycling safety. I’m getting stoked to get back on a bike. And, you know, biking has always terrified me.

I have to say, I’ve climbed the highest mountain on every continent, but I don’t ride my bike around Seattle. It’s too scary. Well, now I feel like I can get back in the saddle, get empowered and start biking more. So thanks so much for that.

Thanks to all of our listeners for joining us today. We really appreciate being connected to you. If you enjoy Germ and Worm, please follow us on the socials, erm and Worm.

And please reach out to us with any questions that you may have about travel, health, travel, wellness or tips for success.

You can get to us by email germandwormmail.com or just visit our website, germandworm.com and that’s where you can find all of our preference episodes. You can binge them as much as you like to your heart’s desire. And we have a question portal.

So if something strikes your fancy, something you’d like us to talk about, just send us a message through that portal and we’ll be glad to include it. And we will use the information that you choose to share. Nothing more and nothing less. I’m Jerm.

WORM
00:21:51.740 – 00:21:55.020
I’m Worm. It’s a big planet. See it in good health and we’ll.

GERM
00:21:55.020 – 00:22:18.950
See you next time.

This podcast is designed to inform and entertain and inspire, but it does not establish a doctor patient relationship and so you should not use it as clinical care before you travel. Please see a qualified healthcare professional for recommendations specific to you and your itinerary.

The opinion in this podcast belong to Dr. Sanford, Dr. Sanford and Dr. Pottinger alone and do not necessarily represent the opinions of University of Washington or UW Medicine.