Accidental deaths of overseas visitors in Australia 1997-2000.

By world standards, Australia is a safe travel destination

for international visitors. Yet tourist safety can never be taken for granted, This paper reports on the deaths of 1513 overseas visitors to the country over a 4-year period, and focuses on the 307 deaths (20%) that were recorded as accidental. Motor vehicle crashes and drowning were the main causes of accidental death. The investigation identifies English, American, Japanese and German visitors as most frequently involved in fatal accidents. However, Irish, Swiss and Dutch visitors appear most "at risk" based on crude accidental death rates per 100,000 visitor arrivals. Strategies to prevent tourist accidents and protect Australia's reputation as a safe travel destination are examined within a risk management framework.

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Since the terrorist attacks of 11 September 2001 in the United States most travellers worldwide have been conscious, if not concerned, about their personal safety (see Taylor, 2001). Surveys show that those destinations perceived to be "safe" have a very real competitive advantage in the current climate of uncertainty (Wanderlust Magazine, 2001). However, even in safe destinations like Australia, the current crisis in public liability insurance has pressured governments and tourist operators to look closely at visitor safety (Liability Insurance Taskforce, 2002; Trowbridge Consulting, 2002).

According to the World Tourism Organization (in press), risks to the safety and security of tourists can originate from four source areas:

1. the human and institutional environment outside the tourism sector

2. the tourism sector and related commercial sectors

3. the individual traveller (personal risks)

4. physical or environmental risks (natural, climatic, epidemic).

It is worth briefly expanding these areas to show the full extent that risk is present in each sector, and the most likely areas of risk to arise in Australia.

The Human and Institutional Environment

The risks from the human and institutional environment exist when visitors fall victim to the following:

* common delinquency (theft, pick-pocketing, assault, burglary, fraud, deception)

* indiscriminate and targeted violence (such as rape) and harassment

* organised crime (extortion, the slave trade, coercion)

* terrorism and unlawful interference (attacks against state institutions and the vital interests of the state), hijacking and hostage taking

* wars, social conflicts and political and religious unrest

* a lack of public and institutional protection services.

Tourism and Related Sectors

Through defective operation, tourism and sectors related to tourism such as transport, sports, retail trade, can endanger visitors' personal security, physical integrity and economic interests through the following:

* poor safety standards in tourism establishments (fire, construction errors, lack of anti-seismic protection)

* poor sanitation and disrespect for the environment's sustainability

* the absence of protection against unlawful interference, crime and delinquency at tourism facilities

* fraud in commercial transactions

* non-compliance with contracts

* strikes by staff.

Individual Travellers

Travellers or visitors can endanger their own safety and security, and those of their hosts by the following:

* practising dangerous sports and leisure activities, dangerous driving, and consuming unsafe food and drink

* travelling when in poor health, which deteriorates during the trip

* causing conflict and friction with local residents, through inadequate behaviour towards the local communities or by breaking local laws

* carrying out illicit or criminal activities (e.g., trafficking in illicit drugs)

* visiting dangerous areas

* losing personal effects, documents, and money through carelessness.

Physical and Environmental Risks

Physical and environmental damage can occur if travellers:

* are unaware of the natural characteristics of the destination, in particular its flora and fauna

* are not medically prepared for the trip (vaccinations, prophylaxis)

* do not take the necessary precautions when consuming food or drink and in their hygiene

* are exposed to dangerous situations arising from the physical environment (natural disasters, epidemics).

Physical and environmental risks are also largely personal risks, but are not caused deliberately. Rather, they are a result of the traveller's ignorance or his or her disregard for potential risks. Indeed, it is now a common international finding that overseas visitors are most likely to be injured in unfamiliar environments and while participating in unfamiliar activities (Bentley, Meyer, Page & Chalmers, 2001; Page & Meyer, 1997; Wilks, in press; World Tourism Organization, in press). Although the four source areas generate a range of threats to tourist safety and security, threats to physical safety have become the major focus and concern for travellers following the events of 11 September 2001 (World Tourism Organization, in press).

Risks in Australia

Overall, Australia is a very safe destination by world standards, having high standards in public health, clean drinking water, a low level of infectious disease, and a well-equipped and coordinated medical system (Wilks & Oldenburg, 1995). However, incidents causing injury and death do occur and the media are quick to report on these events. Recent examples include the murder of English backpacker Caroline Stuttle in Bundaberg (Herde, 2002); the Childers Hotel fire in 2000 that caused the deaths of 14 overseas visitors (Queensland Fire and Rescue Authority, 2000); and the deaths of scuba divers Thomas and Eileen Lonergan who were lost at sea in 1998 (Reid, 1998). Ironically, these high profile fatalities are the exception rather than the rule. A review of all deaths of overseas visitors in Australia between 1997 and 2000 revealed that 76% were from natural causes and, apart from the Childers fire in 2000, there were only three (3) homicides involving visitors in the whole country during that 4-year period (Wilks, Pendergast, & Wood, in press). In order to assist visitors, one focus should be, therefore, on those arguably preventable accidents that cause injury and death, especially any accidents that can be identified as occurring relatively frequently.

Motor Vehicle Crashes

Travel medicine research consistently finds motor vehicle crashes to be the leading cause of accidental death for travellers worldwide (Wilks, 1999). In Australia, the Federal Office of Road Safety reports that the death rate for overseas visitors in road crashes is twice that of Australian drivers, after adjusting for relative population rates (Ellis, 1999). Motor vehicle crashes are also the leading cause of hospital admissions for overseas visitors (Wilks & Coory, 2002). In a review of serious injuries from motor vehicle crashes in Queensland and the Northern Territory, Wilks and Watson (2000) found that German, English, American and Japanese visitors were most at risk on Australian roads. To date, most of the detailed tourist road safety research has been conducted in Queensland (Wilks, Watson & Faulks, 1999). One aim of the present study is to determine the national frequency of overseas visitor fatalities on Australian roads, and to identify any visitor groups that might be at risk. In this paper, at risk is defined as those national visitor populations at greater relative risk of being killed through motor vehicle crashes, based on crude exposure measures.

Drowning

Following motor vehicle crashes, drowning is the next most significant source of overseas visitor death worldwide (Hargarten & Guler Gursu, 1997). In Australia, Mackie (1999) reports that 88 tourists from 12 countries drowned during 1992-1997. Mackie's analysis shows that 61% of these tourists drowned at surfing beaches or elsewhere in the "ocean", while a further 24% drowned while scuba diving or snorkelling. In their review of snorkelling deaths in Australia from 1987 to 1996, Edmonds and Walker (1999) found that around half of the drowning fatalities were overseas tourists. More recently, Wilks (2000) examined scuba diving and snorkelling deaths in Queensland between 1995 and 1998. He found 6/13 scuba fatalities and 18/20 snorkelling fatalities involved overseas visitors, particularly British and American tourists. The aim of the present study is again to determine the national frequency of overseas visitor fatalities caused by drowning, and to identify any visitor groups that might be at risk.

Other Accidental Deaths

Apart from motor vehicle crashes and drowning, it is not clear whether there are any other fatal accidents for tourists that occur on a regular basis in Australia. Homicide, suicide and death through infectious disease are not frequent occurrences with visitors to Australia (Wilks et al., in press), though they are noted in varying frequencies for American (Hargarten, Baker & Guptill, 1991), Scottish (Paixao, Dewar, Cossar, Covell, & Reid, 1991) and Canadian (MacPherson et al., 2000) citizens travelling abroad. Since homicide and suicide are categorised as "intentional" injuries (Sniezek & Smith, 1991) and this report focuses on unintentional or accidental deaths, these two sources of fatalities are not considered further. Details of overseas visitor deaths by natural causes, homicides and suicides are presented in Wilks et al. (in press).

Visitor deaths as a result of air and water transport accidents, falls and poisoning have previously been highlighted for non-US residents in the United States (Sniezek & Smith, 1991) and American citizens travelling abroad (Hargarten et al., 1991). In the Hargarten et al. study of 2463 deaths, 43 (7.2%) were caused by airplane crashes, 39 (6.5%) from poisoning (which included unintentional acute alcohol intoxication and drug overdoses), and 21 (3.6%) from burns. The present study therefore sought to identify any other accidental deaths that occurred among overseas visitors to Australia, and to compare their frequency with the findings from other travel medicine investigations.

In summary, the international literature identifies motor vehicle crashes and drowning as the main causes of accidental death to travellers. These findings are based largely on studies of citizens from developing countries travelling abroad. The purpose of the present study is to test these findings for overseas visitors to Australia and to identify all sources of accidental death. The study also sought to identify any overseas visitor groups that might be at risk based on their relative frequency of accidental deaths.

Method

The Australian Bureau of Statistics (ABS) processes around 130,000 deaths annually. There is a decentralised registration process, with each of the eight State and Territories' Registrars of Births, Deaths and Marriages being responsible by law for the registration of deaths occurring within their boundaries. The ABS receives from each State or Territory Registrar details for each death as provided on the Medical Certificate of Cause of Death. Generally, the attending medical practitioner certifies the Medical Certificate of Cause of Death where death is due to a natural cause. Deaths that are sudden and unexpected, and most deaths due to external causes, are subject to coronial enquiry and a coroner then certifies the death certificate.

Experienced mortality coding staff within the Health and Vitals National Project Centre (NPC) in the Queensland Office of the ABS use the Automated Coding System (ACS) provided by the United States National Centre for Health Statistics (NCHS) to code information from the Medical Certificate of Cause of Death in accordance with the appropriate version of the International Classification of Diseases (ICD). ICD-10 (World Health Organization, 1992) was introduced for coding of deaths registered in 1999, while 1997 and 1998 deaths were recoded using ICD-10, as they had previously been coded in the ICD-9 classification (World Health Organization, 1978).

The present study involved a retrospective analysis of all deaths of those designated as overseas visitors, occurring in Australia over the 4 years from 1997 to 2000. The 4-year period 1997 to 2000 was chosen due to the availability of ICD-10 data for those 4 years. The data selected for this study was chosen on the basis of a usual residence code of "overseas". Cause of death was then grouped according to the Chapters of ICD-10.

Results

There were 1513 overseas visitor deaths (971 males, 64%) during the study period. In the total of 307 accidental deaths (20% of all deaths) the main causes were land transport (10% of all deaths) and accidental drowning/submersion (4% of all deaths). Table 1 presents the categories of accidental death for overseas visitors, by gender. Following ABS policy, small cell sizes have not been reported by gender for reasons of confidentiality. What can be reported is that males were more frequently involved in all forms of accidental death.

Car crashes, where an occupant was killed (97 deaths), were the leading cause of land transport accidents for all overseas visitors. Other land transport accidents included 19 pedestrian deaths, nine (9) pedal cyclists, six (6) motorcycle riders, six (6) occupants of vans or pickup trucks, and four (4) bus occupants.

The largest number of accidental drownings included swimming at surf beaches (18 deaths) or tidal rivers, harbours and bays (12 deaths). Other accidental drownings involved swimming pools (6), lakes and dams (5), being swept off rocks or breakwaters (3), skin diving using underwater breathing equipment (4) and other types of skin diving/spear fishing (4).

In the accidental falls group, deaths were related to a wide range of falls from buildings, cliffs, stairs, trees, and skis or roller blades, while accidental poisoning most frequently involved psycodysleptics and narcotics. Due to the small number of deaths in specific categories, for reasons of confidentiality figures are not provided. Water and air transport accidents most frequently involved collisions of the carriers. In the "all other accidents" category, the causes of death included fire, electrocution, ingestion of food causing obstruction (choking), striking against another person (i.e., they hit someone else or someone else hit them), struck by another object, travel and motion, and air pressure injuries (e.g., barotrauma).

Table 2 presents the number of accidental deaths by selected national visitor groups. The 10 visitor groups with the most accidental deaths were selected. English, American, Japanese and German visitors had the largest number of deaths related to land transport accidents, and with the exception of the Japanese, also the largest number of drowning deaths. In the "other accidents" category, English fatalities were largely due to falls, poisoning, caught between objects, and travel and motion, while American deaths were related to falls, poisoning, struck by a thrown object, and air pressure injuries. Japanese fatalities were mainly due to falls.

A crude death rate was calculated for each visitor group based on a 4-year average (1997-2000) of visitor arrivals to Australia (Australian Bureau of Statistics, 2002). For England, the national group with the most fatalities, it was not possible to calculate a separate crude death rate since information on visitor arrivals in Australia combines English, Scottish and Welsh visitors in one group (the United Kingdom). As can be seen from Table 2, Scotland and Wales have significantly fewer fatalities than England. However, these are the only figures available so they are used to calculate a combined crude death rate of 3.47 per 100,000 visitors for the United Kingdom (UK). Germans had a similar rate of 3.66, while the United States (US) recorded 2.3. Japan, with a much larger visitor base, recorded 0.76.

The group with the largest crude accidental death rate was the Irish (8.06), though it is noted in the table that this rate is calculated on only 3 years of visitor arrivals, and the 1999 figures only extend to November of that year. The second and third largest crude death rates were recorded for Switzerland (5.22 per 100,000 visitors) and the Netherlands (4.44 deaths per 100,000 visitors).

Discussion

Australia has a very good reputation internationally as a safe travel destination (World Tourism Organization, in press). In order to maintain this reputation it is essential that tourism authorities have reliable information on the difficulties visitors might experience, and the types of accidents and injuries that are most likely to occur. This information is critical for directing prevention initiatives, and for placing negative incidents in context, especially for the media. A recent example is the murder of English backpacker Caroline Stuttle in Bundaberg (Herde, 2002), which generated dozens of international media stories questioning whether Australia really was a safe travel destination. The availability of accurate figures showing that homicides involving overseas visitors are rare in Australia (Wilks et al., in press) would have greatly assisted tourism authorities to defend the country's reputation for safety.

The present study contributes to a growing literature on tourist health and safety in Australia by identifying overseas visitor deaths due to arguably preventable accidents. Motor vehicle crashes and drowning were the leading causes of accidental death for overseas visitors during the 4-year study period. These findings reflect those of travel medicine investigations with citizens from developed countries travelling abroad, though the proportion of all visitor deaths in Australia due to motor vehicles crashes and drowning is lower than that reported elsewhere (Sniezek & Smith, 1991; Hargarten & Guler Gursu, 1997). This may be due to the variety of destinations included in other studies, but it does reinforce the finding that Australia is a relatively safe country. These results are timely, given the importance of visitor safety worldwide following the terrorist attacks of 11 September, 2001 and increasing pressure on tourism operators and travel destinations to protect the health and safety of customers as part of their insurance cover (Liability Insurance Taskforce, 2002).

Leading up to the Sydney 2000 Olympic Games there was considerable interest in road safety for tourists (Wilks, Watson & Hansen, 1999). Since then this area of visitor safety has been relatively neglected, though it continues to pose the most difficulties for overseas visitors. Studies consistently show motor vehicle crashes to be the leading cause of hospital injury admission for overseas visitors in Queensland (Nicol, Wilks, & Wood, 1996; Wilks & Coory, 2002), but until now there was very little information about overseas visitor road fatalities for Australia as a whole. The present study shows that car crashes, where an occupant was killed (97 deaths), were the leading cause of land transport accidents for all overseas visitors. While still very important, fatal accidents involving pedestrians, pedal cyclists, motorcycle riders, and occupants in buses and vans were far less frequent. This suggests that any targeted education and prevention initiatives should focus on the overseas drivers of cars.

Driving on the opposite side of the road to that which is familiar, fatigue, language and signage difficulties, and not wearing seatbelts have all been identified as key factors in overseas visitor road crashes (Wilks, Watson, & Hansen, 1999). In addition, analyses of serious road crashes in Queensland show that overseas visitors from Right Side of the road driving countries were three times more often involved in head-on collisions than visitors from Left Side of the road jurisdictions (Wilks, Watson, & Hansen, 2000). In the present study the national groups most frequently involved in road crashes were fairly evenly divided between Right (US, Germany, Netherlands, Switzerland) and Left (England, Japan, New Zealand, Ireland, Scotland, Singapore) side of the road driving jurisdictions at home (Wilks, Watson & Faulks, 1999). This suggests that disorientation is not the only factor that might be placing overseas drivers at risk (Wilks, Watson, Johnston & Hansen, 1999) and that further research is needed to guide programs aimed at assisting overseas road users.

Accidental drowning was the second most frequent type of injury death identified in this study, occurring predominantly at surfing beaches or in tidal waters. Males were more often involved than females, which is a finding consistently reported in other studies (New South Wales Injury Risk Management Research Centre, 2000). In his national review, Mackie (1999) notes that unfamiliar marine environments are a particular hazard for international tourists. In 1992-1997, 88 tourists from 12 countries drowned in Australia. In that review, 38 tourists came from Europe (15 from the UK, 10 from Germany), 35 from Asia (17 from Japan), 7 from the United States and 8 from other countries (Mackie, 1999). In the present study, English, American and German nationals were most frequently involved, followed by visitors from the Netherlands. For both road and water safety areas, identifying those visitor groups who are potentially at risk is very important for tourism authorities in order to present appropriate safety information in the language of the target group (Wilks, in press).

The other areas of accidental death identified in this study occur less frequently than road and water-related fatalities, and in some cases it could be argued that they may not be preventable (e.g., collisions involving watercraft or aircraft). Others such as accidental falls occur across a range of circumstances but should at least be addressed with general advice. For example, Hargarten and Guler Gursu (1997) suggest that tourists should be encouraged to wear good fitting, firm shoes while hiking and when walking on irregular or slippery surfaces. The number of fatal falls in this study (25 or 1.7% of all visitor deaths) is much higher than that of non-US residents (1.0%) reported by Sniezek and Smith (1991), so further investigation of the context of such falls appears justified.

In relation to accidental poisoning, the frequency of visitor deaths in Australia (18 or 1.2% of all deaths) is much lower than that reported by Hargarten and Guler Gursu (1997) for US citizens travelling abroad (6.5% of total deaths). Similarly, among the "other accidents" reported in Table 1, electrocution, fire, striking against/struck by another person, and travel and motion all total only 24 deaths over four years, and are much less frequent that fatalities reported in other studies (Hargarten, Baker & Guptill, 1991; Sniezek & Smith, 1991).

While the total number of fatal accidents in each visitor group is very important, calculating crude accidental death rates based on visitor arrivals provides additional information about at risk groups. In this study Irish and Swiss visitors had the highest crude death rates, and both groups recorded most of their deaths in land transport accidents, specifically as occupants of cars. In contrast, visitor fatalities from the Netherlands were evenly divided between land transport (pedal cyclists and motorcycle riders rather than car occupants) and drowning. By better understanding the specific activities of identified at-risk groups tourism authorities should be able to tailor their education and prevention initiatives.

In addition to identifying the specific activities of target groups, future research needs to be undertaken on exposure rates, both the length of stay in Australia by various national visitor groups, and the amount of time spent participating in various activities (e.g., time on the road during self-drive holidays; time spent at the beach or involved in water-related recreation). Similarly, further investigation is needed on sub-groups that might be at particular risk within the national visitor populations (e.g., young road users). Available evidence indicates that younger tourists are more often involved in fatal accidents, whereas older tourists die from medical conditions (Wilks et al., in press). However, to date there has been no detailed study of subgroups at particular risk. Such information is essential for accurate targeting of prevention initiatives.

In April 2002 Queensland Tourism Minister Merri Rose launched Australia's National Visitor Safety Program, on behalf of the national Tourism Ministers' Council. The launch consisted of a Safety Tips for Visitors video and an accompanying multi-lingual booklet--printed in English, German, French, Italian, Chinese, Japanese, Korean, and Spanish. The program specifically provides advice on the four areas of Beach, Road, Bush and Outback safety (Tourism Ministers' Council, 2002). The findings of the present study suggest that the booklet and video cover the main areas where visitors are likely to experience problems in Australia (road and water safety) and that the languages target the most at risk groups. The program also aims to inform tourism operators about their responsibilities to visitors regarding safety (Ministerial Press Release, 2002). This aspect of the program is particularly important, given that legal and insurance factors are now the driving force behind tourist health and safety worldwide (Wilks & Page, in press).

Risk Management

Until recently the tourism industry relied heavily on insurance as their main protection against risk. Insurance was used to transfer risk (see Figure 1) in circumstances where risk occurred infrequently, but the consequences were severe (e.g., the serious injury or death of a customer). Where risk is infrequent and not severe, operators generally retain risk (self insure); and when risk is frequent and severe the most practical option is to avoid risk (e.g., cancel an activity). Since the terrorist attacks on 11 September 2001, and the global insurance crisis, there has been a strong move toward the reduction of risk through "best practice" initiatives such as written polices and procedures, staff training, signage, visitor and customer briefings, and monitoring of industry standards (Department of Industry, Tourism & Resources, 2002; Liability Insurance Taskforce, 2002).

[FIGURE 1 OMITTED]

In today's business environment, a good risk management program should:

* identify areas of risk

* understand the causes and consequences

* take steps to prevent risks

* deal with incidents when they actually occur

* work with the media and government agencies (Wilks, 2002).

The present study addressed the first two stages of this program by identifying those circumstances where overseas visitors are killed in accidents. For each of the accident types the causes and consequences were discussed, based on current knowledge. The challenge for tourism authorities is to use this information in the remaining stages of an effective risk management program. In particular, taking steps to prevent risk should focus on Risk Reduction (Figure 1) through best practice initiatives (Wilks & Oldenburg, 1995; Wilks & Davis, 2000).

Conclusions

By world standards, Australia is a safe travel destination for international visitors. This reputation provides a competitive advantage to the country at a time when travellers are very conscious about their safety and security. In order to maintain standards it is essential that tourism authorities understand and address those areas where tourist accidents, and specifically fatal accidents, most frequently occur. The present study found that motor vehicle crashes and drowning were the main causes of accidental death involving overseas visitors. The investigation also identified English, American, Japanese and German visitors as most frequently involved in fatal accidents. However, Irish, Swiss and Dutch visitors appear most at risk based on crude accidental death rates per 100,000 visitor arrivals. The recently launched National Visitor Safety Program is acknowledged as a useful start in assisting visitors, as it provides advice on road and water safety in an appropriate range of languages. Also important is the inclusion of a risk management strategy in the federal government's new 10 Year Plan for Tourism (Department of Industry, Tourism & Resources, 2002). Effective risk management is essential if the frequency of preventable accidents among tourists is to be reduced and Australia's reputation as a safe travel destination maintained.

Table 1

Number of Visitor Deaths by Type of Accident, Australia 1997-2000

                                      Males    Females    Persons

Total accidents                         218         89        307
Land transport accidents                100         57        157
Accidental drowning and submersion       48         14         62
Accidental falls                         19          6         25
Accidental poisoning                     --         --         18
Water transport accidents                --         --         11
Air and space transport accidents        --         --         10
All other accidents                      17          7         24

Table 2

Number of Accidental Visitor Deaths by Selected National Groups,
Australia 1997-2000 (a)

National          Land       Drowning    Other       All       Average
Visitor         Transport                         Accidents     Annual
Group                                                          Visitor
                                                               Arrivals

England            27           11        18         56         496125
Scotland (b)        2            2         4          8
Wales (b)           4            0         1          5
USA                16           11        10         37         400675
Japan              12            3         8         23         748200
Germany            11            6         3         20         136375
New Zealand         7            1         4         12         736250
Netherlands         4            4         1          9          50625
Ireland (c)         6            1         2          9          27900
Switzerland         6            1         2          9          43100
Singapore           7            0         1          8         257425

National             Crude
Visitor           Accidental
Group             Death Rate/
                100,000 Visitors

England              3.47
Scotland (b)
Wales (b)
USA                  2.30
Japan                0.76
Germany              3.66
New Zealand          0.40
Netherlands          4.44
Ireland (c)          8.06
Switzerland          5.22
Singapore            0.77

Note: (a) Visitor arrival figures for 2000 are preliminary.

(b) Visitor arrival figures for Scotland and Wales are tallied with
English visitor arrivals to form a United Kingdom category.

(c) Visitor figures for Ireland are based on arrivals for 1997
(25,300), 1998 (31,000) and 1999 to November only (27,400), then
averaged for the three (3) years. These are the most current figures
available.

References

Australian Bureau of Statistics. (2002). Overseas arrivals and departures, catalogue No. 3401.0. Canberra: Author.

Bentley, T., Meyer, D., Page, S., & Chalmers, D. (2001). Recreational tourism injuries among visitors to New Zealand: An exploratory analysis using hospital discharge data. Tourism Management, 22, 373-381.

Department of Industry Tourism and Resources. (2002). The 10 year plan for tourism. A discussion paper. Canberra: Author.

Edmonds, C.W., & Walker, D.G. (1999). Snorkelling deaths in Australia, 1987-1996. Medical Journal of Australia, 171, 591-594.

Ellis, B. (1999). A national road safety overview. In J. Wilks, B. Watson & R. Hansen (Eds.), International visitors and road safety in Australia: A status report (pp.19-26). Canberra: Australian Transport Safety Bureau.

Hargarten, S.W., Baker, T.D., & Guptill, K. (1991) Overseas fatalities of United States citizen travelers: An analysis of deaths related to international travel. Annals of Emergency Medicine, 20, 622-626.

Hargarten, S.W., & Guler Gursu, K. (1997). Travel-related injuries, epidemiology, and prevention. In H.L DuPont & R. Steffen (Eds.), Textbook of travel medicine and health (pp. 258-261). Hamilton, Ontario: BC Decker.

Herde, C. (2002, April 11). Qld: British Backpacker Robbed and Thrown to Death off Bridge. AAP General News.

Liability Insurance Taskforce. (2002). Report to the Queensland Government. Retrieved 22 May. 2002, from http://www.premiers.qld.gov.au/ about/pcd/economic/insurancetaskforce.pdf

Mackie, I.J. (1999) Patterns of drowning in Australia, 1992-1997. Medical Journal of Australia, 171, 587-590.

MacPherson, D.W., Guerillot, F., Streiner, D.L., Ahmed, K., Gushulak, B.D., & Pardy, G. (2000) Death and dying abroad: The Canadian experience. Journal of Travel Medicine, 7, 227-233.

Ministerial Press Release. (2002, April 19). Visitor safety a priority for tourism. Brisbane: Office of the Queensland Tourism Minister.

New South Wales Injury Risk Management Research Centre. (2000). Analysis of drowning in Australia and pilot analysis of near-drowning in New South Wales. Sydney: Australian Water Safety Council, 2000.

Nicol, J., Wilks, J., & Wood, M. (1996). Tourists as inpatients in Queensland regional hospitals. Australian Health Review, 19, 55-72.

Page, S.J., & Meyer, D. (1997). Injuries and accidents among international tourists in Australasia: Scale, causes and solutions. In S. Clift & P. Grabowski (Eds.), Tourism and health: Risks, research and responses (pp. 61-79). London: Pinter.

Paixao, M.L., Dewar, R.D., Cossar, J.H., Covell, R.G., & Reid, D. (1991) What do Scots die of when abroad? Scottish Medical Journal, 36, 114-116.

Queensland Fire and Rescue Authority. (2000). Building fire safety in Queensland budget accommodation. A report resulting from the fire in the Palace Backpackers Hostel, Childers. Brisbane: Author.

Reid, R. (1998, November 7-8). Deep Doubts. The Australian Magazine. 24-26; 30-31; 33; 35.

Sniezek, J.E., & Smith, S.M. (1991). Injury mortality among non-US residents in the United States 1979-1984. International Journal of Epidemiology, 19, 225-229.

Taylor, H. (2001, December 5). Many people unprepared for terrorist attacks or other disasters. The Harris Poll # 60. Retrieved 9 May, 2002, from http://www.harrisinteractive.coml harris_poll/searchpoll.asp

Tourism Ministers Council. (2002). Safety tips for visitors to Australia. Brisbane: Tourism Queensland.

Trowbridge Consulting. (2002). Public liability insurance. Analysis for meeting of Ministers 27 March 2002. Retrieved 22 May, 2002, from http://www.trowbridge.com.au/dir095/home.nsf

Wanderlust Magazine. (2001). September 11--The Aftermath. Retrieved 19 December, 2001, from at http://www.wanderlust.co.uk/survey/ sept11.html

Wilks, J. (1999). International tourists, motor vehicles and road safety: A review of the literature leading up to the Sydney 2000 Olympics. Journal of Travel Medicine, 6, 115-121.

Wilks J. (2000). Scuba diving and snorkelling safety on Australia's Great Barrier Reef. Journal of Travel Medicine, 7, 283-289.

Wilks, J. (in press). Injuries and injury prevention. In J. Keystone, P. Kozarsky, H.D. Nothdurft, D.O. Freedman & B. Connor (Eds.), Travel medicine. New York: Harcourt.

Wilks, J. (2002b, March). Partnerships for safety and security at tourism destinations. Paper presented to the World Tourism Organization Crisis Recovery Meeting, Berlin.

Wilks, J., & Coory, M. (2002). Overseas visitor injuries in Queensland hospitals: 1996-2000. Journal of Tourism Studies, 13, 2-8.

Wilks, J., & Davis, R.J. (2000). Risk management for scuba diving operators on Australia's Great Barrier Reef. Tourism Management, 21, 591-599.

Wilks, J., & Oldenburg, B. (1995). Tourist health: The silent factor in customer service. Australian Journal of Hospitality Management, 2, 13-23.

Wilks, J., & Page, S. (in press). Current status of tourist health and safety. In J. Wilks & S. Page (Eds.), Managing tourist health and safety in the new millennium. Oxford: Elsevier Science.

Wilks, J., Pendergast, D.L., & Wood, M.T. (in press). Overseas visitor deaths in Australia: 1997-2000. Current Issues in Tourism.

Wilks, J., & Watson, B. (2000). Assisting `at risk' tourist road users in Australia. Travel Medicine International, 18, 88-93.

Wilks, J., Watson, B., & Faulks, I. (1999). International tourists and road safety in Australia: Developing a national research and management programme. Tourism Management, 20, 645-654.

Wilks, J., Watson, B., & Hansen, R. (Eds.). (1999). International visitors and road safety in Australia: A status report. Canberra: Australian Transport Safety Bureau.

Wilks, J., Watson, B., & Hansen, J. (2000). International drivers and road safety in Queensland, Australia. Journal of Tourism Studies, 11, 36-43.

Wilks, J., Watson, B., Johnston, K., & Hansen, J. (1999). International drivers in unfamiliar surroundings: The problem of disorientation. Travel Medicine International, 17, 162-167.

World Health Organization. (1978). International Classification of Diseases, 9th revision. Geneva: Author.

World Health Organization. (1992). International Statistical Classification of Diseases and Health Related Problems, 10th revision. Geneva: Author.

World Tourism Organization. (in press). Safety and security in tourism: partnerships and practical guidelines for destinations. Madrid: Author.

Jeffrey Wilks
and Donna Pendergast
The University of Queensland, Australia

Maryann Wood
Australian Bureau of Statistics,
Australia

Professor Jeffrey Wilks, Centre for Tourism and Risk Management, School of Tourism and Leisure Management, The University of Queensland, 11 Salisbury Road, Ipswich, QLD 4305, Australia.