Perils of Passage

After an 11-hour flight from Amsterdam to Tokyo, Eiko Ishii was thanking the attendants at the aircraft exit when her face went white and she collapsed. Her husband helped her to a seat and Ishii lost consciousness. Her hands began jerking in spasms. She awoke to her sister telling her a wheelchair was waiting by the door. Sitting down again, she blacked out once more and her eyes rolled back in her head. "My husband and sister told me they thought I was dying," she says.

Clinic staff at Narita International Airport gave her oxygen and rushed her to the nearby Red Cross Hospital. There Dr. Hiroshi Morio immediately diagnosed a pulmonary embolism: a blood clot that had lodged in her lungs, possibly as a result of deep vein thrombosis (DVT), a condition often prompted by prolonged periods of immobility. "It was easy to diagnose," says Morio. "She was in a critical condition." For seven days Ishii's family kept a bedside vigil, and she was eventually discharged after three weeks. Eight months later, the 57-year-old still takes daily doses of anticoagulants. Ishii knew about DVT and, although she stayed seated the whole flight, made sure she did some stretches. As someone who swims four times a week, she never thought she was at risk. "I guess," she says, "my case proves it can happen to anybody."

Most people are slightly nervous about flying and some are terrified. According to experts and the anecdotal evidence of travelers, things are a lot scarier than you thought up there—and it has nothing to do with the dangers spelled out on the safety card in the seat pocket in front of you. The new concerns swirling around air travel concern high levels of cosmic radiation, the questionable quality of the air we breath in cabins, disease-causing microbes and the famously cramped seating that once seemed something to merely peeve about, not die from. Exactly what risks we face when flying is the subject of an increasingly acrimonious debate among airlines, flight attendants' unions, consumer groups and passengers. "Aircraft have been called incubators of disease," says Farrol Kahn, director of Britain's Aviation Health Institute. "The airlines have a lot to answer for."

In the case of DVT, many airlines will be forced to do just that in the next few weeks, as the summer holiday season takes off. The death last October of Briton Emma Christofferson, 28, after flying home on Qantas from Australia triggered an avalanche of claims. Melbourne law firm Slater & Gordon has collected 2,300, of which 120 involved deaths. It hopes to file test cases later this month in what all sides see as a legal watershed for the aviation industry. "The cases involve just about every airline flying to and from Australia," says Paul Henderson, heading Slater & Gordon's suit. "And we're the tip of the iceberg."

Of all the health fears associated with the skies, it is DVT that has captured most public attention. Erroneously referred to as "economy-class syndrome," DVT can strike cramped passengers in any section of an aircraft. In some victims, the effect of the blood clots might be a sharp stabbing pain and swelling in the lower leg. In others, it might be much more serious: part of the clot may detach itself and travel through the bloodstream to the lungs, where it can cause a pulmonary embolism, an obstruction that can prove fatal. The Slater & Gordon case goes to the heart of the issue: to be successful, the firm must show the airlines both knew the risks and gave insufficient warning. "We are talking about a real risk with real and appreciable harm," says Henderson. "It's a small risk and easy to reduce by taking some fairly simple steps, which are not very expensive for airlines to do. And yet if they do not do it, you might die."

The airlines' defense rests on the lack of conclusive evidence linking flying to dying, or even getting sick. "There is no scientifically valid evidence that the cabin environment in commercial aircraft is unhealthy," declares Dr. Russell Rayman, executive director of the Aerospace Medical Association. As for risk, the airlines maintain there is no evidence so far that suggests a busy aircraft cabin might be more dangerous than sitting still anywhere, whether on a crowded train, bus, car or even at home. Many carriers feel they have been unfairly singled out as the scapegoats of a health scare driven by the media and "no win, no fee" lawyers such as Slater & Gordon. "There's a lot of hype and a lot of lawyers," growls one Asian airline executive. "There are people who might have been genuinely ill and people who see a court case." Airlines insist passengers are primarily responsible for their own health. After all, cramped conditions can lead to stress, and even disruptive and unruly behavior, but no one is blaming the airlines for air rage. "DVT has been around for a long time. It's linked to immobility, not flying," states Patrick Garrett of Cathay Pacific. Says Japan Airline's (JAL) Yoshie Otaka: "Basically it's a matter of primary self care."

But even if there is not enough scientific proof to fundamentally alter the way airlines handle passengers, the challenges have spurred change: regulatory authorities are looking into the matter, and many airlines are upgrading their health advice to customers and crew, as well as assisting World Health Organization research begun in Geneva in March designed to settle the debate once and for all. Says a JAL executive: "The general line is that travelers should exercise their own common sense and not rely on airlines to play 'nanny.' But in this increasingly litigious world, that is a role we may have to play more prominently."

With more anecdotal evidence and lawsuits every month, the pressure is mounting. In May, a British study of 200 passengers over the age of 50 taking flights of eight hours or longer found one in 10 developed early signs of DVT afterward. In February, a 10-year-old girl was struck down with DVT after a 13-hour flight from London to Hong Kong, during which she slept in an economy-class seat without moving. Since the beginning of the year, separate DVT suits have been filed against Cathay Pacific, Delta Airlines, Air France and Greece's Olympic Airlines. Australian Anthony Sharp's case against Cathay claims the 45-year-old developed a pulmonary embolism after an international flight in 1999. Filed in March, it too has the potential to set an industry precedent. More and more doctors are also speaking out. Between 1994 and 2000, Narita's Morio saw 21 patients with DVT. All survived, but Morio says: "There must be more who died before they reached here." Narita clinic head Toshiro Makino confirms that suspicion. He treats up to 60 people a year for DVT, and says 25 patients died from pulmonary embolism between 1992 and 2000. Of the 13 deaths on arrival in 2000, he put eight down to DVT. Other doctors say Makino did not prove DVT as the cause of death. But his figures reflect a worldwide pattern: based on the numbers of passengers treated on arrival in the U.K., British doctors estimate 2,000 people contract the condition each year, 15 of them fatally. "It's the sitting still that does the damage," says Patrick Kesteven, a consultant hematologist at the Freeman Hospital in Newcastle, northern England. "And the one place that 99% of us sit still longest, in the most discomfort, is on an airplane."

Maybe so, but proving cause and effect has been difficult. Those who develop DVT are likely to have a predisposition to do so (see box), and the condition itself can be almost impossible to track. Minor cases may produce no symptoms, while major complications like pulmonary embolisms can show up weeks after the initial clotting. Immobility may play a role, but to some experts the idea of a special link between aircraft and thrombosis simply isn't plausible: last year in Britain, a House of Lords report focusing on air travel and health issues tied DVT to sitting in a variety of cramped conditions, including cars and trains as well as airplanes. This March, a conference by the World Health Organization of scientists and industry representatives in Geneva concluded there was a probable but inconclusive link between air travel and DVT, and decided that up to two years' more research was needed.

It is not only the scientists who want answers. So do the carriers: 16 of them attended the WHO meeting. In February the International Air Transport Association advised all airlines to tell travelers of the risk of DVT when they make reservations. Airbus reports that buyers of its new 550-seat A-380 aircraft have expressed an interest in putting treadmills on board. And some airlines are already providing exercise information to passengers. JAL is showing a new nine-minute in-flight exercise video that refers to DVT. Emirates gives passengers the "Airogym," a sort of half inflated water wing, which they squash with one foot and then the other, pushing the air back and forth. And Taiwan-based China Airlines is introducing new seats that each consist of two airbags, which mold to the passenger's body to reduce seat pressure points and so allow better circulation.

But across Asia, risk awareness is thin, and no pan-Asian transport body exists to call for precautionary measures, as the European Commission did in January. During the Haj season when tens of thousands go to Mecca, Pakistan International Airways routinely refits aircraft to shoehorn in as many seats as possible. In China, Li Ru, spokeswoman for Air China, puts her faith in passenger size. "We are shorter and smaller than Westerners, so we're less uncomfortable in airplane seats," she says. For those airlines that are taking action, the mood is aggressively defensive. Following the WHO conference, the Association of Asia Pacific Airlines, which represents 18 carriers, held a closed-door meeting on DVT in Kuala Lumpur. Director general Richard Strickland cited a "wide gap" between anecdotes and the evidence and said the organization wants to "sift speculation and rumor from fact." Strickland stressed his members would follow the who's eventual recommendations. Until then, "our first priority is passenger well-being, our second is to prevent unnecessary alarm and vexatious litigation." Says AAPA spokesman Carlos Chua: "There is no definite correlation between DVT and flying. My suspicion is that there are probably more factors. It's almost like saying breathing is hazardous to your health." Asked about the legal challenges facing some of his members, he dismisses them as "all shadow play."

Yet to become a legal issue is the worry over cosmic radiation. According to the Federal Aviation Administration, at 12,000 m air travelers are exposed to as much as 265 times the radiation dose they receive on the ground. Some airlines take pregnant female flight attendants off airborne duties to avoid exposing the fetus to cosmic rays. Passengers who make a transpolar journey, like the new direct Hong Kong-New York routes operated by Continental Airlines, United Airlines and, from September, Cathay Pacific, receive on average the equivalent to three chest X rays. (The rays concentrate around the North Pole's magnetic attraction.) Five round-trips on these flight paths would put the traveler in excess of the recommended annual limit for exposure to radiation, experts say. Already, since the flights commenced in March, Continental and United have rerouted one each, Continental citing passenger health concerns, United radio interference from solar radiation. (United said last week it was canceling its flight from next month for business reasons.) Maria Blettner, head of Germany's Radiation Protection Commission, is finishing a large-scale mortality study on cancer among flight crews, which is examining the medical history of 22,000 pilots and 50,000 flight attendants. Results are due soon, but Germany's Cockpit Association, a professional organization of pilots and engineers, warns the findings will reveal breast-cancer rates among stewardesses may be twice as high, and skin-cancer rates up to 15 times as high as those of the general populace.

And what of those who say there is something in the air? Some medical research suggests not. In a 1996 editorial, the New England Journal of Medicine stated flatly that "during most commercial flights today, cabin air is remarkably clean." Airlines generally insist their air is neither polluted nor unhealthy. But in January, British Airways admitted to a problem with its fleet of Boeing 777s after crew members reported a high incidence of nausea and fainting. Poor air distribution led to still pockets of air forming at head height in parts of the airplanes, says BA, forcing some staff to work in conditions that were "like a hot day with no breeze." Boeing has said it is studying ways to improve the airflow. For passengers, too, air distribution has become an issue: many new planes no longer have individually controlled air ducts above their seats. About half the cabin air passengers breathe is recirculated, meaning it has been sucked out of the cabin, passed through filters and returned mixed with fresh air drawn from outside via the engines. "You have to warm the air you bring in from outside," says Ian Perry, a consultant on occupational and aviation medicine. Industry experts currently insist microbes are caught in complex filtering systems and passengers face no greater risk of contracting an illness from a neighbor than they would in any crowded space. "The air goes through a lot of machinery before it gets back to you," says Perry. Any flyer who has listened with dread to a snuffle a few rows back, and then comes down with an illness a few days later, might disagree. But studies suggest proximity, not air quality, is the issue when it comes to contracting colds and other maladies.

Another potential problem relates to barometric pressure. Most aircraft cabins are pressurized to the equivalent of an altitude up to 2,400 m. Anyone who has gone mountain trekking knows that shortness of breath, dizziness and even fainting can occur at such levels on earth. For passengers with a heart or lung condition, the problem could be more severe in the air. (They should consult their doctor before flying.) But airlines resist increased pressurization on economic and technical grounds. "I'd have no wish to fly in an airplane trying to maintain sea-level pressure," says Perry. "You would need a much stronger structure—you probably couldn't have any windows because they might blow out." Says Earle Perera, director of the Building Research Establishment's Environmental Engineering Center in Britain: "It may be technically feasible, but it's just not economically possible."

And that's the way it goes, as airlines, passengers and experts seek a balance between health and the bottom line. Take the issue of humidity. Some passengers find cabin air to be uncomfortably dry—as low as 5% humidity is common, compared with 30% in the earth's temperate zones. Some doctors advise using saline sprays to prevent nasal passages from drying out, which makes them more susceptible to colds and other germs, and wearing glasses rather than contact lenses to ward off dry and itchy eyes. But don't expect the carriers to instigate change. "If airlines increased cabin humidity beyond the customary level, condensation inside the aircraft's interior walls would trickle downward after landing and eventually enter the plane's sensitive electronics system," says Luft-hansa's chief medical officer Lutz Bergau. "As a passenger, would you want that to happen?" As for space, the industry acknowledges it is possible to give economy-class passengers more room, but only for higher ticket prices.

So much for the romance of air travel. "We had no legroom, everyone was grum-py and the air stewardess was unfriendly," says Patrick Schepers, 13, of Peer, Belgium, after a recent long-haul flight. "It's the cocktail of ingredients," says David Dison, 46, a South African lawyer and frequent traveler. "The cabin pressure, the lack of legroom, the lack of air." But airlines' attempts to share blame with passengers may hold some water. Ishii says she knows she should have walked around, but stayed in her seat so as not to disturb her husband and his neighbor. And some passengers' behavior may expose us all. Briton Judith Wilson says she recently boarded a flight to South Africa, armed with eucalyptus drops and decongestant tablets to counter a chest infection she developed days before. Fearful of jeopardizing her cheap, advance-purchase fare, she didn't consult her doctor—or tell the airline. "I'm a danger to other passengers," she admits. "But if I cancel my flight, that's it. My holiday's gone." For Wilson, as for so many others, air travel has become less of an adventure and more of a calculated risk.