Healthy tourism

Authored by: Robyn Bushell

The Routledge Handbook of Health Tourism

Print publication date:  November  2016
Online publication date:  November  2016

Print ISBN: 9781138909830
eBook ISBN: 9781315693774
Adobe ISBN: 9781317437505

10.4324/9781315693774.ch8

 

Abstract

Health outcomes . . . are only partly a consequence of activity within the health sector as narrowly defined. More important determinants of health status of a population relate to combinations of geography, history and culture and to the activities of the public and private sectors which condition food production and distribution, availability of cash income, education, water supply and sewage disposal, housing, policing of motor vehicles and many other factors.

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Healthy tourism

Health outcomes . . . are only partly a consequence of activity within the health sector as narrowly defined. More important determinants of health status of a population relate to combinations of geography, history and culture and to the activities of the public and private sectors which condition food production and distribution, availability of cash income, education, water supply and sewage disposal, housing, policing of motor vehicles and many other factors.

(Taylor, 1994)

This chapter explores the interactions of tourism with the health of people and place and the concept of ‘healthy tourism’ developed as a framework to realign the health–tourism relationship into a more positive one. It considers the role tourism can play to improve the health benefits of local people and places, not just the health of the visitor, thus it is not a form of health tourism. It ties conceptually to ideals of sustainable tourism.

A case study of Ha Long Bay, Vietnam, demonstrates the intersections of healthy places with ‘healthy tourism’. This is an example of a destination enjoying considerable success in terms of growth in visitation, but where pressure from tourism is placing the health of the ecosystem and humans at risk. It demonstrates the need for ‘healthy tourism’ as a socially and environmentally responsible approach to tourism planning. This requires mechanisms that enable and encourage the public and private sectors of tourism and health to work together to improve the safety, health and wellbeing of local people, the natural environment and travellers (Bushell and Powis, 2009).

Unprecedented levels of global travel, especially to developing countries, have major implications for the tourism system. The interconnectedness of the economic wellbeing of tourism and the integrity and health of the natural environment and the people, particularly those from developing countries, for whom tourism represents an important tool for community development, deserves to be better understood. A more ethical framework for tourism planning has been developed to address this need. ‘Healthy tourism’ grew out of a World Health Organization (WHO) initiative seeking to improve the quality of life of local communities.

This requires a more collaborative approach to tourism planning and explicit management of the interrelationships between tourism and human health, environmental management, natural and cultural heritage and sustainable development. This is achieved by drawing together the expertise of the public- and private-sector professionals across tourism, health, environment and community development.

The ecological and social effects of tourism have been widely documented, though the health consequences are often overlooked. For example, marine biodiversity in small island nations significantly influences both human health and the local economy in numerous ways (Bapoo-Dundoo, 2001; McElroy, 2003; Task Force on Small States, 2000) and is directly affected by tourism. Inadequate tourism planning and control may be associated with water pollution from hotels, condominiums, pleasure craft and cruise ship waste water; coastal siltation caused by soil erosion from the removal of mangroves and improper landscaping, often associated with hotel, resort and marina developments; physical damage to coral reefs due to trampling from snorkelling and diving, collecting shells for souvenirs, boat moorings and anchors, sandmining and dredging; over-fishing for recreational fishing as a tourist attraction and excessive fishing to supply hotels and resorts (Conlin and Baum, 1995; McElroy, 2003; Sinha and Bushell, 2002). The consequent health effects include huge decreases in the fish catch (up to 50 per cent reported in the Caribbean: United Nations Environment Programme, 1999), causing decreases in income for fishers and for other families’ budgets due to the need to buy more expensive sources of meat and protein (mostly imported). This in turn can lead to reduced nutrition and increased cholesterol intakes, resulting in increased heart disease, imposing pressure and costs on local health services. Heavy demands on scarce water supplies have direct consequences on local agriculture affecting the diets and wellbeing of local people. The ecological changes also cause a decrease in the scenic qualities in coastal places as well as depleting marine life. These can lead to downturns in tourism and hence a decrease in economic wellbeing. Biodiversity conservation, health and wellbeing of locals and the tourism economy are inextricably linked. The cycle can degrade increasingly over time or, with careful planning and monitoring, sustainable tourism development can serve to protect environmental and human wellbeing.

Other common health effects related to tourism in developing nations may include costs to family and community life associated with the introduction of gambling; organised prostitution and the associated communicable diseases; increased alcohol consumption; smoking; changing dietary patterns with the introduction of imported and fast foods; and family unit dislocation when young parents leave their family and village to work in resorts (Bapoo-Dundoo, 2001; Bushell and Staiff, 2001; Mastny, 2001).

Added to this, the economic benefit, the reason for pursuing tourism development, is often confined to a very small proportion of the local populations (Akama and Kieti, 2007; Mastny, 2001). Experience suggests that at the local or microeconomic level tourism does not always yield the anticipated returns due to establishment and maintenance costs of essential infrastructure, particularly roads, airports, docks, public transport, utilities, including enhanced water supply, sewerage, facilities such as communication systems and visitor service centres, all needed to attract tourism investment (Kennedy, 2002; Manning and Prieur, 1998). Often the economic ‘trickle down’ to the wider community is very limited because of internal, external and invisible leakage through foreign and non-local investment, employment of non-locals and the purchasing of non-local goods and services (Bapoo-Dundoo, 2001; Mastny, 2001; Task Force on Small States, 2000). Governments in developing nations are pouring money into tourism development in a bid to attract investors and diversify their economies (United Nations Conference on Trade and Development, 2001). In gross economic terms tourism investments pay off; however, according to World Bank studies, the average internal leakage for most developing countries is estimated at 55 per cent of gross tourism earnings (Ngone, 2001). A principal export in 83 per cent of developing countries (Richardson, 2010), tourism can place significant financial burden on local authorities (DANTE, 2002) if not strategic. This can divert scarce resources from local needs such as health and education.

The ‘healthy tourism’ concept

The WHO recognised the need for mechanisms and indicators within tourism planning and operations to promote the health, safety and wellbeing in rapidly growing destinations in developing countries (Bushell and Staiff, 2001).

While continuing to have a primary interest in the treatment and prevention of illness and equity in access to safe food, water and air, the WHO has been pursuing a more holistic view of health and wellbeing. This has encompassed the inclusion of tourism-related issues since the 1990s, when the Rio Earth Summit and subsequent meetings paid particular attention to the health and environmental problems of the most vulnerable.

As part of the United Nations (UN)-wide recognition for new and effective approaches in managing complex development issues, the WHO developed a regional policy framework, New Horizons in Health. The purpose was to aid governments and communities in developing new strategies and actions as a sustainable basis for health; to place an emphasis on disease prevention rather than cure; and to encourage community participation as well as intersectoral cooperation. New Horizons in Health gave rise to a range of strategies which were formulated across Asia and the Pacific. These include the use of ‘healthy settings’, such as Healthy Schools, Healthy Workplaces, Healthy Markets, Healthy Hospitals and Healthy Cities (Powis, 1999).

A WHO meeting of Pacific Health Ministers in Fiji in 1995 resulted in the Yanuca Declaration for Health in the Pacific in the 21st Century, leading to the creation of the Healthy Islands concept. It reflected a desire to seek Pacific solutions to Pacific problems. The Healthy Islands concept involved continuously identifying and resolving priority issues related to health, development and wellbeing and enabling these issues to be addressed in partnerships between communities, organisations and agencies at local, national and regional levels (Powis, 1999).

The need for more sustainable tourism practice was one such priority issue, identified along with food importation, tobacco advertising, waste management and resource exploitation as a powerful external influence with health-related consequences for small islands (Ritchie, Sparks and Rotem, 2000). As discussed above, tourism places undue pressure on small island environments. It also adds significantly to the problem of food importation. Additionally, because a large proportion of the economy is accounted for by exports and imports (some 112 per cent of gross domestic product (GDP) in the Pacific nations), even minor disruptions in world markets, including fluctuations in demand and/or prices for services like tourism, can have a major impact on the local economy. In Fiji, for example, at that time, tourism was the single most important export commodity, accounting for 26.3 per cent of export goods and services (followed by sugar at 11.9 per cent) in 1997 (Task Force on Small States, 2000). Since the 2006 coup this has fallen, but remains at 13.7 per cent of GDP compared to 3.1 per cent as the world average (World Travel and Tourism Council, 2015). A similar situation continues in most Pacific Island nations. With this reliance on tourism, any change affects the entire population. Any tourism-related impacts are significant.

‘Healthy tourism’ was developed in 2000–2001 with the WHO Pacific Regional Office and the WHO Collaborating Centre at the University of Western Sydney, Australia, as a component of the Healthy Islands strategy. Based on the ethic that tourism should be a tool for community development, quality of life and health benefits should be built into the goals and objectives of tourism planning (Bushell and Staiff, 2001), supporting the principles of sustainable tourism in Agenda 21 for the Travel and Tourism Industry (World Tourism Organization, 1996).

‘Healthy tourism’ provides a framework for the WHO and the tourism industry to work collaboratively with tourism destination governments, tourism associations and local communities to promote health and wellbeing.

Important health issues relate to the significant role tourism plays in levels of lifestyle illnesses, including those that relate to diet, smoking, alcohol and occupational health and safety and the transmission of communicable diseases. Specific issues include food safety, HIV/AIDS, water quality and the numerous epidemics that have arisen since work began on the concept, such as severe acute respiratory syndrome (SARS), that have spread rapidly because of the vast numbers daily of people travelling worldwide. Early-warning systems on disease outbreaks, the implementation of international health and safety regulations, timely and transparent health and safety information and services for travellers and tour organisations and the appropriate training of staff in the tourism industry are important aspects.

In 2006 the lead UN agencies concerned with tourism set up the Marrakech Task Force for Sustainable Tourism Development. Following a three-year review of practices, policies and programmes worldwide, they concluded:

Tourism policy development requires a strategy that integrates strategies for sustainable development . . . At the national and regional level, policy makers should seek to adopt tourism policies that promote and protect the country as a tourism destination.

(United Nations Environment Programme, 2009: i)

This includes protecting health and safety at destinations.

Healthy and responsible tourism

‘Healthy tourism’ is integral to sustainable tourism, with an explicit focus on policies and processes designed to ensure the management of resources in such a way that the health outcomes for the visitor, the community and the environment are fully integrated and considered by the appropriate authorities.

The tourism sector has endorsed the principle of sustainable tourism, yielding numerous international charters, declarations and codes, including health. The risks posed to the industry, tourists and local communities arising from emerging and re-emerging diseases are significant but remain poorly managed (World Health Organization, 2009). The health impacts of climate change on water and vector-borne diseases such as malaria and dengue have heightened the need to place health more centrally within the sustainable tourism discourse (Bushell and Staiff, 2001). The devastating effects and very rapid global spread of SARS, bird flu, swine flu and, more recently, the Ebola virus and now the mosquito-borne Zika virus are constant reminders of the significant overlaps between health and travel, with consequences for the health of people and the financial viability of tourism in entire destinations.

Responding to health impacts on tourism in the Association of Southeast Asian Nations (ASEAN) region

The swine flu (H1N1) crisis mobilised the Emerging Infectious Diseases Programme within ASEAN in 2008 to examine the health–tourism interface.

Representatives from the Ministries of Health and Tourism with partner organisations identified factors contributing to the emergence and re-emergence of infectious diseases. These included:

  • rapid increases in travel;
  • population growth and urbanisation leading to overcrowding and unhygienic conditions, lack of clean water and adequate sanitation;
  • substantial increases in international trade, mass distribution of food and unhygienic food preparation practices;
  • increased exposure of humans to disease vectors and reservoirs in nature;
  • alterations to the environment and climatic change;
  • traveller susceptibility to illness and the high potential of travellers to carry diseases;
  • travel creating enabling environments for infection;
  • discrepancies in knowledge, beliefs and behaviour in relation to health and safety standards amongst some travellers as well as those working in tourism;
  • inadequate public programmes for healthy travel.

They acknowledged the need to develop policy to improve the safety, health and wellbeing of travellers and local people in tourism destinations (ASEAN, 2008).

One outcome of this regional workshop was to commission further ‘healthy tourism’ research to explore health issues in tourism destinations; to further develop the ‘healthy tourism’ concept; and to propose strategic solutions at a regional level. The project involved the ten ASEAN member states (Brunei, Cambodia, Darussalam, Indonesia, Lao PDR, Malaysia, Myanmar, the Philippines, Singapore, Thailand and Vietnam), ASEAN Plus Three Countries (China, Japan and the Republic of Korea) and partner organisations including the UN System Influenza Coordination; UN World Tourism Organization; International Organization for Migration; Joint UN Programme on HIV/AIDS; and Kenan Institute Asia with funding from the Australian government, AusAID.

Emerging architecture of ‘healthy tourism’

The research comprised tourism and health data surveys, site visits and consultative meetings with national and local stakeholders in both the public and private sectors in each of the ten member states nominated, pilot tourism destinations. Information was collated on local populations, health services, facilities, health priorities, burden of disease data, existing prevention and health promotion strategies, links to tourism and local environmental health issues. Existing guidelines, regulations, training, accreditation and any health- and tourism-related initiatives or collaboration were also systematised. Site visits enabled field observations and discussions about tourism in each place and planned developments. Analysis identified key local and generic issues, priorities, gaps and best practices. Following analysis a second regional workshop facilitated the development of consensus amongst the ASEAN Health and Tourism Ministries for a ‘Healthy Tourism’ Strategic Framework and ‘Healthy Tourism’ Work Plan.

Common areas where health burdens and tourism intersected included: water- and food-borne diseases, sexually transmitted diseases, particularly HIV, respiratory diseases such as influenza (including H1N1) and vector-borne diseases, including malaria and dengue fever. Despite the obvious link to health problems, there was no evidence in any of the countries of any work being undertaken to assess, mitigate or adapt to the impacts of climate change on health and tourism. Also significant in terms of burden of disease were the non-communicable diseases, including diabetes, cancer and mental health problems. These non-communicable diseases represent lifestyle illnesses that are the major causes of morbidity and mortality in developed and increasingly also in developing nations.

The existence of a rapidly developing health/medical tourism industry was also noted as offering opportunities to healthy tourism strategies.

A working definition of ‘healthy tourism’ was agreed:

‘Healthy Tourism’ is a commitment to responsible tourism planning, development and operations which has as its vision the protection and promotion of the health of the tourist and host communities by working in ways which embrace open communication, effective collaboration and engagement between all stakeholders.

(Bushell and Powis, 2009)

Other than Singapore, which was exemplary in its standards and management of tourism within a broader framework of wellbeing, there was evidence of a number of good practices throughout the remainder of the region with potential to be further developed, but these were overshadowed in most of the countries by:

  • poor planning and fragmentation of effort;
  • lack of awareness of the relationship between health and tourism;
  • lack of effective standards and enforcement;
  • lack of collaboration between stakeholders;
  • poor training of operators/tourism staff.

Hence the emerging elements identified were: commitment, collaboration, community engagement, communication and capacity building. These serve as the foundation architecture upon which the concept is built:

  • Commitment: establishing a health ethic that identifies health protection and health promotion for both the visitor and community built into the goals and objectives of tourism planning and operations.
  • Collaboration: establishing working relationships between key stakeholders. Opportunities for collaboration range from networking, information sharing to active coordination, joint activities and shared resources.
  • Community engagement: providing opportunities for the community to engage in the process of setting a shared vision and goals for future tourism; to empower the community to take a lead role and active participation in decision making, implementation and the evaluation of tourism activities where health and wellbeing benefits can be realised.
  • Communication: the development of a range of strategies to promote the health and wellbeing of tourists and the community. Building trust, transparency and being inclusive with all stakeholders, particularly those with a stake in health protection, promotion and tourism and keeping stakeholders informed and engaged is key.
  • Capacity building: addressing the need to provide financial, human and institutional resources to implement ‘healthy tourism’. This includes developing community and workforces by building individual skills, enhancing community engagement, developing organisational leadership, governance and management and, at the highest level, addressing the need for changes in legislation, policy and resourcing.

A ‘healthy tourism’ approach needs to address all these issues within a local context. This will be explored using a case study drawn from an iconic tourism destination in Vietnam.

 

Case study: Ha Long Bay, Vietnam

Ha Long Bay was the selected ‘healthy tourism’ pilot site in Vietnam and illustrates the types of health problems associated with tourism, even when it sits within a protected area with a plan of management.

Located off the northeast coast of Vietnam in Quang Ninh Province, Ha Long Bay has over 1,600 limestone karst islands and islets, of which 775 are included in a 434 km2 core zone of a World Heritage site (Haynes, 2008). Most international visitors to Vietnam visit Ha Long Bay, ranked third after Ha Noi and Ho Chi Minh City by visitor numbers. Most tourism activities concentrate in a relatively small area within the World Heritage site, namely Thien Cung, Dau Go and Sung Sot cave sites and recreation/landing sites of Ti Top and Soi Sim islands (Haynes, 2008).

Tourism creates significant economic benefit for local people, providing work in hotels, restaurants, travel agencies, boats and souvenir shops. Fishermen provide seafood and tour guide services for tourists. Tourism has grown rapidly in Quang Ninh Province due to the inscription of Ha Long Bay on the World Heritage list in 1994. In 2001 Ha Long Bay received 1.97 million visitors, including 679,555 international arrivals. There has been a massive growth, with 4.2 million visitors in 2008, including 2.35 million international visitors. International numbers for all Vietnam had increased to 7.944 million in 2015 (Ministry of Culture, Sports and Tourism, 2015) and Ha Long Bay remains one of the most-visited destinations. This is an unsustainable rate of growth. Numbers might have been even higher, but SARS and the bird flu epidemic caused decreased visitation between 2003 and 2005 (Quang Ninh Administration of Culture, Sports and Tourism, 2009). The Vietnamese government has made a significant investment in tourism in the last 15 years, increasing the number of hotels, restaurants, attractions, entertainment, administration and promotion abroad. But many worry that there is increasing visitor concern about degradation to the site itself, particularly water pollution and this is negatively impacting heritage values and may lead to a decline in tourism.

The average length of stay in Ha Long is quite short, about 1.5 days. Most come on package tours. The main attraction is to visit Ha Long Bay by boat. About 50 per cent of overnight visitors are foreigners staying either on boats or in hotels. The major source markets for international visitors are from within Asia, particularly China. In 2009 there were a total of 74 hotels with 8,437 rooms and 15,087 beds; ten were rated as 4–5 star, each with around 200 rooms and 20 at 3 star, each with around 50 rooms. There are also many small guest houses supplying 3,644 rooms. The city had 111 restaurants and many small cafes (Quang Ninh Administration of Culture, Sports and Tourism, 2009). These numbers continue to grow to service the growing visitor numbers.

In relation to quality assurance procedures, all tourist boats must have a licence issued by the provincial government. The number of licences was restricted to 400 local boats: 100 with 40–50 overnight berths and 300 day-tour-only boats. In addition there were up to 400 international cruise ships per year; the majority visited for one day/night and carried a total of 167,300 passengers in 2008 (Quang Ninh Administration of Culture, Sports and Tourism, 2009). Despite the licensing system, the activity is affecting the integrity of the site, yet the number of boats and licences has increased to meet the continually growing demand.

The Transport Department and Tourism Department jointly manage licensing of boat operators and training with regard to boat safety and customer relations. Food safety and quality assurance problems are well documented and have concerned the Vietnam National Administration of Tourism (Haynes, 2008). In response to these concerns, a Circular (88/TT-BVHTTDL), issued by the Vietnam Ministry of Culture, Sport and Tourism in 2008, stipulated that all 1–5-star hotels in Vietnam must obtain a food safety licence (Quang Ninh Administration of Culture, Sports and Tourism, 2009). The issue of food safety directly affects visitor wellbeing, yet was not required for boats or restaurants. Cruise ships, which are not local, operate outside this system. Hotels do have food hygiene training.

Health impacts linked to tourism

The growth of tourism has created jobs and population growth, with many moving into the city for work. But also due to tourism, the prices for food, accommodation and general goods in Ha Long are more expensive than in other localities in the province. This affects wellbeing in numerous ways, especially for those in the lower socio-economic groups, pushing poverty deeper into the local community despite the successful economic growth.

The UNESCO World Heritage State of Conservation report (World Heritage Committee, 2009: 57) identified population growth, increased tourism pressure, urbanisation and the absence of an integrated planning approach as the main threats to the site and integrity of its outstanding universal value. As tourism has developed, the visited grottos are overcrowded during high season, with a negative impact on the visitor experience and causing damage to caves, a major concern to visitors and regular topic on tourism-related web blog sites (Haynes, 2008). Crowding and inappropriate development around the area detract from the World Heritage values.

The economic activities associated with tourism involving land reclamation, transport, residential development, dredging of the shipping channel and related port development create a range of environmental problems. These include significant loss of mangrove habitat that provides a natural mitigation system. These activities collectively greatly reduce water quality, degrade the underwaterscape and cause loss of biodiversity, especially coral reefs and seagrass beds. Increasing numbers of tourist boats increase pollution through fuel leaks, oil spills, bilge discharge, exhaust fumes, human waste, rubbish and stirring up sediment in the relatively shallow waters of the bay (Haynes, 2008). Cigarette butts were identified as a problem to the island ecology surrounding the sites (Hamilton-Smith, 2007, cited in Haynes, 2008: 28). The State of Conservation report also noted over-exploitation of the marine resources to supply the tourism trade, inadequate waste management systems, low levels of awareness and illegal settlement as major challenges (World Heritage Committee, 2009). The development of Tuan Chau International Tourist Resort with a causeway to the mainland, just outside the core zone, is a theme park-style resort with condominium upmarket accommodation, casino and amusement activities which will further detract from World Heritage values and adds potential for further water pollution and health risks if waste is not well managed.

Water pollution from the boats, hotels, restaurants and urban development is the major health issue. Seafood is the main source of protein in the local diet. Direct health consequences include food-borne disease from the polluted waters, particularly hepatitis B and gastroenteritis; also, the availability of fish, with loss of mangroves (nursery for fish hatching) and over-fishing to meet tourism demand. An increased incidence of non-communicable causes of heart disease can be linked to changes in diet and cancer (unspecified) linked to pollutants in the environment. Car accidents directly relate to huge increases in tourism-related traffic. These tourism-linked health issues are the most prevalent causes of morbidity and mortality. HIV/AIDS and bird flu are also significant in the burden of disease. The increase in HIV/AIDS shows correlations with increases in tourism (Bushell and Powis, 2009).

This case study and the policy discussions within the ASEAN based on our research demonstrated how ‘healthy tourism’ could provide a strategic framework to deal with local public and environmental health issues and ensure ongoing value of tourism-led economies such as Ha Long Bay. A work plan was designed to identify actions and responsible parties across all levels of governance, including a significant role for the ASEAN in supporting member countries in the delivery of their actions.

The provision of training courses and a ‘healthy tourism’ accreditation system (especially for tour boats, hotels and restaurants in the case of Ha Long Bay) relating to waste management procedures to avoid water pollution, food safety, hygiene and food handling are all critical entry points and issues to protect the health of local people, visitors and the marine environment. But the key to the success of the ‘healthy tourism’ Strategic Framework is multiple stakeholder actions, including government at national and local levels, private sectors, non-governmental organisations and community, enabling ‘healthy tourism’ to become an effective management tool for the protection and development of healthy people and healthy places.

The government bodies need to review policy and legislation to ensure that compatible outcomes are feasible. Our research revealed that many different policies are at cross-purposes and that they mitigate against some of the desirable outcomes. Planning processes also require revision to ensure intersectoral collaboration and involvement in tourism planning. Most agencies not directly involved in tourism operations have no voice in tourism planning despite the potential for benefits and despite the numerous negative impacts directly related to tourism that these departments deal with, such as the health and environmental management issues noted in the case study.

The private sector, in particular tourism business, together with various non-governmental organisations, has an important role to play in education and raising awareness about tourism in the local community. The tourism industry has an ethical responsibility as part of good business practice to identify training needs of managers and employees and to raise an awareness of all the issues within their control (or influence) that affect the health and wellbeing of the wider community. Industry leaders are encouraged to devise accreditation procedures to ensure compliance with regulations and legislation. Research shows accreditation systems imposed on industry have limited effect. Systems owned by the sector and designed in a way that works for the industry are more likely to enjoy genuine uptake and effect. Equally, there should be incentives for operators whereby they are acknowledged and promoted to the visitor for contributing to the ‘healthy tourism’ approach. This is a useful marketing tool but also a means to enable visitors to identify and select ethical operations. This increases the incentive to be compliant and proactive. Industry should also be required to adhere to the ‘polluter pays’ principle and take responsibility for the various environmental management issues surrounding the operation of their businesses and not pass these on to local people and places through reduced environmental quality.

Community groups need to be encouraged and willing to become fully informed about tourism developments, to have input into the planning stages and to actively assist in monitoring and assessing the various impacts on the local community and their local environments.

Equally, the visitor has a role to play in ‘healthy tourism’ outcomes. Educational programmes can raise visitor awareness, encouraging more appropriate, socially and environmentally responsible behaviours. This can include adopting a ‘stay another day ethic’ to contribute to the local economy and the ‘user pays’ ethic in relation to community and public resources. Such approaches make visitors aware of the role of tourism and paying for the privilege of sharing special places with local people. Such taxes should be directly applied to monitoring and restoring damage caused by visitors, such as the impacts on water quality and the grottoes in the case of Ha Long Bay, and in time for better management and avoidance of problems and health consequences.

Conclusion

‘Healthy tourism’ represents an attitudinal shift. It provides a framework for tourism to work collaboratively across agencies and others to promote health and wellbeing of the local population and tourists. It encourages integrated tourism planning processes. The framework assists those responsible for tourism to develop an understanding of the interrelationships between tourism and health. It also assists in the development of strategies for capacity building. Rather than simply focus on dealing with issues or preventing health problems, it should bring health promotion and safety into tourism operations. It identifies the need for appropriate authorities to provide incentives to operators to develop sound practices.

There are many ways tourism and individual businesses can make a positive contribution to healthy living conditions, healthy work places and healthy families. This can include the absence of malnutrition and poverty; care for the environment; provision of adequate water and sanitation; developing positive attitudes; providing access to healthcare and education; the conservation of natural and cultural heritage; respecting family and community values; instituting community support systems, both informal and formal; supporting human rights – for women, children, disabled, ethnic minorities, migrants; encouraging political stability, access to justice, law and order; freedom of citizens; freedom of media; recognition of rights and responsibilities; employment opportunity; reducing reliance on imports; support of traditional industries, particularly agriculture; providing good working conditions; equitable distribution of wealth; recreation and leisure opportunities; access to sporting facilities; and access to public lands (Bushell and Staiff, 2001). As such, ‘healthy tourism’ is an ethical approach to tourism planning. It can deliver tangible benefits to all and move beyond the boundaries of usual thinking that the only benefits are economic and that stakeholders are those involved in the business of tourism.

Success comes from thinking outside the box, collaboration and cross-sectoral dialogue amongst government agencies and businesses. Developing appropriate indicators to measure progress of any new approach and providing evidence of the effectiveness of the process itself is important. This might include evidence of intersectoral collaboration; the monitoring, reporting and discussion of standards for water, sanitation, food safety, hygiene, waste management, road safety and their effectiveness in enforcement and prevention; researching broader issues of cultural change and gender issues; together with health-promoting initiatives relating to diet, exercise, smoking and alcohol consumption. ‘Healthy tourism’ becomes an entry point for health promotion. A ‘healthy tourism’ approach should be designed to integrate existing strategies, regulations, policies and guidelines. It should not reinvent them.

The case study highlighted the need to build capacity within both the health and tourism sectors, public and private. The research confirmed the need to place ‘health’ within the discourse and practices of sustainable tourism and to explore practical ways to protect and promote health by developing an understanding of the interrelationships between health and tourism. Ensuring sound management systems, integrated processes, adequate environmental and public health infrastructure and services, appropriate training, business incentives and measurable and recognisable outcomes will foster industry, community and visitor support.

‘As human populations and economies grow it has become increasingly impossible to improve one’s own wellbeing without affecting others’ (Prescott-Allen, 2001). Importantly, the ‘healthy tourism’ approach is intended to ensure that quality-of-life benefits flow to the most needy local people.

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