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Revista de Saúde Pública

Print version ISSN 0034-8910On-line version ISSN 1518-8787

Rev. Saúde Pública vol.41  suppl.2 São Paulo Dec. 2007 



Vulnerability to HIV: tourism and the use of alcohol and other drugs



Alessandro de Oliveira SantosI; Vera PaivaII

IInstituto Ing_Ong de Planejamento Socioambiental. São Paulo, SP, Brasil
IIDepartamento de Psicologia Social e do Trabalho. Instituto de Psicologia. Universidade de São Paulo. São Paulo, SP, Brasil





OBJECTIVE: To describe situations of alcohol and other drug use involving tourists, and their implications regarding vulnerability to HIV.
METHODS: This was an exploratory qualitative study conducted in communities that host tourism in the Vale do Ribeira, State of São Paulo, from October 2002 to February 2003. In the first stage of the study, 29 monitors in four host communities were interviewed to gather scenarios of drug use involving tourists. In the second stage, two workshops were held, bringing together 77 interviewees and health and education professionals from ten communities, in order to dramatize the scenarios gathered in the interviews and share repertoires for dealing with these situations and finding ways for preventing HIV.
RESULTS: The scenarios showed that alcohol and other drug use by tourists increases their vulnerability to HIV transmission through favoring casual sexual intercourse without condoms and sexual harassment and abuse. HIV prevention work in these communities that host tourism needs to take into account the consumption of these substances which use creates difficulties regarding safe sex practices and, in the case of injecting drugs that are shared, constitutes a risk factor for HIV transmission.
CONCLUSIONS: This study provided data to help in understanding how situations of alcohol and other drug use fit within daily life in these host communities, thereby extending the vulnerability to HIV. The study produced analysis of the social context of HIV transmission that may provide backing for drawing up prevention programs that are better adapted to these communities.

Key words: Acquired immunodeficiency syndrome, prevention & control. Tourism. Alcohol drinking, prevention & control. Substance-related disorders, prevention & control. Health vulnerability. Health promotion. Health education.




The concept of tourism host community has been used in the literature to designate places in which the socioeconomic organization revolves around tourism.8 Such places may be inland or on the coast of the country. The infectious diseases that tourists may contract while visiting these communities, and also analysis of the prevention and control strategies, have been the focus of recent collaboration between the World Tourism Organization, the Italian Association of Touristic Medicine and the World Health Organization. The Pan-American Health Organization has also organized meetings on this topic and, since 1990, has held the National Congress of Tourism and Health, in partnership with state and municipal health and tourism departments in Mexico.1

Studies on public health problems that occur in host communities have described: proliferation of water-borne illnesses resulting from the environmental sanitation conditions;2,1 transmission of HIV and other STDs between tourists, between tourists and natives and between tourists and sex workers, as a result of casual unprotected sexual intercourse;7,14,16 medical emergencies that affect tourists because of alcohol and drug abuse (traffic accidents, drowning and overdoses);17 and the increased use of such substances among native young adults.2

Tourists usually behave in a way that differs from their normal behavior when they are away from home, far from the restrictions and tasks of day-to-day life. Some researchers have called this phenomenon "behavioral inversion",5,15 and it contributes towards suppressing personal limits and care, and favors abusive use of alcohol and drugs and unprotected sexual intercourse.4,9

The region of the Ribeira valley, in the State of São Paulo, Brazil, began to attract tourists from the state and from other countries since the 1980s because of its natural spots (waterfalls, beaches, trails, caves, gorges, fauna and flora) and cultural attractions (historical centers, archeological sites and folkloric festivals). There are around 500 community-based environmental tourism monitors in the region and, for 60% of them, this is their principal occupation.3 In general, they belong to the traditional populations of caiçaras (natives of the coastal region), ribeirinhos (natives living along the banks of rivers) and quilombolas (descendents of slaves who founded isolated communities known as quilombos). Most of them are adolescent or young adult males whose schooling did not reach as far as completing high school education.

The aim of the present article was to describe situations of alcohol and drug use involving tourists, and their implications regarding vulnerability to HIV among people living in host communities, based on environmental monitors narratives.



This is a qualitative study involving monitors, residents and health and education professionals in the region, who were invited to participate in the study. Local agents were recruited among the studied community members, and were responsible for organizing the interviews and workshops.

The first stage of the study, which was carried out in October and November 2002, was based on interviews with 29 environmental monitors in four host communities. These subjects were selected intentionally13 to make up a group that could express the diversity of the environmental monitors in the region. In other words, they were men and women aged 16 to 32 years who were either single or in stable relationships and were living in towns or rural districts, and who had at least one year of experience in ecotourism activities. This stage of the study aimed to understand the interaction between tourists and monitors and to collect narrative of scenes of sexual interactions (subject of a separate article) and the use of alcohol and other drugs that involved tourists.. At these interviews, the monitors were asked to narrate scenes that they had observed or experienced: "Tell me about an episode of drug use involving tourists that you have experienced, or observed or heard about".

In the second stage of the study, which took place in January and February 2003, two workshops were held aiming at: (a) dramatizing the scenarios gathered in the interviews; (b) clarifying doubts regarding drugs and STDs/AIDS; (c) training the participants in prevention technologies, thereby stimulating local programs. Monitors, residents, health and education professionals from the region were invited to participate by means of invitations delivered by local agents of the study, to monitor associations, public health services and schools. The local agents were responsible for organizing the workshops (publicizing the study, selecting the interviewees and arranging the transportation and meals for the workshop participants). The workshops lasted for eight hours on average and brought together 77 people from ten host communities. Among the participants were some of the interviewees (monitors) and also employees of the ecological parks, teachers and health professionals of the regions studied (doctors, nurses and community agents).

The participants were divided into four groups: two dramatization groups ("dramatize this episode of drug use involving tourists, showing what you think happened") and two observation groups (responsible for formulating and presenting solutions in a plenary session).

To set up each scene, the procedures included: body warm-up; reading of the episodes taken from the interviews; group discussion; selection of characters and specific warm-up for dramatization; rehearsal; presentation of the scenes; analysis; and presentation of possible solutions.

The thick descriptions of a singular scene experienced by one or more people can be collected by means of an individual or group interview. It could also be staged and thus dramatically shared and analyzed in all its individual and collective dimensions by the group that participated in a program or a prevention workshop. The scene definition used by Paiva11 in the methodology (conceptual framework and method) for investigating sexuality and putting safe sex programs into operation was adapted for investigating situations of alcohol and drug use. In the present study, the task assigned for describing scenes was translated in the instructions: "tell me about a scene of drug use involving tourists that you have experienced, or observed or heard about" (interview) and "dramatize this episode of drug use involving tourists, showing what you think happened" (workshop).

Data analysis of the interviews (on audio recording) and of the workshops identified units of meaning in the narrative of the monitors interviewed10 and content analysis of the scenes (workshops), so as to–clarify the dynamic interaction between personal, cultural, economic and political dimensions that compose the situations of drug use in the communities.

The scenes collected in the interviews were selected for analysis on the basis of their potential for furnishing information on the association between the use of alcohol and other drugs and the implications for vulnerability to HIV. The scenes dramatized in the workshops, in turn, brought into view the topics that were considered to be priority matters for discussion by this segment of the population.

The protocol for the study was approved by the Ethics Committee of the Faculdade de Saúde Pública/USP. The interviewees and individuals legally responsible for them (in the case of individuals aged less than 18 years) signed free and informed consent form and they were given a guarantee of confidentiality.



The group of interviewees included greater numbers of men, non-whites, Catholics, singles and people living in towns (Table).



According to the interviewees, people (tourists and local residents) used alcohol and drugs to relax, have fun, break down shyness and express themselves better. "Fleeing from reality" and the influence of friends were also indicated as reasons. The interviewees said that the substances most used by tourists were alcohol, marijuana, cocaine and synthetic drugs (LSD and ecstasy). One interviewee mentioned that he had sometimes found syringes in the garbage at a place often visited by tourists, thus indicating the possible presence of users of injectable drugs among the visitors.

The scenes reported by the interviewees indicated sexual harassment, unprotected sexual intercourse and sexual abuse.

"(...) there are a bunch of lads (...) and then they get sexually involved with the girls [natives] (...) Depending on how high they are, and what if they don't use condoms? (...) they are a threat to these girls (...)."

"(...) the tourist tries to hit on a girl (...) and then they get together (...) (...) about diseases, using condoms (...) at the time everyone is so high that it just happens."

"(...) it happened at the end of the year (...) drinking a bit too much (...) at a stall (...) it just happened that a condom wasn't used (...)."

"(...) the public of drug users is so big (...) there have already been serious problems (...) a lad who tried to sexually molest a boy from the community (...)."

"(...) there were those girls who would just turn their noses up at the guy, and then the guy would get mad, get hold of her, call her to have a beer and put it in her glass, the girl would fall asleep, and then the guy would take advantage of her, and on the next day the girl wouldn't remember a thing (...)."

The interviewees reported scenes of medical emergencies caused by abusive use of alcohol, marijuana and cocaine:

"(...) a lad [tourist] (...) mixed too much drink with marijuana and ended up having a convulsion, we had to hurry him back to the town."

"A tourist who was high went swimming (...) and jumped onto rocks (...) another friend got some help (...) he was taken away in an alcoholic coma and with the start of hypothermia."

"(...) the guy came running, claiming the girl was feeling ill (...) they provided a stretcher (...) and went to get her (...) they said there was dust coming out of her nose (...) she was hospitalized (...) she spent some days there and then left."

One of the monitors recounted that in his community one death of a tourist due to a cocaine overdose had been recorded. Many interviewees drew attention to the difficulty of dealing with alcohol and drug use when leading groups of tourists. There were rules for excursions and the use of drugs was an illegal practice. However, this was insufficient to stop tourists from using these substances. The scenes reported as follows illustrate the individual attitudes of the monitors, in the absence of any collective guidance for dealing with this situation:

"(...) I arrived, there was that stink of marijuana (...) I left my people 'Guys, hold on for a moment' (...) and then I came up to them and said 'Who's responsible for this?' (...) 'Dude, of all places, you're using marijuana here (...) you're getting in the way of tourism here' (...) I made a police complaint against him (...)."

"How many of you are smokers? [marijuana] (...) whenever you feel like smoking, let me know, (...) we can stop the group, I'll start chatting with the group, and I'll show you a place to go."

"(...) while I'm talking, he's already using it (...) So I'd rather (...) pretend I'm not seeing anything, because I don't even have any guidance for this."

The use of alcohol and other drugs by tourists and the resultant medical emergencies emerged as a central preoccupation for the participants in the two workshops, thus showing that these are important topics for understanding the context within which contacts take place between tourists and residents in the host communities in the Ribeira valley.

In the first workshop, the dramatized scene was the following situation: "the environmental monitor goes out with a group of tourists and gives guidance regarding behavior during the excursion. However, the tourists want to smoke marijuana. The group insists and offers a quantity of marijuana for the monitor to give his OK. He says no. But in the end he accepts and goes out distributing the drug to the community, thus becoming a type of trafficker".

The scene showed that the monitor was unable to stop the tourists from using marijuana and, to a certain extent, they ended up transforming him into a distributor of the drug to the community. This was a fear among the participants and indicates the situation of paralysis that the community sees itself in, upon reflecting on the "seduction/temptation" of the monitors to use drugs and the "destiny" as a trafficker. Indeed, since many tourists use drugs and the local public authorities have limited capacity to control trafficking, there is the possibility for growth in this activity among these communities. The analysis of this scene by the workshop participants indicated that there was a need for greater training for tourism, education and health professionals. It also showed that the environmental monitor discourse needs to emphasize the importance of complying with the rules for the excursion to be a success, and that all the monitors must coherently maintain the same line.

Expanding the focus of the scene beyond the situation and place in which tourists and monitors meet, the workshop participants suggested that guesthouses and tour agencies/operators should form partnerships with the monitors and that the laws for visiting the ecological parks should be adopted by all the communities. Finally, the participants concluded that there needed to be combined community mobilization that should include alliances among local, state and federal bodies and with the third sector.

The participants in the second workshop chose to dramatize and reflect on a scene of abusive use of alcohol by a tourist who had an accident: "an environmental monitor is accompanying a group of tourists and, when they come close to a waterfall, he notices that one of them is drunk and is holding a bottle of drink in his hands. The monitor asks this tourist to remain seated on the ground and turns round to give advice to the other tourists so that they will be able to dive into the pool at the right place. While he is doing this, the drunk tourist dives in headfirst onto a rock. The monitor asks for help by radio and receives the answer that the doctor will get there in 15 minutes. The group holds the injured tourist and tries to revive him, but when the doctor arrives, the tourist is already dead".

This episode, which also had been reported in an interview, was also analyzed from the point of view of the difficulty that the monitors had in establishing and putting into practice the rules for visiting the tourist attractions. The workshop participants identified a lack of training among the monitors with regard to what to do in cases of medical emergencies and a lack of key equipments for working with tourists, such as communications radios. Moreover, the workshop participants reflected on how important it was for the monitors to construct solid arguments for preventing drug use during excursions and drew attention to the need for establishing partnerships with healthcare sectors, municipal authorities and the police (civil, environmental and military) and for monitors to improve their own training.

The analysis of the dramatizations that was conducted in a plenary session focused on the social and programmatic dimensions of the scenes. The analysis of the first episode led more strongly towards the involvement and mobilization of civil society. The analysis of the second episode indicated that training for the environmental monitors had a high priority. The analyses did not include the personal dimension of the "actors", thereby making it impossible to know what the possible individual solutions for the problems staged would have been.

The participants gave a positive assessment to the workshops, thus confirming that the resource of scenes favors learning of repertoires (content and skills) in the fields of education and health, as shown by the following statement:

"The theatricals were very good; it was possible to learn a lot of things I didn't know. I think this method could be implemented in public schools and district associations."

Dramatized scenes are always emblematic of their local sociocultural scenario and bring out charged emotions for the groups who produce them. The collective dramatization by the participants in these workshops make the monitors face the situations they had experienced and offered an opportunity for planning how to act in the future. They helped in understanding what would make the individual or collective initiatives easier or more difficult, for dealing with situations of drug use involving tourists.



Through the interviews and dramatizations, it was possible to gather descriptions of scenes of alcohol and drug use involving tourists in the host communities. The study provided the elements for better understanding of the way in which the situations of use of alcohol and other drugs fitted into the daily life of the host communities and thereby increased their vulnerability to HIV.

The dramatization gave the environmental monitors the opportunity to reflect on the situations of alcohol and other drugs use involving tourists and diminish the prospect that, seduced by easy earnings, they might become drug suppliers for tourists. It should be bore in mind that tourists try to buy these substances from guides, taxi drivers and the employees of hotels, guesthouses, nightclubs and restaurants, especially when they are traveling outside of their own country.2

The temptation to profit from the opportunities for contact with drugs in the monitors' daily lives seems to be related to the tension that exists between the actual standard of behavior among tourists and the standard of behavior expected from the environmental monitors. Although the monitors are in a professional situation in which the rules should be completely enforced, they end up adopting the perspective of tourists and identify with the "life of tourists". This identification is facilitated by the nature of the activity, which obliges them to carry on accompanying the tourists' leisure and pleasure for many hours.

The results from the present study are similar and complementary to the results from the studies conducted by Alleyne,1 Bellis et al4 and Ford & Koetsawang.6

According to Alleyne,1 the use of alcohol and other drugs by tourists has a direct relationship with traffic accidents and cases of drowning. In Barbados, this author observed that, out of all the people detained in a public hospital because of nearly drowning, 60% were tourists and one third of them had consumed alcoholic drinks. This author also observed that trading marijuana and cocaine was common between tourists and the natives, and that there was a greater offer of drugs at peak periods for tourism. The use of these substances forms part of the context within which sexual contact occurs between tourists and the local population, thereby placing difficulties in ensuring safe sex and favoring the transmission of STDs/AIDS.

Bellis et al4 described changes in the patterns of use of drugs among young English people when they visited Ibiza, in Spain. In Ibiza, these young adults used (consumed) more alcoholic drinks, tobacco and synthetic drugs (LSD and ecstasy) than in England. The increased use of these substances is associated with the phenomenon of "behavioral inversion", which may lead tourists to take, on a single occasion, the same quantity of drugs that they would take in a week in their own cities, and to have sex with a casual partner without using a condom. Individuals with little experience of using and combining such substances are more exposed to unprotected sex and overdosing than are those who are accustomed to consuming and combining such substances. According to these authors, access to information about the characteristics of these substances and access to condoms and medical services are fundamental for protecting tourists' health.

Ford & Koetsawang6 described how certain social factors could form a context that was favorable for HIV transmission in a country. These authors showed that the culture of opium consumption and the sexual exploitation of young people who leave the interior of Thailand in search of employment in urban centers and tourist municipalities has resulted in an explosion of the epidemic among women and users of injecting drugs. According to these authors, although Aids is a global epidemic, its propagation is related to certain social factors. Therefore, it is fundamental to know about these factors in order to identify the social context for HIV transmission and to plan strategies for its prevention and control.

Like in the study by Ford & Koetsawang,6 an analysis of the social context of HIV transmission was also made in the present study. This analysis may provide backing for drawing up health education programs that are more appropriate for tourism host communities, thereby stimulating the creation of local preventive technologies that will respond to the challenges posed by the state of vulnerability.3,12 We agree with Bellis et al4 that the responsibility for undertaking programs of this type lies not only with the public authorities, but also with the commercial organizations that operate within the world of tourism. Tour agencies, airline companies, hotels, restaurants, bars and nightclubs must help to protect the health of tourists and local residents through supporting health education initiatives within the host communities, among other actions of social responsibility.



To Prof. Lilia Schraiber, of the Faculdade de Medicina of Universidade de São Paulo, for contributing to the data analysis; to the businessmen Marcelo Soriano and Farooq Khan and the health professionals Sueli Simões and Enio Santos Silva, for their support for the fieldwork; to the educators who conducted the workshops: Julia Meireles Vieira, Marcelo Peixoto, Will Damas, José Pinero, Naíme Silva and Adriana Lima; and to the local agents from the NGOs: Instituto Ing_Ong de Planejamento Sociambiental, Grupo Ecológico Guaraú, BARONG, Centro de Convivência É de Lei: Fabian Theodoro, Felipe Santana, Maria Silvia Muller de Oliveira and, in memoriam, to Nilton Rosa Pinto.



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Alessandro de Oliveira Santos
R. Turiassú, 362, apto51
5005-000 São Paulo, SP, Brasil

Received: 8/8/2006
Reviewed: 2/21/2007
Approved: 7/21/2007



This article's authors are participants of the Núcleo de Estudos e Prevenção da Aids, Instituto de Psicologia da Universidade de São Paulo.
1 Giatti LL. Ecoturismo e impactos ambientais na região de Iporanga – Vale do Ribeira – São Paulo [doctorate thesis]. São Paulo: Faculdade de Saúde Pública da USP; 2004
2 Santos AO. Turismo e saúde comunitária: intervenção e pesquisa no Vale do Ribeira, São Paulo, Brasil [doctorate thesis]. São Paulo: Instituto de Psicologia da USP; 2004
3 Instituto Ing_Ong de Planejamento Socioambiental. Apoio ao turismo de base comunitária no Vale do Ribeira. São Paulo; 2003. 25p.

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