Dear Miss Move Abroad,

My question may be long-winded because I’m sorting out many issues about my decision to move abroad–to Israel.

Here’s my background:  At 26, after completing two degrees in software and engineering-related fields and working full-time for just over 2 years, I quit my job in San Francisco and bought an around-the-world trip ticket. My friend and I traveled from February through July last year. Nearing the end of my trip, I asked myself what things in my life I wanted to do—thing that if I didn’t do, I would regret on my death bed.  One of them came up as living abroad.

Back from the trip now, working freelance, and living at home, it seems like the perfect time to tackle this dream.

I have been to Israel four times in my life, speak enough Hebrew to get by, but have no relatives there, and just a few friends, none terribly close. I always love it every time, and even tried applying for a Fulbright to move there a few years back.  I’ve done all my research on job opportunities (they exist for people in my field) and the benefits the state offers to Jews who would like to move there. They actually pay you to move, roughly $4500 over the first 7 months, free health insurance until you get a job, and 5 months of Hebrew classes, just to name a few of the benefits.  It seems, by the facts, that this should be a relatively easy decision. But it’s not.

What’s nagging me is whether I am running away from a good thing in the States. I have a great education, and lots of well-paying job opportunities. Though I have a free spirit and crave adventure, I’ve learned this year that stability is really important to me.  Needless to say, the transition home has been very difficult for me as I haven’t yet gotten my independent life back.  So one of my concerns is how long it will take for me to really get settled in Israel, and if it’s a process that I can withstand mentally.

The next concern I have is that I’ve been far away from friends and family for a while, going to college out-of-state and graduate school on the other side of the country. This gives me the independence I need to be successful abroad, but also makes me wonder if it’s a good thing to continue to endure the stress it takes to create a new life each time and to be lonely until the new friends become great friends and pillars of support. Ever since kicking off the process to move to Israel in August, I’ve addressed these concerns each month, to great distraught.

Finally, as a seasoned backpacker and solo female traveler, conquering coco huts in 3rd world countries with the best of them, I find myself torn between my material pleasures and my constant challenge to prove that I can live on less.  Moving to Israel would challenge me and my bank account (while their economy is thriving, Tel Aviv is one of the most expensive cities to live in when you compare the rent to the actual salary earned). When I’m feeling empowered and idealistic, I know that it’s worth it. But when I’m feeling a bit more realistic, I wonder who I feel I need to prove to that I can change my life so drastically. And I do have student loans that I need to continue to pay….

I grow jealous of people who have lived abroad and can speak other languages, but I crave my stability and would like my older friends and close family in my life more.  I feel this yearning to be in Israel, yet this body-encompassing lament that I will do it alone, and feel lonely constantly in debating this decision.  Sometimes I wish someone would tell me to stop being foolish and stay, or visa versa.

Did I just pour my heart out to a stranger?  Any advice would be much appreciated.

Torn between the heart and dreams

_______________________

Dear Heart & Dreams,

Your letter got me thinking, and when I think, I write. But although my reply will no doubt be even more long-winded than your question, I’m not going to tell you what to do. I’ve been in your place, wishing someone would make a hard decision for me. But (as you already know) no one but you can make this call. If I tried, you’d protest that I didn’t have the full picture. And you’d be right. The full picture only takes shape in your own heart, and maybe only in the wee hours of the insomniac morning.

For me, decision-making is infinitely more mysterious than rationally weighing pros and cons. I’ll be obsessing for weeks, maybe even months, and then I’ll see or hear something—a line in a book, a scene in a movie, a snatch of overheard conversation in a café—and suddenly the decision in made. (Note the passive voice—as if the decision is out of my hands—a good strategy when pitching the move-abroad idea to employers and mothers).

I like Steven Johnson’s idea that good ideas (and decisions?) come from the collision of various small hunches, some of them residing in different minds. Here’s a cool animated video of that idea.

But back to your letter. As I read, I found myself nodding, thinking, yes, that’s the crux of it, isn’t it? Or rather the cruxes, as there are many axes on which the move abroad question pivots. I’ve got a few decades on you, and yet I must report that the issues don’t really change as you get older. As a serial relocator I confront similar questions each time I make a move.

The question of how moving abroad affects your relationships is perhaps the thorniest of the issues you raise. I know that when I return after extended travel or living abroad, friends and family are not so quick to let me have my old place in their hearts. Even if they were supportive of my move, their lives have moved on while I was away. They’ve adjusted to my absence, and it may be years before they really believe that I’m back.

And, like you, each time I go I ask myself if I’m running away from ‘real life’ and wonder how many more starting over’s I have in me.

I don’t have answers to these questions, but I do know that each question is a world onto itself, and that even the way we frame the questions betrays an array of assumptions that (for me) are revealed and sometime subverted by brushing away all my fears and making the move abroad.  Let’s take the ‘running away from real life’ question. Is our idea of real life so narrow that it can’t include interruptions of the proscribed life path—school, more school, work, family—that so many of us are on, or think we should be on?  Are we running away or are we lurching towards a life that is far my real than our habit-bound workaday existence, where daily repetition has dulled any sense of wonder or possibility?

Reading the particulars of your situation, I was struck by how you seemed to be trying to talk yourself into (or out of) something. I, for one, have never been paid to move anywhere, and there are often meager job opportunities on offer where I end up. You, on the other hand, would be paid to move to a country you already know you enjoy and where there are jobs in your field. The timing for you seems perfect, as well. With no apartment and no fixed job, you don’t have much to extricate yourself from. You didn’t mention anyone you’d be sorry to leave behind, so I’m assuming there’s no significant other. If there is a sweetheart in the picture, then you’re not telling me (or yourself) the whole story. Sometimes we want that sweetheart (or potential sweetheart) to hold us back from a radical move, to prove that they really care.

Another thing about timing: Often the 20s are considered a time to get travel and living abroad “out of your system,” after which you will presumably settle down and never stir again. But for those who are drawn to new experiences and new cultures, the ‘right time’ will come again and again, at various turning points in your life. Throughout my life I’ve been drawn to travel or living abroad when I need a new perspective, when I feel mired in the everyday, when things are closing in and I can’t see the forest for the trees.

If you’re having serious doubt about a move to Israel right now, it’s not as if this will be your last chance. You could even move to Israel, spend a few months there, and then decide to come back to the US. Would that be so bad?

If we look at the urge to move—to hit the road, get the hell out of Dodge, start fresh—not just as an individual impulse but a global one, we might say that it’s time to stay put and to stop running. Time to stop burning fossil fuels on our own personal long-distance quests. Time to face up to who and where we are, time to get our own house in order.

On the other hand, in most of nature, stasis is not an option. Animals roam far and wide to find food, shelter, and mates. Humans add to that the search for work, for recreation, and for that ineffable quality of brand-newness that reminds us that we’re alive and that the world is, despite all the fiber optics connecting us, a very big place. Big enough to get lost in.

And as the writer Andre Gide says: One doesn’t discover new lands without consenting to lose sight of the shore for a very long time.

Sincerely,

Miss Move Abroad

With the new immigration reforms that go into effect in Costa Rica on March 1, expats who are legal residents in Costa Rica must enroll in the national healthcare system called the Caja, which gives them low-cost access to neighborhood clinics, pharmacies, and public hospitals.

Some Costa Rica expats are satisfied with Caja (public) care; others opt to supplement or replace it with private care, paid out of pocket or through national or international health insurance.

One whole-hearted and one half-hearted fan of the Caja (Costa Rica’s national healthcare)

San Ramon-based expat Stephen Duplantier, 65, is a Caja fan. “We are very happy with it,” he said recently. “It’s US$18/month (a discounted rate through Association of Residents of Costa Rica–the ARCR). We go to local EBAIS (a neighborhood clinic), where there’s an excellent doctor and excellent nurses, plus all pharmaceuticals are free. Recent surgeries, diagnostic tests, ER use, pharmacy, etc.–all are totally free and high quality, and the waiting time is equal to our experience in the States.”

I agree that the Caja can be great for routine care, but when I found I needed surgery, I moved from the public to the private realm. I’d been part of the Caja system, paying around $60/month at the age of 41 and happily using their neighborhood clinics for routine care, tests, and medications. But when it became clear that I would need a major procedure, I defected to private care, opting to pay out of pocket (I’d let my U.S. insurance lapse). I was happy with the care at private Clínica Bíblica, though the final price for my stay, while quite low in comparison to U.S. prices, was still more than twice what I’d been quoted in a formal estimate.

Two that had bad experiences at public Costa Rica hospitals

Others are not so happy with the Caja.

After a motorcycle accident in Costa Rica, Matt Hogan sampled both public and private hospitals. Photo: David W. Smith

Take Matt Hogan, 35, co-founder of Finca Bella Vista, a sustainable treehouse community near the Osa Peninsula. In late 2009 he had a motorcycle accident, and was taken to the newly opened public hospital in Ciudad Cortéz. “All the newspapers had been boasting about the brand-new, state-of-the-art facilities and medical equipment, 300 clean new beds, and the rest,” says Matt. What the newspaper accounts failed to mention, according to Matt, was that all those new beds were serviced by only a few doctors who showed up only once in a while.

Matt says he suffered serious neglect and misdiagnosis (they told him he was fine). Feeling anything but fine, he had himself driven by ambulance to San José and checked himself into private Clínica Bíblica. There he was found to have one collapsed lung and the other in mid-collapse, as well as severe internal bleeding in his chest cavity. The doctors at Bíblica said that if Matt had waited another day to seek proper care he most likely would have suffocated.

Matt was very happy with the care he received at Bíblica, adding with a smile that “all the nurses were very attractive young Ticas.”

Alex Murray after being released from a 20-day hospital stay.

In another example, Alaska native Alex Murray, 72 at the time of a fire that burned over 20 percent of his body, endured an extended hospital stay that also allowed him to compare private and public care in Costa Rica.

“While expat friends with residency have had important procedures successfully performed at slight cost in the public system,” he says. “I recommend avoiding it in life-threatening situations if at all possible.”

Alex was burning garden trash at his home in the Lake Arenal region when he spilled some gas, causing the fire to flare up and burn him over much of his body. Alex spent the next 20 days in two hospitals in the capital city of San José, first at the public Hospital San Juan de Dios, and then at private Clínica Bíblica.

“Of course,” he admits, “it’s a foregone conclusion that such a comparison is unfair to the underfunded public hospital, but the devil’s in the personal details.”

Alex was first picked up by a Red Cross ambulance and taken to a clinic in nearby Tilarán. Then he was moved to the public hospital in Liberia (about an hour north), where the doctors decided to send him to the burn unit at San Juan de Dios (a public hospital) in the capital city of San José, 4 hours away.

“Arriving in San José,” says Alex, “we should have directed the driver immediately to Bíblica or Clinica Católica [two private hospitals], but, ignorant of the quality of the public hospital and anxious to get treatment, we let the driver take us to the teeming mystery that is San Juan.”

Hospital San Juan de Dios in Costa Rica

Three days at a Public Hospital: San Juan de Dios

“In our three days there,” says Alex, “no doctor ever consulted us, though one led a group of students into my room each day. The nurses, male and female, sometimes seemed like the proverbial five or six workmen who stand around a pothole gabbing while one guy fills the hole. For the most part, they were not dedicated, not attentive, not very competent, and not sympathetic. They seemed the dregs of the nursing schools. A friendly nurse assigned to draw blood samples spent three days drilling mostly dry holes all over my landscape, partly due to my extremely low blood pressure. One rough middle-aged nurse told me that I was not much hurt nor in pain. I finally had to yell at her, “Don’t touch me. Don’t touch me.” She desisted, smiling to herself, it seemed.

“A night crew came on and half-heartedly started to bathe me and change my dressings. Three stood on one side of the bed and made little come-hither motions with their fingers. Two stood on the other side and made little shooing gestures. Finally, they decided to help me turn.

“They would not let my wife sleep in one of the three extra beds crowded into my room. Instead she spent her nights trying to sleep in a plastic chair. In the not-very-clean bathroom, she found bloody bandages in a corner.”

Clínica Bíblica in Costa Rica

Seventeen Days at a Private Hospital: Clínica Bíblica

Alex and his wife decided that they needed to move him to a private facility. “When I was admitted to Clínica Bíblica,” he says, “I recognized immediately that here was a competent staff. The emergency room nurse quickly found a vein and soon had a set of color-coded vials filled with my blood. All staff were purposeful and attentive.

“The next evening I began to rave and tried to tear off my bandages and leave the hospital. A doctor soon arrived and said my actions were due to a lack of oxygen to the brain. I was then moved to intensive care where a coma was induced and I was intubated, remaining thus for five days, not a reassuring sight for my four daughters who arrived from points around the globe.

“I doubt that these measures would have been taken at San Juan de Dios. Three doctors tended me at Bíblica, one a burn doctor, one a plastic surgeon who moved skin from my thigh to my hip, and one a staff doctor. They each came by almost every day to talk with us. The nursing staff was a no-nonsense but friendly and attentive group, evidently the better graduates of the nursing schools. Midway through my stay, physical therapists began visiting daily to exercise my wasted muscles. When I left, I had lost 14 pounds and could walk only a few steps unassisted, but I was recovering.

“And throughout my stay, my wife was permitted to sleep on a narrow built-in bed or cot in each room. “

For more information on health care in Costa Rica, see Living Abroad in Costa Rica by Erin Van Rheenen, or visit www.livingabroadincostarica.com.

When the U.S. State Department issues a swine fly alert in Argentina, say, or a warning against travel to Honduras, just what does that mean?  What is a Travel Alert? How does it differ from a Travel Warning? And how should they affect your travel and relocation plans?

Travel Alerts
U.S. State Department Travel Alerts refer to short-term conditions (like flu epidemics) that pose risks to the security of U.S. citizens (and others, of course, but the State Department concerns itself with U.S. citizens). Their web site clarifies the Travel Alert designation further:

“Natural disasters, terrorist attacks, coups, anniversaries of terrorist events, election-related demonstrations or violence, and high-profile events such as international conferences or regional sports events are examples of conditions that might generate a Travel Alert.”

The Alerts have expiration dates. For example, a Mexico alert, which centered around crime and violence (especially along the U.S.-Mexico border), expired August 20, 2009 (though alerts may be renewed at their expiration dates, as this one was).

Just because there’s a Travel Alert in place doesn’t mean you should necessarily cancel your trip. In the case of Mexico, for instance, even the Alert itself allows that

“Millions of U.S. citizens safely visit Mexico each year (including thousands who cross the land border every day for study, tourism or business),” but “violence in the country has increased recently. It is imperative that travelers understand the risks of travel to Mexico, how best to avoid dangerous situations, and whom to contact if one becomes a crime victim.”

In early 2010,  these countries were on the State Department’s Travel Alert list: India, the Philippines, Malaysia, Niger, Germany, Tanzania, and Mexico.

Travel Warnings

Travel Warnings, on the other hand, are more serious, and of special interest to those considering moving to that country. Warnings  “describe long-term, protracted conditions that make a country dangerous or unstable,” according the State Department. The Warning can also mean that the U.S. Government is hindered in helping Americans living or traveling in that country due to the closure of an embassy or consulate or because of a reduction of its staff.

The Warnings are useful in that they often give very specific information about problems and potential problems. In the case of Pakistan, for instance, we learn that

“Since 2007, several American citizens throughout Pakistan have been kidnapped for ransom or for personal reasons. Kidnappings of foreigners are particularly common in the Northwest Frontier Province (NWFP) and Baluchistan. In 2008, one Iranian and two Afghan diplomats, two Chinese engineers, and a Polish engineer were kidnapped in NWFP. In February 2009, an American UNHCR official was kidnapped in Baluchistan. Kidnappings of Pakistanis also increased dramatically across the country, usually for ransom.”

Still, a country being on the Travel Warnings list doesn’t mean that you should never in a million years consider going there. Independent travelers will use the warnings and alerts as starting points, seeking more information from a variety of sources. For example, I was planning a trip to Nepal a year ago (there have been Travel Warnings for Nepal for several years now). I read the State Department’s warning (paying close attention to which parts of the country were highlighted as problematic), sought out books and articles about the country and its politics, and spoke with people who’d been there recently. After all my research I concluded that I still wanted to go. Health problems made me cancel that trip, but I would have gone and still hope to go, Travel Warning or not.

And the director who recently made a movie about Surfing Gaza obviously didn’t let the Gaza and West Bank Travel Warning deter him.

Travel Warnings have no expiration dates—presumably the State Department monitors the situation and removes the warning when conditions improve.

As of early 2010, these countries were on the State Department’s Travel Warning list: Haiti, Pakistan, Sudan, Somalia, Mauritania, Chad, Mali, Sri Lanka, Nepal, Algeria, Colombia, Guinea, Lebanon, Cote d’Ivoire, Philippines, Democratic Republic of the Congo, Eritrea, Central African Republic, Israel, the West Bank and Gaza, Kenya, Afghanistan, Burundi, Nigeria, Haiti, Iran, Yemen, Saudi Arabia, Uzbekistan, Iraq, Georgia, and Syria.

Intense training can be a risk in travel-related DVT

In hospitals, deep vein thrombosis (DVT) may occur after surgery, especially surgery below the waist, like hip surgery. And it’s true that you should avoid surgery for at least 30 days after air travel if possible.  But the risk factors for DVT on an airplane are very different from those in a hospital, and include recent intense athletic conditioning, particularly training for endurance sports like marathons.

According to Airhealth, the most common travel-related risk factors for DVT are:

1. Athletic training, especially training for endurance sports like marathons.

2. Recent surgery or injury. If you have just run a marathon, you probably have at least minor bruising that can trigger clotting. Kick-boxing also produces such injuries.

3. Personal or family history of DVT.

4. Cancer, heart disease, diabetes. Obesity is often cited as a risk factor, but probably ranks much lower than the preceding diseases.

5. Women who are pregnant or taking estrogen as birth control or hormone replacement.

6. Age over 40 is often cited as a risk factor; sometime age over 60 is cited. Butin Airhealth’s registry, over 80% of those suffering DVT while traveling are under age 60, and the majority are under 50.

See also How to avoid blot clots while traveling.

They're squeezing more and more passengers into coach these days. Photo from blisstree.com

Take heart, obsessive travelers: according to the Centers for Disease Control (CDC), more than 63 million Americans travel abroad each year, and the great majority of them never have any major problems.

Still, we need to pay attention to the risks of travel. A study released yesterday by doctors at Harvard University found that travel is associated with a 3-fold higher risk for blood clots, called deep vein thrombosis (DVT), with the risk increasing for each 2-hour increase in travel time.

The clots, which often form in the deep veins of the legs, may occasionally break loose and head for the heart or lungs, which may lead to heart failure or stroke (which may, in turn, lead to death). Lots of “maybes” in that chain of events, but still, we need to pay attention.

Any type of travel where you sit still for long periods can be potential dangerous, but flying seems to be especially problematic. It’s harder to get up and move around on a plane, your legs are often stuffed into a woefully small space (in fact, DVT is often called “economy class syndrome.”) And the air in planes is also very dry, raising the risk of dehydration.

Scary, to be sure. But the CDC offers some simple but effective steps to minimize your risk.

While traveling

1. When sitting for long periods of time, such as when traveling for more than four hours:

• Get up and walk around every 2 to 3 hours.
• Wear loose-fitting clothes.
• Drink plenty of water, and avoid drinking anything with alcohol or caffeine in it.

2. Exercise your legs while you’re sitting by:

• Raising and lowering your heels while keeping your toes on the floor
• Raising and lowering your toes while keeping your heels on the floor
• Tightening and releasing your leg muscles

Lifestyle changes that help you avoid DVT:

• Exercise regularly
• Maintain a healthy weight
• Don’t smoke
• If you have a family history of DVT, talk to your doctor about medication (anticoagulants) to prevent or treat DVT

At Airhealth.org you can download a handy wallet card that reminds you of how to avoid DVT.