In 2007, I embarked on a study abroad program to China with the Hotchkiss School. What I expected to be an adventure full of cultural and language immersion quickly turned into a nightmare for me. After hiking down Mount Panshan in China, I developed Bell’s Palsy, which progressed to full paralysis, all from an encephalitis-carrying tick bite. I was left unable to speak, something that I still struggle with to this day. Something less noticeable, but again recognized as a deficit, was my ‘executive functioning’ or planning skills. Of course, there were other deficits, such as fine motor movements. Speech is considered a fine motor movement, but we’re talking more about hands and fingers. My hands were balled into fists and turned inward.

My parents flew to China. They found me in a local hospital, highly confused, even incoherent. I didn’t recognize them at all, nor understand what had happened to me. My last memory was of celebrating the 4^th of July with Hotchkiss students and faculty, then nothing but my body’s fight for survival. 

Two-and-a-half weeks after my parents arrived, we flew from China to a hospital in New York City. I ‘woke up’ there. I understood two things: the people standing next to me were my parents, and something terrible had happened to me because now I was paralyzed and unable to speak.

In the following days and weeks, I quickly discovered how encephalitis had impacted my body. For example, once my hands were opened or closed, it was hard for them to move either way definitively. I used one hand to open the other, and vice versa. My handwriting was, and still is, a struggle. But in today’s digital world, it’s becoming less of a necessity. Typing is the new issue for me since two fingers on my right hand stubbornly refuse to bend unless manipulated. This leaves me to type with only 3 fingers on one side and 5 on the other.

In 2008, my parents and I filed a joint negligence lawsuit against Hotchkiss. The case wasn’t fully settled for ten years. Hotchkiss fought tooth and nail to win. However, in the end, to the credit of a great lawyer and my own positivity, we won the second-largest payout in Connecticut history.

The outcome of Munn v. Hotchkiss School was a historic moment for sure, but it was more of a relief for my parents and me. A relief that I wouldn’t have to be dependent on my parents for the rest of my life. A relief that I would have enough money to pay for therapy for the rest of my life if needed. Of course, many people with disabilities have to work; had I not won the lawsuit, I would probably be working, as well. However, as the months and years have gone by, the difficulty of obtaining a job with my particular disability has become more evident: why hire someone with a speech disability when you can hire someone without one?

Given the publicity around my case, I have wondered how it has impacted schools. Might they be motivated to collect and share better safety information with students? When I spoke with my lawyer about this, he emphasized the student’s age at the time of their injury or death. I inferred from our conversation that, if a student is under 18, winning a case is more likely. (I was 15 when I attended the Hotchkiss program in China.)

When I spoke with Protect Students Abroad (PSA), a non-profit that advocates for transparent and comprehensive safety data collection from academic travel programs, cofounder Elizabeth Brenner said, “Aside from two narrow Minnesota bills, regulatory oversight of high school or higher ed study abroad is non-existent. No other state requires schools to report deaths or injuries during academic travel programs, no matter the student’s age.” Attempts at New York state and federal legislation, such as the Ravi Thackurdeen Safe Students Study Abroad Act, have met stiff resistance from schools. It is impossible not to conclude that high schools and colleges have done little to improve safety information for education abroad students and their families.

As the years have passed, I am increasingly aware that I wouldn’t have survived without my parent’s ability to travel to China and bring me home. Especially in today’s climate, I recognize that I’ve benefited from that privilege. After hospitalization and rehabilitation, I was able to attend college. Actually, I attended two colleges, the first Trinity College and the second Barnard College of Columbia University in New York City.

I found that some professors didn’t know what to do with me. They even seemed upset by my situation. Once, when I used my computer’s text-to-speech app to ask questions, the professor said, “Oh, I see—you can’t talk.” She said this to a lecture hall of 200 students, which was just as embarrassing and insensitive as it sounds. Others adapted better and were much more caring; this tended to be in smaller seminar courses where professors could get to know me. Socially, as you can imagine, it was exceedingly hard for me to make friends and form lasting bonds with people who I couldn’t talk to without my cellphone.

Given my issues with typing, it was also very tough for me to take notes. Though I sometimes received notes from classmates, there were times when they forgot, which often led to me not having notes for several classes at a time.

In the two years after college, I slid into a lackadaisical attitude about practicing speech; it took place in the course of everyday conversation, and that was it. I didn’t have much interaction with others. I mostly spoke with my mother and occasional visitors. I viewed myself as unlovable, so dating was something that I shied away from. Whenever someone didn’t understand me, the text-to-speech app was something I used as a crutch. Then, in January of 2018, we won the lawsuit.

Winning emboldened me to make changes in my life. I decided to try online dating and met I.M. on Hinge. I used the text-to-speech app for the entirety of our first date. Needless to say, I was surprised when I got a second date. That was two years ago, and I.M. is now my boyfriend.

I.M. tells me that there’s not a day where he doesn’t see me just waking up and talking again. And then, of course, when I do wake up, reality hits me that I’m not able to speak as I did before. In my boyfriend’s mind, practicing every day yields results. He has worked with me tirelessly on getting my speech back to 100%.

My boyfriend came into my life and said that I needed a schedule, a set time to practice every day, and a Google Sheet to help me be accountable. He told me that I’d hear it from him if I didn’t practice and enter time spent. Over these last two years, my speech has taken off, and I think it’s primarily because of the sheet he set up. I can now pronounce my name—something that I couldn’t do when I first met I.M. Today, my boyfriend told me that he is proud of me for the improvements I’ve made in my speech. He noted that we hadn’t used the text-to-speech app at all on our daily walks.

I have done everything throughout these 13 years to carry both difficulty and good fortune with grace. Advantage brings responsibility, which is part of why I give back to two of the educational institutions I attended (Sacred Heart and Barnard). I want to support them taking good care of their students during study abroad.

As my life moves forward, I see myself as I.M. sees me: a courageous human spirit who has a penchant for positivity, someone who will not let a virus destroy her light but will use what has happened to shine even brighter. I am thrilled to tell you that, this August, I.M. and I moved in together!

Cara Munn is currently writing a self-help memoir.

The Forum on Education Abroad, also known as “the Forum,” is a large U.S.-based institutional membership organization and standards setting body for the education abroad industry. The Forum’s website states their purpose, to “disseminates comprehensive standards of good practice, resources and training, advocates for education abroad and its value, and engaged the field in critical dialogue to benefit students,” including “health, safety, security and risk management.”

In March of 2016, the Forum released a report that purportedly analyzed education abroad student deaths for the year 2014.  The question that framed their analysis was this, which is safer, study on-campus or study abroad? The resultant “key finding” was widely announced by the Forum: “College students studying abroad are less likely to die than college students studying on campuses in the U.S.” Thereafter, in press coverage of subsequent student deaths, news stories were accompanied by a restatement of the Forum’s key finding.

Two years later, the Forum asked the same question, though this time they considered seven years of data (2010-2016). Again, they came to the same conclusion: “College students studying abroad are less likely to die than college students studying on campuses in the U.S.”

In order to determine on-campus risk, both Forum reports used data from what they refer to as “the Turner study.”  In 2013, Turner and colleagues published the results of a pilot study, a small-scale study intended to better understand potential issues with conducting a larger one. Their objective was to identify leading causes of death and mortality rates for students attending U.S. institutions of higher education. To accomplish this, Turner sent out 1154 surveys to institutions of higher education.

Survey research is always challenging, and there are significant challenges with the Forum using Turner’s study. For one thing, only 166 surveys were returned. Turner rightly dropped nine of those surveys, for a final total of 157, which at a below 15% response rate must have been disappointing. That this study relies on a self-selected convenience sample with a low response rate limits the ability to make inferences and raises concerns about sampling error, mistakes in statistical analysis due to using a subset population that does not adequately represent the whole. Moreover, since there’s no standardized methodology for schools to track and report student death, survey information arrived in widely variable formats. Turner never did conduct a larger study, so there exists no expanded response rate, nor has the definition of student death been standardized.

To obtain information about deaths during study abroad, two large insurers confidentially shared claims data information with the Forum.* This information represented insurance claims made by bereaved families for the cost of repatriating their child’s body. (Issues with these two data sources have been previously discussed in PSAs’ blog “Scientific Research Versus The Forum Report.”**)

Table 1 of the 2018 Forum report lists decedents from 2010 through 2016, by gender, country of death, and cause of death. When comparing this information against Protect Students Abroad ad hoc data, we surmised students who were included and not included. For example, my PSA colleague, Ros Thackurdeen’s son was not included. His program did not carry insurance. My son was also not included. Though his program was insured, the program’s carrier did not participate in the Forum’s data project. Also, Thomas’ body was never found, making a repatriation claim a non-issue.

Though personal, these examples are not exceptional. We are aware of other education abroad students who have died, but are not a part of the Forum’s claims data. This may be because not every bereaved family makes a claim, or they may make a claim through a different insurance policy or carrier, or the program might not be insured at all. All of these possibilities represent missing data, which is why insurance claims data is generally not considered high quality information for assessing risk.

In summary, datasets used by the Forum have weaknesses that were inadequately addressed in their reports. Much to the disappointment of PSA, the 2018 report asked the same hollow question they asked in 2016, a question that undoubtedly means more to the education abroad industry than to student safety advocates and bereaved families. It uses the same qualitatively weak data, the same researcher and the same flawed methodologies. The final product reads as if criticism should be limited by simply supplying larger numbers.

Improved understanding of risk can never result from replicating flawed numbers with more flawed numbers. This approach can only result in a larger version of itself, which inevitably will remain deficient. So for the remainder of this blog, PSA will focus on four specific weaknesses with both Forum reports. These weaknesses fall under the heading of bias, ways in which systematic error can be introduced into a research project to damage the validity of conclusions.*** We will discuss reasons why Turner data and insurance data are not comparable, which ultimately compromises the Forum’s key finding.

Confounding—

Students who engage in study on their home campus likely have many differences from those who engage in education abroad. Examples of such differences include a student’s age, gender, academic standing, disciplinary issues, physical health, mental health, socioeconomics, previous travel experience, and so on.

While research methods can sometimes allow for comparing disparate groups, the Forum offers no information about these differences. This suggests that no attempts were made to understand, account for, or control for confounding factors. In a sense, by using Turner data and insurance data, the Forum compared apples and oranges, claiming that because both are “fruit”—that is, both groups are made up of students—they’re comparable.

Ascertainment bias—

As previously discussed, one of the most basic problems with comparing Turner and insurance data is that there’s no standardized definition of student death. This is true both for student death on the home campus and student death during during study abroad.

Perhaps this seems like a frivolous point; after all, even if students are different from one another, death is still death. Nevertheless, how student death is defined has enormous implications for what researchers count and what they do not count. Given the distinct differences with which Turner and the insurance companies collected their data, and given the aforementioned problems with both of these data sets, we can rightly suspect that who Turner did and did not count was different than who the insurance companies did and did not count.

Healthy traveling student effect—

The “healthy worker effect” is a type of selection bias that occurs when the subjects being studied (population groups of workers) are not like the comparison population with regard to overall health. Likewise, the “healthy traveling student effect” is a type of selection bias that occurs when subjects being studied (population groups of students) are not similar to a comparison population with regard to overall health.

It is reasonable to assume that students with pre-existing conditions would be less likely to study abroad than students without pre-existing conditions. In other words, less healthy students probably are more likely to stay put, while healthier students may be more likely to venture out. Furthermore, students with marginal behavioral health may be less likely to study abroad than those who are behaviorally strong. Thus, the general population of students on study abroad may have overall better health than the general population of students on campus.

This type of self-sorting can impact research results in a significant way, by some estimates reducing measures of mortality in the healthier group by fifty-percent. For this reason, when comparing Turner and insurance data, the Forum should have considered the pre-death health of both groups. However, they did not.

Missing deaths—

The term all-cause mortality is used by researchers to indicate all deaths that occur in a particular population experiencing a particular exposure during a particular period of time. For the purposes of the Forum reports, exposure is either being a student on a college campus (Turner data) or being a student on study abroad (insurance data). The value assigned is measured in number of deaths per 100,000 subjects (students) per year.

Turner found an all-cause mortality rate of 22.4, which the Forum annualized to account for the variability in study abroad program length. This shifted Turner’s death rate up to 29.4 deaths per 100,000 students per year. In contrast, insurance data from 2014 yielded an all-cause mortality rate of 13.5, while the 2010-2016 insurance data resulted in an all-cause mortality rate of 17.6.

All of these numbers seem low. For comparison, it may be useful to consider scholarly studies of youth deaths around the world. For example, in 2012, Gopal K. Singh published “All-Cause and Cause-Specific Mortality among U.S. Youth.” Singh found that youth between the ages of 15-24 had an all-cause mortality range of 23.1 (Hong Kong) to 167.1 (Russia), with the United States at 80.1.*****

In light of this information, if the Forum’s 13.5 and subsequent 17.6 all-cause mortality rates do not make sense, what’s going on? Is their analysis being impacted by healthy traveling student effect? Ascertainment bias? Both? Surely healthy traveling student effect would account for a lowered mortality rate for study abroad students. As for ascertainment bias, under ascertainment in both student groups seems likely.

To their credit, the 2016 Forum report seems to understand the weakness of their data, for they state, “With such a small number of deaths it is very difficult to infer anything to the general population of students studying abroad.” And yet, the Forum leaps ahead to do just that, calculating a confidence interval of 99% that their key finding is accurate.

But determining confidence intervals only works if the numbers being compared have validity. The Forum report has calculated a 99% confidence interval of what? That the two populations (campus and study abroad) are different? This means nothing if the all-cause mortality rates are implausible in the first place. The Forum has not only produced apples and oranges, they’ve produce apples and oranges that are rotting with flawed methodologies.

The Forum’s all-cause mortality rate is so low that, if it is to be believed, it suggests that U.S. students on study abroad are literally the safest youth in the world! At the very least, the reasons for such outlier numbers should have been interrogated in the discussion section of both Forum papers. But they were not. This failure to stringently examine begs many questions, from professional competence to motivation.

There is no way to soft pedal our conclusion. Bad studies can be worse than no studies. Both the 2016 and 2018 Forum report are not true academic research. Their findings are weak, at best, and misguided, even manipulative, at worst. They provide no scientific information upon which to draw conclusions about education abroad student safety, risk and risk mitigation. Rather, these are industry reports, written by the industry for the industry. Sadly, their loose resemblance to research allows media to pick up and repeat the “key finding” like a tagline, thus sending an inaccurate message to students and their families.

While the first Forum report may have represented an attempt by the organization to move their membership toward shared safety data, their persistence with the same question, the same data, the same researcher and research methods, represents something else. In spite of proclamations by both the Forum and the education abroad industry that student safety is priority #1, a difficult truth is revealed by the failures of the second Forum report, as well as the industry’s unquestioning acceptance of these results, despite their persistent refusal to share safety data.

Survivor families understand that student safety risks during education abroad are unique and challenging, as are safety risks on campus. Before our children-as-students leave home for the world, they deserve safety information built upon the best academic scholarship. We continue to hope for and work toward the day when the education abroad industry recognizes transparent safety data and true scientific research as in everyone’s best interest.

~

* Cultural Insurance Services International (CISI) and GeoBlue (GEO, formerly known as HTH)

**https://protectstudentsabroad.org/to-begin-again-3-2/

***https://catalogofbias.org/

****https://protectstudentsabroad.org/telling-the-untold-2/

*****https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665977/

Several months after Ravi Thackurdeen’s death, his mother, Ros, began searching the Internet for well-established study abroad programs. On this day, Ros telephoned a private college whose international program had a large Internet presence. She intended to inquire about the safety of their student travel.

“I’m wondering what safety procedures you have in place for study abroad,” Ros asked.

“Oh, we only run safe programs,” the woman answered.

“What kinds of specific safeguards do you have for students?” Ros guessed that the woman believed she was speaking to a prospective student’s parent, so Ros played the part. She was not intending to speak of Ravi.

“I’m not sure what your question is.”

“What kinds of things do you do to protect students from injury? Or death?”

“We’ve never had a student death.”

“But you might, someday…”

“Well, we’ll deal with that when it happens.”

Now Ros felt angry, “My son died on his study abroad. Do you understand, someday is somebody’s child?!”

“I’m so sorry about your son, ma’am. As I said, we run safe programs.”

This conversation is a glimpse into two distinct modes of perception. One looks at the world through the lens of a working professional. The other looks at the world through the lens of a bereaved mother.

In all honesty, Ros and I didn’t know about “the other lens”—not until the deaths of our sons. Bereaved parents are said to be in “a club no one wants to join.” But more than that, bereaved parents are in a club no one wants to imagine. With profound grief comes the complete extinction of innocence. In its place, a new way of perceiving, a lens replacement so abrupt and thorough, the world can never be viewed as before.

As Ros’ conversation with the study abroad professional implies, most higher education institutions have policies and procedures regarding student injury and death during study abroad. Hence, the woman’s response, we’ll deal with [it] when it happens. And no one would argue against protocols for terrible outcomes; from this woman’s professional perspective, having protocols for when bad stuff happens is about safety.

In contrast, through a bereaved parent’s lens, safety is actually very different. Safety is about ensuring, to the best extent possible, that bad stuff doesn’t happen in the first place. This type of safety exists. It is known as “fatality and injury prevention”. Such strategies are well established in the health care community and always rely on transparent data.

What concerns us about basing student safety on reactive protocols is this: Protocols for negative outcomes are paired with insurers and lawyers, plus one unspoken wish: We’ve never had a student death [and we hope we never will].

Most of us call this luck. There is good luck and bad luck, and everything in between. Hoping to be lucky is what waivers are about. Risk is shifted to an eighteen year old who signs the bottom line because he or she doesn’t really understand risk like a fifty year old, or even a twenty-five year old. And besides, the study abroad industry is great at selling sizzle: Study abroad as an adventure, a far away land, different customs and culture, language and topography, and sure, some unknowns.

The industry can do better.

But they don’t. Not yet. To date, no one in the study abroad industry has publicly advocated for industry-wide comprehensive and transparent safety data.

How can this be? We are talking about one of America’s most sacred institutions, higher education. Higher ed understands that the noblest purpose of academia is the collection and sharing of information for the common good. With comprehensive data, plus statistics to search of patterns, risk can be clarified, allowing for strategies of prevention. A proactive approach to student safety depends on science. Unknowns need not be unknowable.

So here is a little secret from our horrible club: We recognize our kind. They know radical change—a dramatically shattered world, plus an internal wound that will never fully heal. For many, the life that remains becomes a kind of purgatory. Survivors reside in a liminal space, not fully here, with the living; and yet, not quite there, with the dead. Rather, it is through this “other lens” that the profoundly bereaved see both ways.

And what we see in this world is that it goes on and on as always, with barely a registry of what we have lost and the human potential we all have lost. Our children’s deaths are sad stories, old stories, too rarely told stories, only to be lived by some other family in the not too distant future. After all, the business of study abroad is complex, enormous, important, and for some, lucrative.

It is for this reason that we purposefully recall those who have preceded us into grief. Sixteen years ago, John Amato testified before a Congressional hearing about study abroad student safety. He spoke of the death of his daughter, Virginia, plus seven others, including three American students.

“Nearly from the day after the accident, we parents have been attempting first to learn the facts that resulted in our daughters’ deaths, and secondly to work toward preventing such accidents from occurring in the future. We have endured a frustrating struggle in both regards.”

Mr. Amato asks for two things. First, the facts. Not agendas, no spin. Truth.

Second, Mr. Amato asks for prevention efforts to protect someone else’s child.

These should not be a big asks. And yet, apparently they are, for bereaved parents are still seeking the same two things!

The absence of transparency from schools meant to serve our children as students multiplies the devastation of their deaths. And it is in this context that the emotional leveling extends, from families, through friends, and into communities as unmeasured collateral damage.

For many, these student deaths come to represent more—a betrayal by the very institutions we raise our next generation to believe in, as well as the values that propelled us to embrace study abroad in the first place.

Education. Hard work. The understanding of others. Wonder for this world.

We expected more from higher education.

Sometimes now, it is impossible for the bereaved not to wonder, Who are these people who would spend the children of others in favor of their own deal-with-it-when-it-happens ignorance?

The answer begins with good intentions.

Next: To begin, again (Part 3)

The year was 1996. Study abroad students traveling the world with Semester at Sea were meant to get from Delhi, India, to Agra. When one of their busses plunged off the road, seven people were killed, including four American students. Many more were injured.

Immediately, survivors were connected by grief. One newly bereaved father happened to be an attorney. From professional experience, he knew that when things go wrong facts get lost, which means there’s a limited time to get the true story. So he recommended that the families hire an independent investigator, and that is what they did.

What these families learned is that Semester at Sea was working with a new tour operator. A last minute itinerary change moved students from plane to bus, two busses at night on the Grand Trunk Road, dubbed by travel writers as “one of the most perilous roads in the world.” Neither students nor parents knew that locals stay off this route at night; the U.S. embassy advises their personnel to do the same. Moreover, the bus driver had been driving all day and night, and Semester at Sea’s tour operator was uninsured.

The 1996 Semester at Sea incident resulted in headlines such as this, “Death clouds floating college” (L.A. Times). But this was not Semester at Sea’s first student death, nor last.

Two years later, in 1998, armed gunmen removed St. Mary’s of Maryland study abroad students from their bus traveling through Guatemala. All students were robbed and five were raped. This time, headlines read, “Traveling in a troubled land” (Washington Post).

And then, in the year 2000, two Antioch College students were shot. News accounts spoke of their deaths as “Hell in a heavenly place” (Newsweek) and “Their paradise lost” (People). Once again, media commented on the landscape, as if the beauty of a place should protect America’s collective innocence.

But where were the names of the dead? Virginia Amato, Sara Schewe, Cherese Laulhere, Jenna Druck, Emily Eagan, Emily Howell. Real people, someone’s child, sibling, or friend, young learners dying horrific deaths far from home. The New York Times went so far as to say, “Costa Ricans fear slaying of U.S. women will hurt tourism.”

These three incidents joined as an American pivot point, in part because each incident resulted in more than one victim, which garnered more than one day’s news. At the time, Peter Hoekstra was a Republican congressman from Michigan’s second district, member of The Education and the Workforce Committee, and chairman of its subcommittee, Oversight and Investigations. Hoekstra was reportedly moved by Detroit Free Press coverage of the Antioch College deaths. After all, one of the dead hailed from Ann Arbor.

In October of 2000 study abroad student safety took the national stage, with six stakeholders testifying before Hoekstra’s subcommittee. Included were John Amato, the aforementioned lawyer and bereaved father, and also Peter McPherson, president of Michigan State University, home to the nation’s largest study abroad program. Additionally, ten appendixes contain written testimony.

The resulting document is one hundred seventy pages long. And for all of these pages, so many words, this Congressional hearing resulted in what? Though many federal and state officials have promoted the growth of study abroad, it’s been sixteen years since our national legislators considered study abroad student safety. Our sons, Thomas Plotkin and Ravi Thackurdeen, have been dead for more than four years, and during this time, how many other study abroad students have died or been injured?

No one can say. The study abroad industry still does not count and report safety incidents. As a consequence, when Ros Thackurdeen and I meet newly bereaved families, it is common for us to hear the very words we once spoke, “I thought my child was study abroads’ first death.”

This is why ProtectStudentsAbroad’s inaugural blog begins by asking the question every bereaved family wishes to have answered.

What will it take for student safety to become America’s priority?

Next: To begin, again (Part 2)