I recently traveled to Egypt and before departing was met with expressions of surprise from friends who thought the place too dangerous to visit. Images of the downed Metrojet plane in November surely informed their opinion. But a review of the U.S. State Department’s registry of American deaths abroad reveals that the horror of the Metrojet bombing obscures reality: It turns out Egyptian drivers are responsible for far more American fatalities than Egyptian terrorists.

Curious about this disconnect, I dug deeper into the registry. It features almost 13 years of data and comprises over 10,000 deaths from non-natural causes. The registry is updated every six months, and includes only those deaths reported to the State Department. All the same, it is an extraordinary record of where Americans go, and of the dire consequences faced by some of those who travel. What it also reveals the relative rarity of deaths abroad. On average, over the last 13 years, only 827 Americans died of unnatural causes while abroad each year. When you consider the significant number of Americans who travel abroad, more than 68 million Americans in 2014, nearly all returned home.

While there is always the danger of being in the wrong place at the wrong time, the most common causes of death to Americans in Egypt—based on the 69 Americans in the registry who died there over the past 13 years—are auto accidents (18 deaths) and bus accidents (11 deaths). Terrorist action (3 deaths) figures beneath drownings (6 deaths) and suicides (5 deaths). After observing the mayhem of Cairo’s traffic, the relative danger of auto accidents seemed obvious.

What is more startling and curious, when looking at American deaths around the world, is how prosaic the cause generally is. If you want to stay alive on vacation, the most important thing you can probably do is to buckle-up. As in Egypt, vehicle accidents kill the most Americans abroad overall. Out of 10,545 deaths abroad between October 2012 and June 2015, cars were responsible for 2,181 deaths, and vehicles, more generally (cars, motorcycles, buses, bicycles, etc.), were responsible for a total of 3,104 deaths or 29% of all deaths. If you include train accidents (43 deaths), air accidents (343 deaths), and maritime accidents (121 deaths) one third of American deaths abroad were due to a mode of transportation. To put this in perspective, the Institute for Highway Safety reports that there were 32,675 deaths in motor vehicle accidents in the United States in 2014, while the State Department has records for only 159 auto accident fatalities in its most recent 12-month period. At home, motor accidents are the fourth leading cause of death, according to a recent Centers for Disease Control report (pdf here).

Foreign travel is exciting and illuminating; however, it is not without other risks. You should avoid places that are lawless and where drug wars are raging. And please be careful in the water; beaches are one of the biggest specific dangers to American travelers.

Most common causes of death (October 2002-June 2015)

Cause of Death Reported Number of American Deaths Abroad Traffic accidents 3,104 Homicide 2,000 Suicide 1,461 Drowning 1,320 “Other accidents” 1,294

Drowning

One under-appreciated cause of death abroad is drowning. The registry records 1,320 drownings, including many examples of multiple drownings. Costa Rica, perceived as a peaceful place that offers just the right amount of adrenaline, has had 101 American drownings since the registry first began in October 2002. Mexico has had the most, with 355 drownings. However, the number of American visitors to Mexico is the greatest of any country, with 25.9 million Americans visiting in 2014 (2014 was a year in which an unusually large number of Americans traveled abroad, providing a conservative perspective on the relative impact of any deaths). That same year, Costa Rica had only 937,000 visitors, a mere fraction of Mexico’s tourism numbers. On a per visitor basis, Costa Rica’s waters are more dangerous than Mexico’s. These drowning deaths highlight the fact that Costa Rica has no law requiring lifeguards on its beaches, and even those beaches with guards are often under-protected.

American deaths by drowning

Number of Drownings Reported American visitors in 2014* Mexico 355 25,900,000 Costa Rica 101 862,000 The Bahamas 83 1,108,000 Dominican Republic 47 2,700,000 Jamaica 46 1,385,000

*Data obtained from US Department of Commerce, National Travel and Tourism Office, July 2015

Suicide

Suicide is also under-recognized as a cause of death for Americans abroad. The Department of State has records of 1,461 suicides, which amounts to over 100 American suicides abroad per year. Mexico is the most common country for American suicides (250 since 2002), reflecting the frequency with which Americans visit. María Elena Medina Mora, head of Mexico’s National Psychiatric Institute, has linked the drug war to an increase in suicides, a rate which has tripled in the past 30 years according to the Mexican Ministry of Health. Has this cheapening and coarsening of life in Mexico rippled out to visitors, too? The registry indicates that Germany had 100 American suicides, but Thailand, with far few American visitors, has a comparatively shocking number: 87 suicides.

American suicides abroad

American Suicides Reported American visitors in 2014* Mexico 250 25,900,000 Germany 100 1,878,000 Thailand 87 339,000 Korea 71 523,000 Japan 59 800,000

*Data obtained from US Department of Commerce, National Travel and Tourism Office, July 2015

Switzerland, with its 22 suicides, is a special case as it highlights the emergence of suicide-travel. Of the Swiss suicides, 9 took place in the small town of Pfaffikon (population 11,390). Dignitas, a society that undertakes assisted-suicide, has a house in Pfaffikon where guests are interviewed on film immediately prior to being offered a lethal dose of Pentobarbital. (We cannot tell from the Department of State records if the Pfaffikon suicides were as a result of Dignitas.)

Most common places to die

The most recent 12-month period (July 2014 to June 2015) in the database confirms that Mexico remains the most popular place to visit, and the most common place for Americans to die (228). Thailand, however, emerged in second place with 35 U.S. deaths. Of those, however, 12 were due to suicide and 10 were specifically due to motorcycles. Of the 11 deaths in Switzerland during that period, all but one were attributed to suicide. Of the 31 deaths in Costa Rica, 17 were due to drowning. In the Philippines, there were 12 reported homicides of the 29 deaths, making murder the most common cause of death with vehicle accidents a close second with 10. The Dominican Republic had 28 deaths, of which 10 were due to drowning. These drownings included a horrifying multiple drowning where four family members (three of whom were American) died when a young pharmacist from Philadelphia, Kajal Patel, was caught in a current, and her new husband and two of his family members jumped in the waters off Punta Cana to save her.

Countries with most American deaths 2014-15

American Deaths July 2014- June 2015 American visitors in 2014* Mexico 228 25,900,000 Thailand 35 339,000 Costa Rica 31 862,000 The Philippines 29 708,000 Dominican Republic 28 2,700,000

July 2014- June 2015

*Data obtained from US Department of Commerce, National Travel and Tourism Office, July 2015

Drugs

Drug-related travel inevitably deserves a category of its own. Although Mexico and Costa Rica saw more drug-related deaths, Cambodia and Thailand were in the top five for American deaths. Cambodia, in particular, stands out. It saw 21 American drug deaths since 2002, while receiving only scant American visitors (191,000 in 2014). The Pnomh Penh Post reports that drug overdose is a very common cause of death among foreigners, reflecting the country’s past (the heroin trade began in the nearby Golden Triangle), easy access to illicit substances, and Cambodia’s modest health care infrastructure.

American drug deaths abroad

Drug-related Deaths Reported American visitors in 2014* Mexico 59 25,900,000 Costa Rica 23 862,000 Cambodia 21 191,000** Thailand 20 339,000 Germany 16 1,878,000

*Data obtained from US Department of Commerce, National Travel and Tourism Office, July 2015

**Data obtained from the Cambodia Ministry of Tourism

Murder

Mexico leads in this area – reflecting the large number of American visitors but also, the consequences of the drug war. These homicides are more common in places like Tijuana and Nuevo Laredo where gang and drug activity are at their most intense. Not included in the homicide number were the executions of 16 Americans in Ciudad Juarez, the home of the Juarez Cartel a major player in the drug war. What is also notable about the homicides of Americans is how many of them also occur in Honduras and Haiti. These two countries receive only a modest number of American visitors each year (so low, that the numbers of inbound American visitors go unacknowledged) and yet their baseline crime rates are so high (Honduras has one of the highest murder rates in the world, so the State Department warns against visiting the country) that American lives are at risk, even if they are not targeted specifically.

Americans murdered abroad

Homicides Reported American visitors in 2014* Mexico 843 25,900,000 Philippines 110 708,000 Dominican Republic 91 2,700,000 Honduras 91 Unavailable Haiti 89 Unavailable

*Data obtained from US Department of Commerce, National Travel and Tourism Office, July 2015

Deadliest places

Of those countries that have a significant number of inbound American visitors, the country with the highest rate of un-natural death by American travelers is Thailand. There have been 348 un-natural deaths since October 2002, but relatively few Americans visit the country. Vietnam, Costa Rica and the Philippines each have substantial American deaths relative to the number of visitors, three to four times more than Mexico, when adjusted for volume.

Highest rate of un-natural death by popular destinations for Americans

Number of American Deaths Reported since October 2002 American visitors in 2014* American Deaths Reported Annually/1,000,000 visitors Thailand 348 339,000 80.5 Vietnam 106 246,000 33.8 Costa Rica 339 862,000 30.8 Philippines 259 708,000 28.7 Australia 153 431,000 27.8

*Data obtained from US Department of Commerce, National Travel and Tourism Office, July 2015

Thailand is a special case, however, as the number of American deaths when adjusted for the volume of American visitors, is more than twice that of Vietnam and about 9 times greater than that of Mexico. Suicide is very common in Thailand, with some 87 of the 348, or about 25% of deaths since 2002 being self-induced. Motorcycles take many casualties (76 deaths), as do cars (35 deaths). The Tsunami in December 2004, a random disaster, took at least 22 American lives, while drugs took a further 20 lives. Thailand’s attractions mask an environment that can be dangerous and chaotic.

Deaths in Thailand

Cause of Death American Deaths Reported Since 10/2002 Suicide 87 Vehicle Accident – Motorcycle 76 Other Accident 38 Vehicle Accident – Auto 35 Homicide 26 Disaster 22 Drowning 20 Drug-Related 20 Other Causes of Death 24 Total 348

Popular places

A traveler who wants to make it home alive will have excellent odds almost anywhere, but especially at any of the five top countries visited by Americans. Canada, with its scant 189 deaths in almost 13 years, would be the safest choice. Mexico and the Dominican Republic are less safe, but not substantially so. They are safer, still, if you happen to be a strong and careful swimmer.

Most popular destinations for Americans

American visitors in 2014* Number American Deaths Reported from Oct. 2002 to June 2015 American Deaths Reported Annually/1,000,000 visitors Mexico 25,900,000 2,931 8.87 Canada 11,500,000 189 1.29 United Kingdom 2,800,000 113 3.16 Dominican Republic 2,700,000 271 7.87 France 2,100,000 107 4.00

American visitors in 2014*

25,900,000

11,500,000

2,800,000

2,700,000

2,100,000

*Data obtained from US Department of Commerce, July 24, 2015

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