Chapter 9

Effects of the Sun, Maladies, etc.

   The #1 Threat  My Travel Clinic  Self-Diagnosis  Playing Doctor  Maladies  Items of the Colon  Food Poisoning  Rehydration Therapy  Women's Concerns  AIDS  Insects...Urine Fish  Mosquitoes  Wounds, Rashes  Foot Care  Effects of the Sun  Cold and Frostbite  Altitude Sickness  Jet Lag  Medical Kits  Returning Home  Tips

IN NORTH AMERICA, Europe, Australia, New Zealand, South Korea, Japan, and a few other places your most likely health problems are foot blisters, colds, constipation, and hangover. In the rest of the world most travelers are likely to encounter nothing more than mild diarrhea from unfamiliar microbes introduced into the intestines.

Don't allow fear of health problems forestall developing world travel--if you sit at home you might have a heart attack or develop a horrible disease of the ass! While headline-grabbing diseases such as Ebola, Lassa Fever, and plague are terrifying, travelers don't get them. These are diseases of grinding poverty and ignorance. For twenty years we of the developed world have been suffering the deadliest and most insidious virus of all--so try to maintain perspective.

With the sensible precaution of seeking and following advice from a travel clinic your health risks are greatly reduced, as most risks are directly related to awareness. You don't want to be as naïve as I on my first backpacking trip into the developing world. (See photo below and Drinking Tips in Chapter 21.)

Photo: Here I'm  feeling chipper compared to a few hours earlier. Note the language dictionary in my right hand--the doctor spoke English, the nurses did not. Many thanks for the wonderful care from all.

The #1 Threat

By far the greatest threat to the traveler is being run over by a moving vehicle, or from a crash while in a moving vehicle. Even for Americans on comparatively safe American roads there is about a one in one-hundred lifetime chance of perishing in an automobile accident, and many times that for serious injury.¹

Therefore the most important steps for traveler safety are obvious--always wearing a seat belt or helmet, always looking both ways before crossing a street, and standing well-back from the curb. Keep this in mind as you read about malaria, cholera, and urine fish.


Driving in Developing Countries and Remote Areas (Chapter 21 Considerations)

From a March 1997 email (bottom)

Sources For Current Information

If planning a journey to the developing world, this chapter will not provide all the information you need. That information is not available in any book, as epidemics and outbreaks occur and change much too quickly. Constantly updated information is available from:

Centers For Disease Control, Atlanta, Georgia (voice tel. 404-332-4559  fax-back 888-232-3299)
cdc.gov

The CDC webpage is used by travelers from everywhere for the latest worldwide disease and health information. You can also listen to exhaustive recordings of health information over the phone by requesting specific topics via touch tones, or use their fax-back service. Many travel clinics receive software updates from the CDC, and provide that information to customers, one of which you should be before and after developing world travel.

My Travel Clinic

Most major cities have a private or public travel clinic to assist international travelers with preventive measures, and to treat diseases brought back. After being pitifully laid out and hospitalized on my first tour into rural Mexico due to stupidity, there was no question that before my next journey into the developing world I would seek a travel clinic and spend whatever necessary to get fully immunized, as well as medically and mentally equipped.

Soon I had the opportunity for a few months in Central America, so I made an appointment with the Travel Clinic in Austin, Texas. During the initial $45 visit a knowledgeable Registered Nurse discussed my case. She also had access to a computer file from a private company called Travax, which was a compilation of information from the CDC and the State Department. It was updated weekly.

I was given forty pages of useful computer printout on eight Central American countries. Topics for each country were AIDS, cholera, malaria, hepatitis, polio, rabies, typhoid, yellow fever, cholera, insect-borne diseases, food and water-borne diseases, testing requirements, and a general description of each country. Most eye-opening were U.S. Department of State travel advisory reports, including descriptions of recent criminal activity against travelers, warnings about possible drug penalties, assessments of medical facilities, and embassy locations and phone numbers.

On my first visit to the clinic I received a polio booster shot in one arm ($25) and a tetanus-diphtheria (Td) booster shot in the other ($15). Both arms were slightly sore at the place of injection for two days.

I was given prescriptions for chloroquine, Cipro, and a Typhoid oral vaccination. Chloroquine is an anti-parasitic drug which usually kills malaria-causing protozoa in the blood. It is taken once weekly beginning one or two weeks before entering an infected area, and for four weeks after leaving an infected area. I bought the generic chloroquine for about $2.50 per capsule--$1 less than the brand name.

Cipro is a brand of ciprofloxacin antibiotic available through prescription. It is effective against travelers' diarrhea since it causes fewer side effects than broader-ranging antibiotics. Recommended dosage was one 500 mg tablet twice per day for three days. Cost was $20 for six tablets, but I bought twelve as Cipro has a long shelf-life, and I knew from experience how vital an effective antibiotic could be.

I was instructed to carry Cipro, Immodium, and a thermometer. If I contracted mild diarrhea, which was defined as several bowel movements per day while feeling fairly well, no treatment was indicated. If the diarrhea was severe I was instructed to check my temperature. If it was above normal I was to take 500mg of Cipro twice per day for three days. If my temperature was normal, I was to take the Cipro as above, and to take one Immodium tablet four times per day for three days.

The reason for not taking the Immodium while running a fever is that fever may indicate organisms in the bowels which are likely to invade the intestinal lining. Since Immodium slows intestinal movement (plugs you up), it would allow the bad bacteria a better chance to invade the lining and prolong diarrhea.

I was also told to seek medical help if self-treatment did not work, and if there was accompanying high fever, blood, or mucus in the stool, which are all indicators of infection.

The Oral Typhoid Vaccine cost $42 and consisted of four capsules to be taken with cool water one hour before meals every other day. Since this was a live vaccine the capsules had to be kept cool. I was given an ice-pack for transport home. This oral vaccine was said to have fewer side effects than the injectable version.

About ten days later I returned to the Travel Clinic for an immunoglobulin (gammaglobulin) injection ($9) in the hip, and a yellow fever vaccination ($52) in one arm. The immunoglobulin shot contained antibodies to combat Hepatitis A, which provides some protection for up to five months. It should, however, be taken as close to departure as possible to ensure maximum effectiveness. The yellow fever shot is effective for ten years.

After this second visit to the Travel Clinic I had a very slight fever and chills, and was slightly tired for a few days. This was considered a normal reaction. My hip definitely ached from the immunoglobulin shot.

Find a travel clinic in your area by checking the yellow and white pages under Travel Clinics, or by calling your local public health agency, hospital, or doctor.

International Health Certificate (Yellow Card)

This card documents your immunization history. Required for entry to some countries for proof of yellow fever inoculation, it is available from travel clinics, and possibly your doctor. It's yellow.

Travel Health Insurance

Many companies sell travelers' health insurance for one to several dollars per day. Usually you pay the medical costs while abroad, but are reimbursed upon return. More expensive plans pay for emergency air transport home.

If you already have health insurance check if your current plan provides coverage in other countries. There's a good chance it does, though it probably won't cover emergency air transport.

ISIC (International Student Identity Card) holders get coverage with the card. Other plans are available from many travel agents, including Council Travel and other budget/student specialists. Search the web or see Chapter 23-b Useful Information for a dozen companies that offer travel insurance.

Some European and other advanced countries with national health systems treat--at no charge--travelers from other countries on a reciprocal basis. Citizens of the United States, of course, are on their own.

A Warning on Self-Diagnosis

The knowledge base doctors use to diagnose is a thousand times greater than the following list of symptoms and disease characteristics. Don't try to diagnose yourself or someone else--seek professional advice as soon as you can. Even in developing countries where doctor training may not be extensive (in Mexico I was superbly treated by a twenty-two-year-old), they will be familiar with local health problems.

Another point is that treating yourself with too few or the wrong antibiotics can be seriously unhealthy. The wrong antibiotics can facilitate germ entry into new areas of the body, while too few might allow the infection to spring back worse than before.

Playing Doctor

Learn from my mistakes!

• You may not notice a slightly elevated rate of breathing, or if you do, you may not connect it with rapidly developing pneumonia. You may also be fooled (not that you have any knowledge or experience to fool) because the patient's symptoms (temperature, vomiting, etc.) appear (to you) to be improving. The situation can suddenly change for much worse or disaster due to something under the surface of what untrained and inexperienced eyes can see.
  
  
• "What's going around" may have relevance in a macro sense, but it may also have little or nothing to do with your patient/friend/loved one due to age, health, medication, etc.
  
  
• Don't put too much stock into advice over the phone (unless it's to seek professional help right away), even if it's from a good source. The difference between a description by someone with nearly zero experience and the patient being seen by a medical professional is like night and day.
  
  
• Many lives could be saved and much suffering avoided if people who basically don't know anything (unless you're a doctor or nurse, that's you!) would get successively wiser, more experienced, better educated, better trained hearts and minds involved to help think and make decisions. This should be done in minutes or hours, not days.
  
  
• Get her the best trained, best equipped, and most compassionate care available. While this must be balanced with time/distance/transport factors, it's probably wise to go sooner for the superior care.
  
  
• If you are the patient, don't downplay your symptoms. The doctor needs to know exactly how it is so he can make good decisions. In one case the patient kept telling the doctor, "It's probably nothing, I'm okay," etc., when in fact he was having a major heart attack with a lot of pain!
  
  
• It can be especially difficult if you normally rely on the patient/friend/loved one for decision-making help, but the patient is too sick to provide reasonable guidance. Seek professional medical help right away!
  
  
• You must act to preserve life, ease suffering, and increase joy by properly valuing your patient/friend/loved one as early as possible, and by getting professional medical help as soon as possible.
  
  
  

Maladies of Interest to Travelers

The following is a concise overview of major threats facing travelers. I hope it encourages you to seek professional medical advice from a travel clinic before visiting the developing world.

Most of this information came from the CDC, my travel clinic, the American Medical Association Encyclopedia of Medicine, several travelers' health books, and my limited experience. While I have tried to be accurate and informative, please understand that I am writing outside my fields of expertise (travel gear, hitchhiking, women), that I am neither a doctor or nurse, and that the best and only course of action is to see a medical professional.

Colds

are common among travelers. One had five over six months in Europe. He was also drinking more alcohol than usual, and not eating well. Because there are over two hundred viruses associated with colds, those prevalent in Europe or China may quickly overwhelm your immune system.

Since colds are transmitted primarily by direct contact, incidence is reduced by washing hands, especially before eating, and by keeping fingers away from the face. Colds gain initial foothold in mucous membranes, so drink plenty of fluids to keep them in good shape.

 

Diphtheria

is very rare in developed countries due to widespread use of the Td vaccine, but is still endemic in poor, developing countries, and a hazard to non-immunized travelers. There is currently a diphtheria epidemic in the countries of the former Soviet Union.

 

Diphtheria is an acute (suddenly developing) bacterial illness which causes a sore throat and fever, and can be life-threatening when the bacteria release a toxin into the bloodstream. About ten percent of victims die. Prevention is by updating your Td vaccine.

Tetanus

is also called lockjaw. 500,000 cases develop annually worldwide, but only about one hundred in the U.S. due to widespread immunization with the Td vaccine. While a booster is recommended for the general population every ten years, the vaccine's effectiveness falls off enough that if you get a major cut or puncture between years five and ten, it's apparently standard practice to get another booster. (Hence I'll get a booster every five years for developing world travel.)

Symptoms include stiffness of the jaw, back, and stomach muscles, and a contraction of facial muscles. Wounds should be thoroughly cleaned and an antiseptic applied. Tetanus is serious and sometimes fatal. Prevention is by the Td vaccine.

Diarrhea

is often contracted by visitors to the developing world for a few days. It is generally no great problem, and the discomfort usually lessens after a day or two.

Diarrhea is most often caused by unfamiliar bacteria. Mexicans traveling in the U.S. sometimes get Uncle Sam's Revenge. Anxiety is also a precipitator.

It's best to let normal diarrhea run its course, which takes two to five days. Drink plenty of liquids to flush-out your system, and to avoid dehydration. Eat no solid foods on the first day. On the second day begin eating bland foods such as toast, soup, rice, and bananas.

If you need to plug your system for a day so you can travel, the over-the-counter drug Immodium works safely and well. The active ingredient in Immodium is loperamide, which is also used in several other medications. Do not use loperamide for extended periods as the intestines must be cleansed naturally. Loperamide doesn't cure anything.

Many travelers swear by Pepto Bismol tablets for soothing the stomach and easing diarrhea. I usually have these tablets in my pack, and when traveling developing countries, several in my wallet. Pepto Bismol turns your stool a dark black.

Dysentery

is a severe infection of the intestines, characterized by passage of mucus and blood. It has two forms: bacillary and amebic. While both are prevalent in many developing countries, they are rare in travelers compared to simple diarrhea.

Bacillary dysentery

is also called shigellosis, after the shigella bacteria which cause it. Bacillary means "rod shaped," which describes the bacterium. The usual source is from infected food handlers failing to wash hands properly, and from flies landing on food after having been somewhere nasty.

Symptoms begin one to four days after infection, and are characterized by a sudden onslaught of watery diarrhea, abdominal pain, vomiting, nausea, and fever. After several days blood and mucus begin passing. It is highly contagious.

Treatment consists of rehydration therapy. Solid food should not be eaten for the first day or two. Antibiotics may be useful. Most victims begin recovering after about a week. Babies, children, and old people risk death due to dehydration.

Amebic dysentery

is also called amebiasis, from the single-celled ameba (smallest animal) parasite entameba histolytica. Amebic dysentery results from swallowing the histolytica cysts via infected water or food (especially beware lettuce, uncooked vegetables, and unpeeled fruit). It is found in the same areas as bacillary dysentery.

Symptoms range from a few loose stools with rumbling pains in the stomach, to a severe case with high fever and bloody, watery diarrhea. It comes-on slower than bacillary dysentery. It can cause shaking chills, fever, weight loss, and painful enlargement of the liver.

Treatment is with rehydration therapy and amebicide drugs such as metronidazole, which effect full recovery within a few weeks. It won't go away on its own like bacillary dysentery.

Prevention for both types of dysentery is by eating only cooked vegetables and peeled fruits, and by only drinking boiled or purified water.

 

Cholera

results in severe water loss due to watery diarrhea and vomiting. The cholera bacterium produces a toxin which increases the passage of fluid in the bloodstream to the intestines. Death can result in a few hours from rapid fluid loss. Infection is by ingesting food or water infected with the bacteria, but especially from shellfish. In two hundred years cholera has spread from northeast India to most of the developing world, including South and Central America, and Mexico.

While the risk of cholera to travelers is slight, in 1993 in Guatemala City I read a full-page newspaper article about a cholera outbreak/scandal in Chiquimula, a thriving middle-class city I had visited the previous week. Water works employees had failed to chlorinate the water, and four hundred people had come down with cholera, killing eleven.

Symptoms begin one to five days after infection, and include diarrhea and usually vomiting. Treatment consists of immediate rehydration therapy to prevent dehydration and death. Ninety-nine percent of victims recover given adequate rehydration.

Prevention consists of drinking only bottled or boiled water, and taking as much care with food as possible. A vaccine is available, but is only about fifty percent effective for three months. My travel clinic did not recommend the vaccine due to its ineffectiveness, expense ($45), and the rarity of cholera in travelers. Other backpackers have taken the vaccine because they were told it might reduce symptoms.

 

Constipation

is common due to the change in routine and diet. Make a point to drink plenty of fluids, and eat roughage. Fighting has been reported in England over lettuce. Otherwise a pint or two or three of Guinness provides relief.

 

Hepatitis type A

is also called infectious hepatitis, and is the most common serious disease among travelers in the developing world. Type A is transmitted by a virus through fecal contamination, again via food or drinks prepared by an infected person with poorly washed hands. While it is found worldwide, travelers are most susceptible in developing countries with low food handling standards.

Symptoms are either nonexistent or abruptly begin two to six weeks after exposure. They resemble the flu, including fever, aches, loss of appetite, nausea, abdominal discomfort, and liver pain (on your right side). Urine may darken, and stools may become lighter and yellowish. After four to seven days the symptoms may become more severe, including diarrhea, vomiting, itching, and jaundice. Skin and whites of the eyes may turn yellow. Most recover within six weeks. Hepatitis type A does not lead to chronic hepatitis.

There is no treatment for hepatitis A. Victims must rest and abstain from alcohol until they recover. This recovery of the liver so weakens the victim they often can do no more than hole-up in a fleabag hotel, or swing in a hammock under a palapa twenty hours per day. Prevention is by taking care what and where you eat. An immunoglobulin shot provides some protection for up to five months, the Havrix vaccine for up to ten years.

Hepatitis type B

is also called serum hepatitis. It is found in the blood, semen, and other body fluids of infected persons. It is spread in the same manner as AIDS (sexual contact, IV drugs, and infected blood products). Type B is found worldwide, but is much more prevalent in Asia and Africa. Symptoms, when they occur, are the same as for hepatitis A, except sometimes more severe. Many people are completely symptomless.

About ten percent of hepatitis type B cases lead to chronic hepatitis, which is a severe inflammation and destruction of cells within the liver. This leads to cirrhosis.

Prevention is with the hepatitis B vaccine, although this is usually only recommended for health care workers, people who have many unprotected-sex partners, and drug addicts.

 

Typhoid

is caused by the bacteria salmonella typhi. Feces, urine, and contaminated food and water are the principal sources of infection--again often through a food handler with poor hygiene. Sewage-contaminated shellfish is also a source.

 

Most symptoms are limited to a fever of one week, but can include headache, anorexia, general malaise, and constipation, giving way to diarrhea, a non-productive cough, nosebleed, and raised pink spots on the upper abdomen. Complications may result, and the death rate for serious cases is ten percent for those untreated, one percent for those treated.

Treatment is with antibiotics. Prevention is by cautious eating and drinking, and by an oral or injectable vaccine, both of which are about sixty-five percent effective for five years. The oral vaccine is four pills taken every other day; the injectable requires two shots one month apart. The oral vaccine has lesser side effects.

Antibiotics are not recommended as a preventive since they disrupt normal intestinal bacteria and can facilitate infection with salmonella typhi.

Polio

is a viral disease which has been virtually eliminated in the developed world, but is still a threat to non-vaccinated travelers in developing countries. Some beggars in developing countries with wasted feet and legs are polio victims. There is no effective treatment for polio. Prevention is with either the oral or injectable vaccine.

Malaria

poses the greatest health risk to travelers in warm climates, and is in fact the greatest health threat to humanity. Up to 300 million cases occur worldwide each year, with about one million deaths in both Africa and Asia. The tragedy is currently increasing as mosquitoes become insecticide-resistant and forms of malaria become drug-resistant.

Malaria is spread by the bite of the Anopheles mosquito, which generally feeds dusk through dawn. It is caused by four types of a single-celled protozoa: vivax, ovale, malariae, and falciparum. These parasites attack and explode red blood cells.

Symptoms for the first three types may include the classic malarial fever, which is called an ague (pron. ae gyoo). This occurs in three stages which rhythmically coincide with millions of parasites being released into the bloodstream after bursting out of red blood cells. First is a cold stage characterized by severe shivering, followed by a high fever stage of up to 105º F (40º C). Finally there is intense sweating which brings the fever down. The victim may also vomit and have a bad headache. The patient is left weak and tired, and sleeps.

These stages may occur cyclically, either every other day or every third day, but only after the disease is well-established. Malaria can be very difficult to diagnose in early stages.

Falciparum is a more severe type of malaria as all red blood cells are attacked. Death may result a few hours after symptoms begin. The brain may be affected, and liver and kidney failure are common.

Treatment is usually with a big dose of chloroquine. Falciparum malaria is resistant to chloroquine, however, so other drugs must be used. Discuss treatment with your travel clinic before you go, and immediately with local medical professionals if you acquire malaria-possible symptoms.

Malaria prevention is complicated, so only trust a high quality travel clinic to prescribe the proper medications for your specific destinations and singular physiology.

 

Chloroquine (brand names Aralen, Avloclor, and Resochin) should be taken weekly beginning at least one week before entering a malarial area, and continuing four weeks after leaving. Beginning the regimen two weeks before departure is often recommended so there will be time to change medication in case of reaction. It's traditional to take chloroquine--and to remind other travelers to do so--on Sunday.

In falciparum malarial areas, such as Panama east of the canal, a weekly dose of mefloquine (brand name Lariam) may be prescribed. Three tablets of sulfadoxine/pyrimethamine (brand name Fansidar) may be prescribed to be taken immediately if flue-like symptoms suddenly develop. Some people have severe skin reactions to Fansidar, and various neurological, psychiatric, and flue-mimicking symptoms have been ascribed to Lariam.

Chloroquine and the other anti-malarial drugs are not vaccines, and they do not guarantee immunity from infection. They are prophylactic medications--taken properly, they usually suppress and prevent malaria. Thus most travelers who take the proper medications, use DEET insect repellent (detailed below in How to Avoid Insect Bites), wear long sleeves and pants, and drape mosquito netting around their beds don't get malaria.

Yellow fever

is a viral, hemorrhagic (bleeding) disease transmitted in urban areas from person to person by Aëdes aegypti mosquitoes, which feed during the day. In jungle areas it is transmitted from monkey to man by various mosquitoes. Yellow fever is found east of the Panama canal, in parts of South America, and in much of Africa.

Symptoms begin three to six days after infection, are relatively mild in eighty percent of cases, and include fever, headache, and weakness, which last up to four days. The other twenty percent are more serious, including high fever, chills, nausea, vomiting, bleeding from the gums and nose, and severe pain in the neck, back, and legs. These may last a few days, followed by a remission, and then followed by a more severe illness, including increased fever, vomiting of blood, and jaundice due to liver damage--hence the name yellow fever. Approximately five percent of all victims die within days of symptom-onset.

Treatment consists of maintaining blood volume and fluids. No drug works against this virus.

Prevention is by the yellow fever vaccine, which lasts ten years. A yellow fever vaccination certificate (yellow card) is required for entry into and from countries where the disease is prevalent.

Dengue fever (pron. den gay)

is also called breakbone fever after the debilitating pain it causes. It is another viral, hemorrhagic disease transmitted by day-feeding Aëdes aegypti mosquitoes, and thus found in tropical and subtropical regions worldwide. While I was in the Petén region of Guatemala an epidemic of dengue was ravaging the local population.

Symptoms appear five to eight days after a bite from an infected mosquito, and include high fever, severe muscle and joint pain, and rash. They subside and recur about every three days. Recovery takes several weeks, with victims rarely dying.

Treatment is with pain killers to relieve symptoms--there is no specific treatment.

 

Prevention is, as always, by avoiding mosquito bites. There is no vaccine.

Chagas' disease

is also called American sleeping sickness, and can be fatal. It is transmitted by the bite of the assassin bug, which makes its home in thatched roof and adobe huts in rural Central and South America, but especially Brazil. This bug prefers to bite on the face and defecate. Single-celled parasites called trypanosomes enter the body, grow to huge numbers, then attack many organs, including the heart. Diagnosis is by a hard, purple swelling which appears on the bite site about a week later.

Treatment is effective only if caught early.

 

Prevention is by not sleeping in mud huts, by using mosquito netting, or by at least sleeping in the middle of the room away from walls. This disease is extremely rare in travelers.

Plague

is transmitted to humans by the bites of rodent fleas. While a few cases of plague occur every year in the American Southwest, it is mostly a disease of South America, Africa, Southeast Asia, and India. Plague is the "black death" that repeatedly wiped-out Europe during the middle ages. The risk of plague to travelers is almost zero, especially if you make a habit of not handling rats, dead or alive.

Rabies

is also known as hydrophobia, and is an acute viral disease of the nervous system. Almost invariably fatal if left untreated, it is transmitted by animal bites, scratches, or even licks on an open cut. There are about 30,000 deaths every year from rabies, nearly all in developing countries.

Skunks, raccoons, and bats are the major carriers in North America. In Central and South America dogs and vampire bats are the primary vectors. Rabies is fairly common in some areas. Stray dogs are numerous, and vampire bats are a threat to those sleeping outside without mosquito netting. A vampire bat lands near a sleeping mammal, creeps up, and delivers a painless bite with razor-sharp teeth. It then laps up the blood, which doesn't coagulate due to inhibitors on the tongue. Horses and cattle are the usual prey, not backpackers. Any bat found on the ground is quite possibly a rabies victim. Do not touch it.

Jackals are the primary carriers of rabies in Africa. In Southeast Asia and India dogs are the leading vectors to humans. Note, however, that any mammal bite may transmit rabies.

Ireland, Britain, Norway, Sweden, Japan, Australia, and New Zealand do not have the disease, and require an extensive quarantine for pets entering the country.

Symptoms of rabies begin from nine days to many months after exposure. These include fever, hyperactivity, seizures, and often an intense thirst that cannot be quenched since liquids produce violent and painful spasms in the throat. The victim will die within three to twenty days from onset of symptoms.

Prevention and treatment is through passive immunization before symptoms appear, and ideally within two days of exposure. Competent medical advice should be immediately sought after a bite in a rabies endemic country. (Not a snake doctor.) Clean the wound thoroughly with soap and clean water for at least five minutes, but don't stitch it closed. The sooner vaccination is begun, the better the prognosis. Today's vaccines are not so painful, and are no longer given through the stomach.

Brucellosis

is a rare bacterial infection in the U.S., but travelers who drink unpasteurized dairy products in Latin America and Mediterranean countries may be at risk. Symptoms include high fever, shaking, sweating, and severe depression. Treatment is with antibiotics and rest.

Schistosomiasis (bilharziasis)

is common in tropical regions worldwide, affecting about 200 million people. It is caused by several species of flukes (flattened worms) called shistosomes. They live in fresh water lakes and rivers, where they live part of their life cycle in snails.

Symptoms vary from none to serious. The first is usually an itchy rash where the parasite has burrowed through the skin. Weeks later flu-like symptoms may begin, including high fever, chills, muscle aches, and diarrhea. The symptoms may go away and recur a month or two later. Long-term damage includes cirrhosis and kidney failure.

Treatment is with a single dose of an anthelminthic (antiparasitic) drug, which kills the flukes. Prevention is by avoiding freshwater rivers and lakes in the tropics, but especially the Nile Valley, where schistosomiasis is rife.

Leishmaniasis

is a variety of diseases caused by a single-celled parasite transmitted via sandfly bites. Some varieties affect mostly the skin, producing large ulcers at the bite area. In the Middle East this is known as the Baghdad boil. South American forms of the disease may cause more severe tissue damage, especially to the face. Another variety, called kala azar, causes internal organ damage.

Treatment is effective with sodium stibogluconate. Prevention is by avoiding sand fly bites by wearing shoes, socks, pants, long-sleeves, and by using DEET.

Filariasis

is a variety of tropical diseases caused by larvae or worms, and transmitted to man by insects. These diseases include the childhood bugaboo elephantitis, which causes enlargement and hardening of arms, legs, and scrota, and onchocerciasis, below.

Onchocerciasis (river blindness)

is caused by a worm infestation in Central and South America, and Africa. The parasite is transmitted from person to person by the black simulium fly, which is found only near fast-moving rivers and streams. Up to twenty million people are affected, causing blindness in many. In some African villages fifty percent of the old people have river blindness.

Treatment is with the drug diethylcarbamazine, which must be administered under close medical supervision since severe reactions to the dead and dying worms may occur. Prevention is by avoiding black fly bites.

Giardiasis (beaver fever)

is the bane of wilderness backpackers in the United States. It is also found worldwide, especially in the tropics and the public water systems of the former Soviet Union. It is an intestinal infection caused by a single-celled parasite. Wilderness backpackers in the U.S. must treat all water, even from crystal clear brooks in Yosemite, due to the prevalence of this organism.

Giardia cysts (eggs) are spread from the feces of infected animals. The cysts hatch two or three weeks after ingestion, causing abdominal symptoms such as violent diarrhea, foul-smelling gas, and cramps. Sixty percent of those infected, however, show no symptoms. Giardiasis clears up on its own after two or three weeks, although metronidazole speeds recovery.

Prevention is by drinking only pure or treated water.

Women's Concerns

Cystitis

is a common infection of the urinary tract and bladder among travelers. The main symptom is a frequent urge to urinate, accompanied by burning or stinging. The amount of urine passed is usually small, and the pain can be great. Cystitis is sometimes associated with sex, and symptoms are similar to several sexually transmitted diseases which can lead to infertility and cancer if not properly treated. Therefore a doctor must always be consulted.

 

Treatment is with an antibiotic to eliminate the infection and prevent it from spreading to the kidneys. Drink large quantities of liquids, especially cranberry juice, to speed recovery and as a possible preventative.

 

Initial pain can be relieved with the urinary tract analgesic phenazopyridine hydrochloride, available through prescription (Pyridium) or over the counter (ask a pharmacist). This is a pain reliever, not an infection fighter, so again, a doctor must always be consulted, perhaps especially if symptoms seem to go away on their own.

Vaginal infections

Tropical climates and taking antibiotics for diarrhea and other ailments may increase incidence, which may  be reduced by wearing light, loose clothing, and cotton underwear instead of nylon.

Pregnant

women should consult their doctor before traveling to developing countries. Some vaccinations, antibiotics, and antimalarials may be harmful to the fetus.

AIDS

Nearly 20,000 people are infected every day.

The hardest hit area is sub-Saharan Africa, where AIDS is called "slim" due to its wasting effects. In some areas up to twenty percent of the population are carriers, as well as nearly all prostitutes. In Africa AIDS is spread primarily through heterosexual sex. The blood supply in Africa is likely to be poorly screened, if at all, so you must avoid transfusions. Travelers in Africa should bring their own hypodermic needles for emergencies.

AIDS is also spreading rapidly in Asia, again primarily through heterosexual contact. Since the epidemic became widespread there only a few years ago, deaths are still rare. Thailand is the main foci, with a significant percentage of prostitutes infected. In 1996 over three million cases of HIV (the virus that eventually causes AIDS) infection were estimated in India--this number will mushroom.

Insects, Worms, Single-Celled Animals, and Urine Fish

Jiggers

are also called burrowing fleas, and are a type of sandfly found in tropical areas of the Americas and Africa.. They burrow between toes and under toenails, where eggs are deposited under the skin. Symptoms are a painful and itchy pea-sized swelling. Treatment is by removing the jigger with a sterile needle, and thoroughly cleaning with antiseptic. Prevention is by wearing shoes or at least sandals, and by keeping nails well-trimmed.

Chiggers

are found worldwide on grass and weeds. These red mites attach themselves to bare legs and ankles and feed on blood. They may cause a painful, itchy swelling about a half inch in diameter. Prevention is by wearing socks and pants, and by applying DEET to exposed skin, socks, and pant cuffs.

Bedbugs

are small, flat, usually brown bugs. They live in beds and furniture during the day, and come out at night. Bedbugs often leave a straight line of red bites across the skin. They rarely spread disease, but the bites should be cleaned with antiseptic to prevent infection. Avoid bedbugs by checking bedding carefully--look for tiny red splotches on sheets and blankets. If you see their sign, take another room or string-up your hammock.

	Left: These are large black ants. The column is about a foot wide.
	Right: Here large red ants rampaged a 20 by 20 foot area, attacking and devouring insects across the jungle floor. Very interesting to watch. They ignored me.

Sandflies

are tiny, nearly-invisible long-legged flies common to tropical areas. Sandflies can transmit several diseases to humans, including leishmaniasis, bartonellosis (in the Andes), and sandfly fever.

Since sandflies are most active at dawn and dusk, walking at those times stirs them up and results in numerous, amazingly irritating bites. You won't be bothered as much if you sensibly remain in, or retreat to, your hammock during dawn and dusk. Also cover exposed skin, especially legs, ankles, and arms, and use DEET. Socks help a lot.

Lice

are tiny, flat, wingless bugs. Body lice are killed by washing clothes in very hot water, or by using a hot dryer. Head and pubic lice can be killed with lotions and shampoos containing benzene hexachloride.

Scabies

are tiny mites that burrow into the skin, lay eggs, and cause intense itching, especially at night. Treatment is with an insecticide lotion.

Hookworms

are half-inch long worms that live in the small intestines of  700 million people around the world, especially in the tropics. They have hook-like teeth. Their life cycle begins with larvae burrowing into the feet, or by ingestion. A large infestation of several hundred hookworms may eat several ounces of blood per day, causing anemia.

Symptoms, called ground itch, may include a red and very itchy rash on the feet that lasts for several days. A cough and pneumonia are also possible when a heavy infestation passes through the lungs.

Prevention is by wearing shoes or sandals. Treatment is with an anti-worm drug.

Guinea worm

is the "fiery serpent" scourge of the Biblical Israelites. It is an up-to three-foot long female worm that now plagues eighteen African and Asian countries, although recently eliminated from Pakistan. Infection is by drinking water containing the cyclops crustacean water flea.

Symptoms begin a year later when the worm is fully grown and ready to reproduce. It comes to the surface of the skin where a blister forms. Hives, diarrhea, and vomiting often occur at this time. When the blister bursts the end of the worm is exposed, and debilitating pain begins.

The traditional treatment is to wrap the exposed worm around a stick, and then gently wind it out over several days. This is dangerous (although impressive) as the worm can break and an infection develop.

As guinea worm must live part of its life cycle in man, it is only the second disease (after smallpox) targeted by the World Health Organization for eradication, aided by great diplomatic imprimatur from the Carter Center.

Beefworm (botfly larvae)

is the only creature known to penetrate my defenses in Central America. It is common in the jungles of Belize.

The botfly is an ordinary-looking fly with unusual child-rearing habits. It captures a mosquito in flight and lays eggs on it. The mosquito is released, and when it subsequently bites a warm-blooded prey some of the eggs fall off and are hatched by body heat. These creatures then burrow into the skin (my sandal-clad foot, your pretty face?) where they feed and grow just under the skin. After several months they reach maturity, painlessly squeeze out, and fall to the ground to continue their life cycle.

Diagnosis is by a mosquito bite that doesn't go away. After several weeks it resembles a boil, except for a tiny hole in the center. If you look closely with a magnifying glass you will see something pushing to the surface every so often to breathe and expel waste. (Yes, the botfly larvae breathes through its butt.) As it feeds it occasionally delivers a sharp pain like a hot needle stabbing into flesh, which lasts only a few but very long seconds.

Treatment is simple, if you know how. You cannot just squeeze it out as the beefworm is ringed with barbaric barbs which tightly hold flesh. And since the beefworm produces its own antibiotic to prevent infection while alive and healthy, you don't want to rip it apart as an infection would likely develop. The traditional Mayan method is to pour tobacco juice into the hole, which kills the beefworm in about an hour. You then easily squeeze it out.

Another method which worked for me is to suffocate the beast overnight by covering the hole with multiple layers of Elmer's glue and plastic wrap. It becomes poppable if you manage to cut off 100% of its air. On the second try mine flew several meters through the lower atmosphere before smashing into an obstruction.

Tumbu fly

This African fly lays eggs on clothing left out to dry, which later hatch with skin contact. Results and treatment are similar to the botfly. Prevention is by ironing clothes to kill the eggs, or by hiring fly swatters,  although this is said to be unreliable.

 

Urine fish

Reported in some Central American rivers to also hang on with barbaric barbs. I haven't yet determined whether urine fish are fact or of the same class as the Amazonian ear weevil, which renders victims insane from otherworldly pain as it bores from one side of the head to the other. (See a medical professional before developing world travel!)

Hydraulic Currents and General Lessons

How to Avoid Insect Bites

The best way to avoid malaria and over one-hundred other mosquito and insect-borne diseases is to avoid being bitten in the first place. Since only some insects are disease carriers, you vastly reduce your chance of infection by limiting the number of bites. Furthermore, it may take more than one bite from a disease-carrying insect to transmit disease.

The first line of defense is long sleeves and pants. In jungle areas I'm much more comfortable wearing loose-fitting cotton pants and a long-sleeved cotton shirt. They are plenty cool and dramatically reduce every kind of insect bite. Note that mosquitoes can slide their proboscises through a knit or too-thin shirt. Light colors such as khaki are less attractive to mosquitoes.

The second mosquito defense is DEET (diethyl-meta-toluamide). This is a powerful (it melts some plastic) insect repellent recommended and used world-wide. While the FDA is currently investigating possible side-effects in children, it has stated the benefits of DEET far outweigh these side effects, which are likely to be minor. Indeed, not contracting malaria and other insect-borne diseases is priceless.

DEET repellent should be applied following the manufacturer's instructions to all exposed skin. Do not apply it under clothing. Many travelers also apply DEET to sleeves, collars, socks, and cuffs to further discourage bugs.

Some DEET products consist of a 100% formulation for maximum effectiveness of up to eight or ten hours. 3M makes Ultrathon, a 33% DEET product with a special carrier which slowly releases the DEET for a claimed effectiveness of up to twelve hours. Ultrathon is also absorbed less through the skin, thus making it safer than 100% DEET. The CDC recommends formulations from about 25 to 35%.

I've used Ultrathon in a tube with good results. Many health care professionals recommend it. It also comes in a spray can with a 23% formulation which lasts up to eight hours, and is better for sensitive skin. The tube is lighter and lasts longer.

I reapply a little Ultrathon cream every few hours while hiking since all DEET products lose effectiveness as you sweat.

Other Mosquito Defenses

Permethrin is an effective repellent which is only approved for application to clothing and mosquito netting, not skin. It is considered safe when used in this manner. Permanone, Coulstan's Duranon, and Sawyer are brand names of permethrin aerosol spray marketed as tick repellents. One good spray treatment lasts several weeks. Coulston's Perma-Kill 4-Week Tick Killer is a liquid which lasts four weeks on clothing, longer on mosquito netting.

Mosquito netting is essential for sleeping in the tropics. It drapes around your bed or hammock from a hook or line strung above it. While many hotels in the tropics lack screens, they often have fans which produce enough breeze to prevent mosquitoes from landing. Unfortunately, you can count on electric power regularly going out.

Mosquito netting with too-fine mesh can be stifling. On the other hand if the mesh is too coarse black flies and no-see-ums can penetrate. Spraying or soaking mosquito netting in permethrin dramatically increases effectiveness. Store the net in a plastic bag to keep the permethrin effective longer. Be certain there are no gaps or holes in the netting around you, and that no part of your body rests against it, as mosquitoes are seriously bloodthirsty. Make sure there are no mosquitoes already inside the netting.

Mosquito head nets may also be useful. I used one while summer camping in Norway where the mosquitoes were frighteningly monstrous and multitudinous. (Two could whip a dog, four could hold down a man and butcher him--Mark Twain.) Head nets alone are not enough in malarial areas, though.

Mosquito coils are spiral-shaped candles that repel mosquitoes and other bugs with the natural chemical pyrethrum. They burn for several hours, and are useful when cooking dinner while camping, or in hotel rooms without screening. Cintronella is another natural repellent adequate for backyard use in the States, but not effective in serious biting insect areas where efficacy is vital.

Insects are also attracted to scents, so don't wear perfume or cologne, or use scented soaps, shampoos, or deodorants. Unscented deodorants are available. Several women have advised that Avon's Skin So Soft lotion fends off minor backyard flying insects in the U.S.

Mosquitoes do not attack as long as you walk at a fair pace, or if there is a breeze. They wait for the wind to calm, the electricity to shut off, or for you to fall dead from exhaustion.

Skin Wounds

Cuts, blisters, and other wounds can become infected very fast in the tropics due to the rich microbial environment. Great care must be taken to thoroughly clean wounds, and to treat with an antiseptic such as tincture of iodine, which is good because it also kills viruses. Keep wounds covered with a clean bandage and recheck. Double-strength triple antibiotic ointments such as Neosporin are also helpful.

Rashes

To combat itching from stings and plants in the tropics, be sure to have antihistamine pills and a tube of 1% hydrocortisone anti-itch cream. After two mysterious, expanding red rashes appeared on the back of my leg, you can bet I'll never again travel in itch country without serious anti-itch medication.

I may have crushed a poisonous millipede between my calf and thigh. While I didn't feel anything,  I noticed two small, elongated black spots which looked like burns. I should have immediately irrigated with water and wiped with alcohol to remove as much poison as possible. Instead I ignored the situation for two days. Gradually the poison expanded about three inches beyond the initial sites, creating two purple and red, excruciatingly ³ itchy rashes. By scratching I transferred poison to other parts of my body.⁴

Calamine lotion was next to useless. Benadryl antihistamine pills worked well. I later discovered 1% hydrocortisone cream also works well. There is a new Benadryl cream which is probably effective.

Plants and stings that cause nasty itching are a surprisingly effective and common defense. The best counter-defense is always a layer of clothing and shoe leather.

If afflicted take immediate action by washing the affected area with water, beer, or spit. Run water over it for ten or more minutes if possible. (For a cobra sting run it all night.)  Then disinfect with soap or alcohol.  Again, in the tropics you risk infection by scratching severe itches.

Foot Care and Blisters

This is probably the #1 backpacker health concern. Have a thick pair of socks such as Thorlo in your pack in case blisters develop. Also, at the very first sign of a "hot spot," take action. Don't trudge on doing more damage than necessary. Allow the healing process to begin sooner on something not so bad, as opposed to later on worse.

I keep a piece of Compeed, a great blister product, in my wallet, more in my pack. When you do get a blister it may be miles to the nearest pharmacy, which is too far, too late. Duct tape, Moleskin, and a liquid product called NuSkin also work.

Blisters become easily infected in the tropics, so be extra careful to avoid them, and keep them clean and disinfected when they develop. If you decide to pop a blister, use a sterilized needle and apply antiseptic. Cover and check regularly.

I also have a 1/3 ounce (10 milliliter) plastic bottle of Lotrimin AF (clotrimazole) antifungal solution in my medical kit to treat fungal infections. (I just noticed the use-by date has expired.) An effective antifungal is necessary to treat athlete's foot, ringworm, and other unusual skin infections which may crop-up during extended tropical travels.

Effects of the Sun

In rural Mexico I came across an Austrian traveler who had been wandering three weeks without hat or sunblock. He was as red as a beet, and obviously dazed from excess solar radiation. Weakly pointing to my straw cowboy hat, he mumbled, "That's what I need..."

The sun is very intense in the tropics and at higher elevation. For every 5000 feet (1500 meters) in altitude gain, UVB radiation increases by twenty percent. Travelers should wear a hat with at least a three-inch brim all around, and use sunblock with a sun protection factor of at least fifteen.

Sunglasses with ninety-nine percent UVA/UVB protection will be much desired by the hitchhiking traveler, and protective goggles are a must for preventing snowblindness at altitude.

Heat and Humidity

In one to three weeks the body gradually acclimates to heat through a physiological process. Unacclimated travelers run a risk of heat exhaustion or heat stroke if they try to do too much, too soon.

	If you are AC-addicted or from a cool climate, use caution and allow time--soon the hot environment will seem cooler. Knowing your body is adjusting should be a comfort.
	Photo: Here I'm jungle trekking and drinking six quarts per day.

Travelers may be able to partially acclimate themselves to a hot environment like Egypt by taking daily saunas for a week or two before departure, gradually building exposure levels.

High humidity is the worst aspect of the tropics for many travelers. Wear loose cotton clothing and drink lots of clean water. A wet bandanna around your neck or forehead provides good cooling.

Prickly heat is a red rash which occurs under clothing. I've had it a few times on my legs before becoming acclimated. It has a moderate prickly feeling, and goes away after a day or two. Prickly heat is assuaged by cool showers, cold water sponging, calamine lotion, and loose-fitting, breathable clothing. In my case clothing should also be well-rinsed of detergent, which is harsh in developing countries.

Heat exhaustion

is caused by overexposure to heat by a non-acclimated person, or insufficient water or salt intake by any person.

Symptoms include fatigue, dizziness, nausea, headache, and possibly muscle cramps. Treatment consists of rest, shade, and drinking water at a slow but steady rate, including water with a weak salt solution of approximately 1/4 teaspoon per eight-ounce (1/4 liter) glass. Cool the body with water, wet towels, and a fan, if possible. If the victim becomes unconscious, feet should be raised twelve inches above the head.

After twelve miles of jungle hiking in one day--half with a pack--I suddenly realized I had heat exhaustion as I had stopped sweating and was beginning to feel nauseated. I had drunk several liters of water that day, but that was far from enough. Luckily I was only half a mile from camp (I was on a night hike), so I immediately returned and slowly drank two more liters of water. I had moderate nausea and chills, and felt terrible. In the morning I was much better and drank several more liters.

Heat stroke

follows untreated heat exhaustion. It often results in rapid death due to a breakdown of the body's heat regulating mechanisms. Body temperatures can reach soaring levels.

Symptoms usually include a cessation of sweating; shallow breathing; hot, dry, and flushed skin; unconsciousness; and if conscious, disorientation or stupor.

Treatment must be immediate. The victim should be placed in shade and his body cooled as quickly as possible. Remove all clothing and wrap him in wet towels, or sponge the body continuously with cool water. Direct a fan at the victim. If unconscious, raise feet twelve inches. If conscious, give the victim water, preferably with 1/4 teaspoon salt per eight-ounce (1/4 liter) glass. Medical help must be summoned.

Cold

Hypothermia

is a life-threatening condition defined as body temperature below 95º F (35º C). Temperatures do not have to be extreme to cause hypothermia, since water and wind can combine to rapidly chill a person. Most deaths from hypothermia occur in well-above freezing temperatures.

Symptoms include a pale, drowsy, confused, and cold victim. She may become unconscious. Treatment consists of seeking immediate medical help and warming the victim. Warm drinks are effective, as well as hats, blankets, emergency aluminum blankets which reflect body heat, and, of course, warm shelter. Remove wet clothing.

Prevention is by wearing warm clothing in insulating layers, a windproof/waterproof shell, and a hat. An aluminum reflective space blanket should be in every traveler's pack. Avoid cotton clothing in cold, wet conditions.

Frostbite

must be treated immediately by warming affected areas. Massage is not helpful, but placing feet and hands under armpits is. If warm water is available, place the affected areas in it. The water should not be hotter than 110º F (43º C). Remove constricting clothing, rings, and watches. Don't warm affected areas with direct heat, such as from a lighter. Don't allow someone to walk on a frostbitten foot, unless it's necessary for survival.

Altitude Sickness

Altitude sickness is also called acute mountain sickness (AMS). It occurs when ascending to altitude before the body has time to adjust to the lower air pressure and lower oxygen content of the air. It usually occurs at altitudes above 8000 feet (2500 meters). About twenty-five percent of travelers to high altitudes will be affected, but younger people are more susceptible.

Symptoms are usually mild and flu-like, such as headache, shortness of breath, dizziness, nausea, and fatigue. Insomnia often results due to shortness of breath. Usually these symptoms last only a short time as the body adjusts. Many travelers have trouble sleeping their first night or two in high altitude cities such as Quito, Ecuador (9350 feet or 2850 meters).

Severe cases result in fluid buildup in the lungs. This leads to intense breathlessness, coughing and wheezing. Fluid may also build-up in the brain, leading to severe headache, seizures, vomiting, hallucinations, and even coma.

Treatment for mild cases is usually just rest. Plan for an easy day or two upon landing in Quito. Aspirin may help. Avoid alcohol and drink plenty of fluids. Locals drink coca tea to alleviate symptoms. It acts as a mild stimulant and pain killer.

Treatment for severe cases requires immediate action--if you wait until morning the victim may die or suffer brain damage. She should be brought down at least two or three thousand feet and have oxygen administered. She should also be brought to a hospital as soon as possible where diuretic drugs may be given.

Prevention is best by slowly gaining altitude. If you walk to gain altitude you can go back down a few thousand feet if you begin feeling symptoms. One rule of thumb is to always sleep below the highest altitude achieved that day.

Motion Sickness

If you are susceptible to motion sickness, Dramamine pills work better if taken before symptoms develop. Scopolamine ear patches may also help. While at sea or riding a bus get as much fresh air as possible, and focus vision towards the horizon--not the chicken cage next to you. Think pleasant thoughts. Avoid greasy or spicy foods. During an attempt to earn travel money on the Bering Sea my bargemates and I ate crackers to alleviate queasiness.

Jet Lag

Jet lag isn't much of a problem for most backpackers. We don't have to be up for an important meeting at a certain time, and for the first few days can simply rest when we need to. Our internal clocks adjust to the new sunlight and social schedule within a few days. Traveling east, say from the Americas to Europe, takes a slightly longer adjustment period since you must begin sleep earlier to synchronize with the environment. Traveling west mainly requires staying up extra late. Jet lag is more of a problem for anachronistic Chinese leaders experiencing democracy and rule of law for the first time/people on speeding bus tours.

Note that airplane air is extremely dry (one or two percent humidity), so on transocean flights drink plenty of fluids to avoid partial dehydration on your very first day.

Backpackers' Medical Kits

Right now in my pack I have a quart-sized plastic zip bag I call a medical kit. It consists of a few band-aids, larger bandages, and butterfly closures; a few yards of cloth tape wrapped around a pencil; a one-ounce dropper bottle of iodine antiseptic; a 1/2 ounce (15 milliliter) tube of triple antibiotic ointment; an unopened bottle of Potable Aqua water disinfectant tablets; Compeed blister pads; a 1/3 ounce (10 milliliter) bottle of Lotrimin AF antifungal solution; a 1/2 ounce tube of Cortaid 1% hydrocortisone anti-itch cream; aspirin; a thermometer in a taped-shut plastic case; tweezers; twelve Immodium tablets; ten chewable Pepto Bismol tablets; ten antihistamine pills; twelve Ciprofloxin antibiotic capsules as prescribed by my travel clinic; a packet of rehydration salts; and 144 condoms.

Additional medical items elsewhere in the pack are small folding scissors; one-a-day-type vitamins; duct tape; a small piece of Compeed or Moleskin in my wallet; and a four-ounce bottle of rubbing alcohol which I use for disinfecting hands when soap and water isn't convenient.

Before my next trip to the developing world my travel clinic will prescribe a combination of anti-malarial pills, another antibiotic, and possibly a sterile syringe and needle.

Outdoor shops and catalogers sell pre-assembled medical kits that range in price from $8 to over $100. They don't contain doctor-prescribed antibiotics or medicines. I've always assembled my own. See Chapter 23-b Useful Information for two companies that specialize in medical kits.

Upon Returning Home

If you come down with an illness soon after returning from the developing world, inform your doctor of that fact. Many tropical diseases are very difficult to diagnose, and mimic the flu. You may need to see a tropical disease specialist. You may also want stool and blood tests to see if anything unusual is lurking about. Otherwise wait two years to see if your stool becomes bloody and lower intestine blocked by a gigantic mass of ascaris lumbricoides, or other.

Travelers' Tips

Make a notecard of your medical history and keep it in your wallet. Indicate whether you have any known food and drug allergies, and any known health conditions. Also your blood type, and any other instructions. Several companies, such as Medic-Alert, make bracelets and chains which also contain this information. Aida, Brooklyn

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Beware of salads, especially lettuce, in developing countries with suspect water supplies. The rule is if you can't wash it, peel it, or boil it, don't eat it. Lisa, Christchurch, New Zealand

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When we arrived in Sri Lanka and engaged a driver with car we insisted on having a car with seat belts....We may owe our lives to this because after ten days our driver went off the road and down a six metre drop into a culvert. We were wearing belts and so--for the first time--was our driver. We all walked away...thankfully with no serious injuries. Andrew, UK

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My schedule will be drastically compressed if the test comes back positive in five and a half months. Turbo, USA

Notes

1. My rough calculation: 50,000 automobile deaths per year x 70 year lifespan = 3.5 million total deaths. 350 million projected population ÷ 3.5 million = 100, or a 1 in 100 chance. back

2. After a years-long night and first light filtered through the front of the bus I cried out to myself, Thank God! We're there! But nay, it was five hundred miles and many mountains, many mountains to go. back

3. Chosen over torturously, because in uncivilized countries that's a lifetime punishment for thinking and speaking. back

4. O to learn. back