$12.95The Art of Staying Clean and Healthy while Traveling

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By Dr. Jane Wilson-Howarth
January 2006
ISBN 1-932361-32-4 198 pages

Read and “Go” in Peace

Introduction by Kathleen Meyer, best-selling author of
How to Shit in the Woods

“Worth digesting.”
Arthur Frommer’s Budget Travel

“A cheery and common-sensical guide.”
The Independent

Straightforward advice…a great bathroom read.” —The Washington Post
International travel is rewarding and a great deal of fun, but sometimes it exacts a price. Activities we take for granted—eating, bathing, and going to the bathroom—can range from challenging to risky in unfamiliar territory. In How to Shit Around the World, Dr. Jane Wilson-Howarth takes a sympathetic and funny approach to one of the most basic human activities, interweaving hilarious anecdotes from fellow travelers with sensible tips and techniques.

More than just a how-to, How to Shit Around the World inspires the traveler to be adventurous in dealing with foreign toilets, and to heed the fascinating cultural lessons to be learned from the simple act of using the bathroom

Learn How To:

  • Eat and drink safely in a foreign country
  • Avoid diarrhea, parasites, and diseases such as malaria, typhoid, and hepatitis
  • Cope with unfamiliar facilities
  • “Go” outside when no facilities are available
  • Manage on long bus rides
  • Outsmart gastrointestinal diseases—the traveler’s most common complaint

By Kathleen Meyer
Author of How to Shit in the Woods

Travelers come in all shapes and sizes, lengths of hair and colors of fur and feathers. Those blessed with the DNA of humans, after surviving an escapade, will sometimes turn to writing about it. Thus, sweet as it is, the raison d’être for the publisher Travelers’ Tales. In collecting and publishing the wild scrawlings of our stories, they also pass along—as with How to Shit Around the World: The Art of Staying Clean and Healthy while Traveling—hard-won, but invaluable, advice.

The yearning to explore the world and the genius for leisure wandering got their starts long, long ago, in all probability as outgrowths of survival-driven chases after migrating food and more hospitable climes. With the first crude dugout nosed into the water, the first sack slung over a shoulder, likenesses of you and me began evolving into a species of globetrotters, desirous—even more so than Ursus, the bear—of seeing the other side of the mountain. We’ve been known over the centuries for packing kit bags and departing familiar turf as hitchhikers, vagabonds, and stowaways. We sign up for overseas’ jobs, we join the Peace Corps, we jet on our own time to aid victims of war, poverty, and natural disasters. Off we go to study—cultures prehistoric and modern, geology through its eons, a rare species of South African beetle. There are, of course, those of us content with walkabouts of more limited duration and extent, wanting nothing more than to traverse the river path, curl up under a tree, and dissolve into the pages of a good book. Then again, inspiration will chance along and spur us to build a raft and float it down the Mississippi, ride a horse across Cameroon, drive to Greenland, bag the peaks of McKinley and Everest, or retrace the high-seas voyages of Captain James Cook.

Whatever the occasion for our traipsing off to far-away places, within hours, we are all similarly confronted by the daily, away-from-home basics of eating, drinking, bathing, and excreting—and praying to remain sound as a bull doing so. Enter: Dr. Jane Wilson-Howarth, fellow of the Royal Society of Tropical Medicine and Hygiene, veteran traveler and revolving resident of countries from Nepal to Madagascar, Peru to Bangladesh. Prompted by a respect for diverse cultural customs and a longstanding fascination with parasites and intestinal pathogens, Dr. Jane offers up this guide to healthy sojourning. In it, she shares expertise derived from her ecological and medical backgrounds and her personal global experiences.

An Englishwoman by birth and heredity, Dr. Jane is not readily held back from thoughts about stinkers and squirters. From her scientific mucking about in the guano of many species, she is known to friends and colleagues as the Shit Doctor. I embrace her as a woman who can write with openness, intelligence, and humor on a topic that is still, in many circles, received only with titters and shame. Or, as Dr. Jane puts it, a certain, less-than-direct “coyness.” Forthright with her advice, she may give some would-be travelers pause—in fact, pause enough to stay home. Yet others will be enticed to light out immediately—better equipped, as they will be—for far-flung adventures and mingling in less developed cultures. Still, even the tourist playing it safe on a cruise ship, once schooled by Dr. Jane, may find that eating at an otherwise alien street stand becomes the high point of a vacation.

Expect to learn in the chapters that follow how to eat armadillo without contracting leprosy; how to avoid death-by-paralysis from things of the sea; and, somewhat indirectly—but not of least importance in a pinch—how to become a cannibal without getting Creutzfeldt-Jakob, the human form of “mad cow” disease. This last was of particular interest to me, being, as I am, a descendent of Scottish cannibals and continually going about in life never quite sure if, under duress, faint genetic leanings of this sort might just crop up. In addressing traveler’s trots, Dr. Jane’s emphasis on prevention is laced with instructive advice for those feeling that their lazily snaking twenty-seven feet of intestine has suddenly shrunk to a six-inch drainpipe. Rounding things out are tips on travel for seniors, people of special needs, and those accompanied by small children.

All the while we absorb the good doctor’s treatments for our travel maladies, the pages of this book brim with their own “treatment” issuing from scores of travelers sharing their experiences in pithy, always entertaining, and often hilarious sidebars. Watch for the man in the wetsuit and the “chap” catching the train—my favorites. A bit of translation when it comes to the Doctor’s British turns of phrase may be necessary for some of us: rest assured that “opening your bowels” does not require any type of field surgery, and the adamant promotion of “serious drinking” involves nothing beyond watery solutions of sugar and salt.

Once you light out, whatever little bit you haven’t learned from Dr. Jane, you will discover for yourself, one way or another. Oddly enough, people along the way are frequently not only willing, I find, but eager, to toss open the ordinarily taboo topics of bodily functions.

So go. I mean, travel. Venture boldly out to loose yourself of the familiar and known; although, now and again, you may find yourself stepping in stuff, you’ll also likely stumble right into the rich intimacy that, in so many ways, reifies us as a world family. For instance, the stranger who hiked up her billowing sari to demonstrate for Dr. Jane how to pee down a ceramic hole. Such straightforward exchanges pop up in the rarest places, resonate through the most curious connections, all told, serving as refreshing breezes, hopes replenished, in a more than screwy world.

Whatever you do, travel. Wherever you go, stay healthy.
Kathleen Meyer is the author of the international best-selling outdoor guide How to Shit in the Woods: An Environmentally Sound Approach to a Lost Art, with more than two million copies in print, in seven languages. Her Montana memoir, Barefoot Hearted: A Wild Life Among Wildlife, was published in 2001, and her new book on “the life and ludicrous times of an unlikely best-selling author” is due out in 2006. Meyer was the founding editor ofHeadwaters, the primary publication of the California organization Friends of the River, and has written articles for Anvil magazine, the Professional Farrier, and various Travelers’ Tales anthologies. A lifelong outdoorswoman, Meyer lives in an old dairy barn in western Montana with her true love, farrier Patrick McCarron, three useless cats, a nursery colony of seventy-five big brown bats, countless wild skunks, and a Clydesdale mare. Visit them all (almost) at the author’s web site: www.KathleenintheWoods.com.

Introduction by Kathleen Meyer

1 Travelers’ Diarrhea
Knowing It, Avoiding It

2 What’s in the Water?
When Is It Safe to Drink?

3 Eating Right
The Pleasures and Perils of Seafood

4 Weird Foods
The Risks of Fearless Dining

5 Squat Loos and Long-Drops
Which Way to the Ladies/Gents?

6 Water, Water
Dehydration, Rehydration

7 Caught Short?
Managing on Long Bus Rides

8 Tummy Troubles
Dysentery and Serious Kinds of Infections

9 Immunization Against Diarrhea and Travelers’ Ills
Precautions Now and in the Future

10 Coping Without Paper
Time-Honored Methods for Keeping Clean

11 Women’s Unmentionables
Challenges and Solutions for Female Travelers

12 Can It Be Worms?
Avoiding Them

13 Bad Beasts
Snakes and Spiders and Leeches, Oh My!

14 Going Outside
Taking Care of Nature’s Call

15 Bathing
Hazards and Techniques in Unusual Circumstances

16 Children
Keeping Little Ones Healthy

17 Senior Travelers
Assessing Special Needs

18 Homecoming
You’ve Returned, Are You Healthy?

19 Packing List and Minimal Medical Kit

20 Resources and References

Index

Index of Contributors

Acknowledgments

Chapter 1Travelers’ Diarrhea

KNOWING IT, AVOIDING IT

The young American put his head down to the milk-bowl and the milk darkened, from white to grey, as his head blocked out the light. The bowl was half a calabash. He held it in his palms and felt the warmth coming through. There were black hairs floating on the surface and a faint smell of pitch. He tilted the bowl till the froth brushed against his moustache. “Shall I?” He paused before his lips touched the milk. Then he tilted it again and gulped.
—Bruce Chatwin, Anatomy of Restlessness

Traveling is a little hazardous; that is what makes it exciting. But what are the risks? What about all those tropical diseases that are out to get you: plague, hantavirus, dengue, rabies, cholera, typhoid, typhus (what’s the difference?), tuberculosis, dysentery, yellow fever, malaria? Malaria literally means bad air, the name originating from a time when the disease was rampant in Europe and people got it from venturing into dank, marshy places. No one understood how it was caught; it was a mysterious and feared infection. A lot of worries about this and other travelers’ ills stem from misunderstanding or ignorance of avoidance strategies, but the following chapters explain how risks can be minimized.

It surprises many people that it is not tropical disease that takes most travelers’ lives. It is accidents that are most likely to kill you. Infectious or communicable diseases take surprisingly few adventurers’ lives: less than 4 percent of those few who do die abroad. Tropical infections don’t kill many travelers, but that doesn’t mean that we avoid illness: on the contrary, most of us get sick when we travel. The most common infection which gets us is diarrhea, and studies say that about half of those traveling to the developing world will get a dose of Montezuma’s revenge each trip. The highest-risk destinations are tropical Latin America and the Indian subcontinent; North Americans import their diarrhea and dysentery from Mexico, Ecuador, Peru, and Bolivia, and Europeans bring theirs mostly from India and Nepal. It isn’t just travelers who suffer either; the diarrheal diseases cause a lot of illness (and even deaths) in the local population, too. You only need to look at the consistency of the brown deposits on the streets of Kathmandu to realize this.

What is travelers’ diarrhea? Diarrhea means loosening of the bowels so that the sufferer “goes” at least three times in twenty-four hours. The most common form makes you ill for around thirty-six hours then symptoms disappear without doing any real harm, except perhaps leaving a somewhat battle-worn tail end. There are as many names for travelers’ diarrhea as there are kinds of microbes that cause it. There is gastroenteritis, food poisoning, upset stomach, Montezuma’s revenge (from Latin America), gyppy tummy (from Egypt), Delhi belly, the Kathmandu quickstep, Tandoori trots (from the subcontinent), the Aztec two-step, turista, the runs, the squits, the squirts, the screaming shits…. The most common culprit is snappily known as enterotoxigenic Escherichia coli or ETEC to those who know it more intimately. These little blighters produce a toxin that acts in the same way as cholera, stimulating an outpouring of water and salts into the bowel; the result is thirty-six to forty-eight hours of frequent trips to the lavatory to deposit said water and salts. Studies have shown that this is responsible for up to 40 percent of cases of travelers’ diarrhea, and this is the most likely criminal especially in Africa and Central and South America. ETEC is the most common but there are others.

  • Among ETEC’s many cousins are: Enteroadherent, enterohemorrhagic E. coli, and others
  • Rotaviruses or “small round viruses”
  • Campylobacter, causing spasmodic pains with the diarrhea
  • Shigella, only ten bacteria need to get in for a brisk bout of bacillary dysentery (see Chapter 8)
  • Other bacterial causes of diarrhea, like Salmonella food poisoning
  • Giardia, which will cause you to generate smelly emissions that will make you most unpopular (see Page 57)
  • A variety of other parasites and worms (see Chapter 12)
  • Amebic dysentery (see Page 56)
  • Cryptosporidium, which causes a tedious type of diarrhea that lasts for two weeks with a lot of cramps; there is no specific treatment
  • Norwalk and a catalog of rarer diarrhea-causing viruses
  • Cholera (see Pages 60, 66)
  • Cyclospora (see Page 57)
  • Tropical infections (like malaria) which can cause diarrhea along with other symptoms.

There is a range of nontropical, noninfectious causes of diarrhea that are unrelated to travel but may occur in travelers coincidentally. Just because you are traveling and you have diarrhea does not mean that you have travelers’ diarrhea. See a doctor if in doubt.

The microbes that cause stomach problems abroad are many and varied, yet fortunately for us the prevention strategies and the treatments are similar for most of these. So where does it come from? Most “stomach upsets” in travelers come via a revolting route known by medics as fecal-oral transmission; I call it the filth-to-mouth route, or getting someone else’s feces into your stomach. Someone has the Kathmandu quickstep and uses the long-drop lavatory but doesn’t wash his hands before preparing your sandwich and soon you too are running to the loo. Most travelers’ diarrhea gets you via contaminated food: food handled by someone with traces of feces on their hands. The term “diarrhea” includes the full range of filth-to-mouth infections listed above (the exotic ones are detailed in Chapter 8), but in addition there are filth-to-mouth diseases (including typhoid, paratyphoid, hepatitis A and E, and some of the worm infestations), which cause symptoms other than diarrhea. All the microbes in this formidable list can be avoided by following similar, simple precautions.

None of these microbes survives cooking. However filthy the food was when it arrived in the kitchen and however unhygienic the cook has been, thoroughly cooked food will not harm you. Well-cooked, piping hot meals are safe, but food that is lukewarm or has been cooked, allowed to go cold, and then is handled by someone is risky. Cold dishes like quiche, pizza, and savory pies might be a source of Delhi belly if the food has been badly stored or touched with dirty hands. Meat is more risky than vegetarian dishes, because animals can become infected while they are still alive, and, once slaughtered, flesh is a better environment for the survival and multiplication of harmful microbes than is vegetable matter.

Salads are often grown in highly contaminated ground (people without toilets often relieve themselves in vegetable gardens), and low-growing fruits, especially strawberries, can easily become contaminated by human feces. The most hazardous raw foods are those that can trap filth in crevices and are difficult to clean—lettuce is among the worst. Conversely, smooth-skinned items can be cleaned quite well, so carefully washed tomatoes and items that can be peeled like carrots or radishes are fairly safe. Washing or peeling is also advisable to reduce the amount of pesticides you swallow. There are no foods that are 100 percent safe, but the challenge is to reduce risks to a minimum, without making the traveling experience one of precautions, worries, and anxieties from morning until night.

There are innumerable myths about what causes bad stomachs in travelers, but it is nearly always contaminated food, or occasionally—just occasionally—dirty water. Mellor’s voice of experience (this page) illustrates some of the common misconceptions of many travelers. The myth of locals being immune is ill-informed travelers’ folklore, and the distressingly common idea that eating bad food will immunize you is responsible for a lot of unnecessary illness in travelers, as well as exposing them to dangerous filth-to-mouth infections like typhoid. In short, hot street food = safe. Hotel water = may be safe, could be chancy. Ice cream in India or Nepal = clench your buttocks.

Tips

  • Peel it, boil it, cook it, or forget it: this is the maxim to protect you from travelers’ diarrhea and other fecal-oral diseases when visiting less sanitary places.
  • In the Middle East and South Asia, some melon sellers puncture the fruits and soak them in roadside drains to make them weigh heavy before sale. This is a probable explanation of why, in the days of the British Raj, melons were blamed for Indian chlolera outbreaks.
  • Choose freshly cooked, piping hot food rather than reheated food or food kept lukewarm on a hotel buffet.
  • Sizzling hot street food is likely to be safer than just-warm food, even if produced by an international hotel.
  • In international hotels order à la carte foods if you can.
  • In busy local restaurants eat what everyone else is eating; don’t ask for dishes that are “exotic” for them.
  • Avoid salads—especially lettuce—and also uncleanable soft fruits like strawberries unless these items have been grown and prepared hygienically. In Kathmandu, La Paz, and many other places, the only safe lettuce is boiled lettuce.
  • Fresh mayonnaise can carry Salmonella bacteria. This bacteria usually causes a week of severe diarrhea, with abdominal cramps and sometimes fever.
  • Dishes containing meat are riskier than vegetarian foods so becoming vegetarian when you travel will reduce stomach troubles.
  • Fried rice often makes people ill in Nepal, especially if it is made with leftover meat. The ingredients have often been hanging around unrefrigerated and are often flash-fried and thus inadequately reheated.
  • Where environmental hygiene is poor, pork and dog are the riskiest of meat types. Pigs and dogs are often the local rubbish disposal consultants. Any pork (or dog) that you choose to eat must be very thoroughly cooked. Nepalis say that it is unwise to eat pork during the hot season—for good reason.
  • In most developing countries, fresh milk—even milk that says it is pasteurized—should be boiled before drinking.
  • Yogurt is usually safe because the milk is boiled before fermentation and the final product is slightly acidic and thus less favorable for the survival of noxious bacteria.
  • The worst two meals of my life were cold old goat stew in Java and cold fatty lamb stew in Greece. Restaurateurs couldn’t be persuaded to reheat them properly. They couldn’t see the point.
  • Sorbet tends to be acidic and, since acids are unfavorable to bacteria, this is a fairly safe food.
  • Ice cream is often risky in developing countries since power cuts make it difficult to store safely, and it is microbe paradise.
  • Ice, too, is often made with dirty water or handled with dirty hands. Sometimes it is delivered in huge blocks that are dumped onto the ground outside the drinks stall or hotel.
  • There are a few rare tropical infections that come via the filth-to-mouth route. These are hantavirus, which comes from eating foods that have been excreted upon or nibbled by mice; Weil’s disease (leptospirosis), from swallowing food or drink contaminated with rat urine; and Lassa fever, which often comes from consuming food contaminated with the urine of the multimammate rat. Following two simple rules reduces the risk of acquiring all of these nasty but rare infections: eat your food piping hot, and drink safe water.

Dr. Jane Wilson-Howarth graduated first in ecology and then organized a six-month-long expedition to the Himalayas to study lesser wildlife there. Interested in cave life, she soon discovered that a lot could be learned from the brown deposits animals leave behind, as well as from watching creatures themselves. She spent a couple of years at Oxford University studying rabbit parasites, then entered medical school where her friends called her the Shit Doctor because of a continuing interest in parasites and poo. On completion of her studies, she was awarded a B.M.—a bachelor of medicine degree; this is equivalent to the American M.D. qualification.

She organized two research trips to Madagascar where dunes of bat guano hid rare species of invertebrates unknown to science. She also watched and photographed attractive creatures, completing the first-ever study of the endangered crowned lemur in the wild; this involved meticulous observations, and—of course—examinations of their emanations. Her first book, Lemurs of the Lost World, describes the Madagascar expeditions. Field studies in Peru continued on the ecology of excreta, and she worked where mounds of subterranean guano seethed with fascinating crawlies, and where spelunkers risked catching histoplasmosis and rabies.

She has lived in Asia for most of the last eleven years, working on various community health projects in Sri Lanka, Indonesia, Pakistan, India, Bangladesh, and Nepal; some of this work involved screening people for worms and also encouraging villagers to build and use latrines. She now lives with her husband and two sons in England where she teaches and lectures on travel medicine, works as a general practitioner, and enjoys the luxury of a home with three flush loos. Her two travel health guides, Bugs Bites & Bowels (Cadogan Guides) and Your Child Abroad (Bradt Publications), are published in the U.S. by Globe Pequot.