Introduction
By Kathleen Meyer
Author of How to Shit in the Woods

Travelers’ Diarrhea

Knowing It, Avoiding It

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 low-income regions 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 battleworn 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 sub-continent), 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

➢  Campylobacter, causing spasmodic pains with the diarrhea

➢  Shigella, only ten bacteria need to get in for a brisk bout of bacillary dysentery

➢  Other bacterial causes of diarrhea, like Salmonella food poisoning

➢  Giardia, which will cause you to generate smelly emissions that will make you most unpopular

➢  A variety of other parasites and worms

➢  Amebic dysentery

➢  Cryptosporidium, which causes a tedious type of diarrhea that lasts for two weeks with a lot of cramps; there is no specific treatment

➢  Rotaviruses or “small round viruses,” aka Norovirus or Norwalk-like viruses and many others causing epidemic vomiting

➢  Cholera

➢ Cyclospora

➢ 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 longdrop 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 chef 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, smoothskinned 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 cholera 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 harbor Salmonella bacteria. These bacteria usually causes a week of severe diarrhea, with abdominal cramps and sometimes fever.

➢  Dishes containing meat are more likely to make you ill 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.

➢  Pork and dog are the riskiest kinds of meat. Pigs and dogs are often the local rubbish disposal consultants where environmental hygiene is poor. 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 non-industrialized countries, fresh milk—even milk that claims to be pasteurized—should be boiled before drinking.

➢  In Kyrgyzstan it is normal to put jam in tea, whereas you are expected to swallow fermented mares’ milk straight. I’m not sure I’d risk it. Raw camels’ milk too can be risky—it was found to be a source of the Middle East respiratory syndrome coronavirus.

➢  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.

➢  Sorbet tends to be acidic and, since acids are unfavorable to bacteria, this is a fairly safe food.

➢  Ice cream is often risky in low-income 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.

➢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.

➢  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 achieved a pinnacle of professional development by being invited to teach on diarrhea at Cambridge University Medical School. The path that has led to that dubious distinction started with a childhood interest in creepy-crawlies which drove her to study zoology and then organize a six-month-long expedition to the Himalayas to research 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 BM—a bachelor of medicine degree; this is equivalent to the American MD 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 discovered and documented an array of dung-eating invertebrates that were unknown to science.