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12. health on the road

One of the main concerns among potential travelers is their health on the road, and it should be, but don't be put off. In reality, with a little common sense and luck, most travelers should not come down with anything worse than mild diarrhea or a periodic upset stomach.

water

Water is what most of us are afraid of. Everybody tells you not to drink the water, no matter where you are going. Purified bottled water is sold nearly everywhere, and is generally quite cheap (around 10-50 cents/liter) in the third world. So all is good, right? Unfortunately, porting around a liter or two of water is just that: porting. When your bag is small and light, a liter of water feels like a rock in your bag, not to mention the fact that bottles frequently leak and get your journal and books all screwed up.

Imagine yourself at a small roadside cafe in northern Cambodia. You're in the middle of an eight hour ride in the back of a pick-up, and youíre thirsty as hell. You have to drink. But there is no purified water available from the roadside eatery! The locals are all drinking from plastic pitchers of ice water and ice tea which are sitting out on each table, using cups that are shared from one customer to the next. Situations like this will either make you carry around a bulky liter of water (or two) at all times, or force you to accept your fate and just drink what everybody else is drinking.

My honest suggestion is that you try a mix of things. Around town, buying a liter of water is a good, practical idea, since youíre not carrying much with you and you have a home base (your guest house) where you can store it. But when youíre on the move and your bag is full, donít worry about it too much. Donít always be scared to try the local water. The fact is, if the people aren't dropping like flies, if a cholera outbreak hasn't been reported in the papers, and the water looks and smells ok, then you can probably drink it too. (Indirectly, itís likely that you already are if you're eating in market stalls. Dishes are rarely dry before your food is served). I'm not saying the water will be entirely perfect, but when you consider the odds that the locally bottled purified water is actually pure, I really don't think you're doing too poorly by doing this. I heard countless stories from locals about the bottled purified water coming straight from the tap. Who knows?

Some travelers rely on the ubiquitous Coca-Cola or Fanta to rehydrate them. This is a bad idea. Not only does it add considerably to the price of your meal, but sugared sodas are diuretics, which means they encourage your body to urinate more often than normal, which means you have to drink even more of them to keep up. Besides, remember what your mom said about sugar?

Let's get the record straight. Carrying around a liter of bottled water, and worrying about when or where you will buy the next one, is simply a pain in the ass. Not only that, if you whip out a bottle of water in a restaurant, you will look like a freak. It may be cheap for you, but that stuff is too expensive for most people in the third world. Most of them don't understand why people drink it in the first place, since it tastes the same as their water and costs about as much as a hefty serving of rice. Consequently, if you rely on bottled water to pull you through for several months, you will inhibit your ability to mingle with the locals. What are you going to do if some nice family invites you to stay for a while? Say no, because you don't like the water? Or will you bring 20 liters of water with you? That's not how you get your foreign experiences. Accept your fate and start drinking the water early, so that your gut can get used to it.

I began my trip drinking bottled water, or adding iodine to the tap if I couldn't find another bottle quickly enough, then abandoned it. It wasn't practical for the types of goals I had. Considering that a liter of water weighs almost one kilogram, is quite bulky and frequently leaks (Asian foggy plastic water bottles are not known for having the best seals), the bottle was adding a considerable burden to my tiny bag. Consequently, I drank the water all over Bangladesh, Burma, Thailand, Cambodia, Laos, Malaysia, Brunei and Singapore, and came down with nothing worse than mild diarrhea a couple of times. Malaysia, Brunei and Singapore are quite modern places, and most guidebooks even admit it's safe to drink the water there. As for brushing your teeth, it's again up to you. To carry a bottle to the sink, or to rinse with the tap water? I always opt for the tap, unless the water is simply nasty.

Again, though, you need to use common sense at all times. My hints above donít mean that you should drink the water if it's murky, smells bad, comes straight from a pond or river, or comes from a faucet in a decrepit guesthouse. In these cases, it's best to look around for a bottle, and if none is available, ask what the locals are drinking. As a last resort, two drops of liquid iodine solution per liter will make your water safe. This stuff is available in pharmacies in most provincial capitals of the third world, and costs just a few cents for a bottle that will last you an eternity.

food

Food in Southeast Asia varies in standards of hygiene from downright filthy to immaculate, depending upon the country you're in, the type of restaurant/cafe you choose, and the habits of the individual cook. In general Malaysia, Singapore and Brunei have excellent standards of cleanliness, as does much of Thailand. India, Nepal, Bangladesh, Burma, Cambodia and Laos are entirely different stories, and a little common sense may be needed at times. Even so, I rarely came across a meal that I thought was inedible for health reasons. I attribute this to the belief that all over the world, people don't like to eat dirty or spoiled food.

Street vendors are the way to go in Southeast Asia if you're looking for the best combination of low price, authentic cuisine and friendly company (see 11. how to eat). The problem that most Westerners have with eating street food is that it is not prepared with the level of hygiene that we are accustomed to. Pots, dishes, cups and utensils are not always scrubbed with soap and clean water between uses, food sits out in the warm sun for hours on end, dust from vehicles on the road is kicked up and spreads over everything, car exhaust is in your face... but these are the worst it gets, and in general the food is actually quite clean and fresh. Use your common sense at all times. If a place looks sketchy, check out the food and if it doesn't look good then you don't have to eat there. The good thing about street food at the market around meal time is that the stalls are usually quite busy, which means the locals like it and the turn around time is short, i.e. it won't be sitting around long before it's eaten. Stalls that fry or boil things up in front of you are generally safe because the food is obviously fresh and most bacterial things are killed off in the heating process. In Malaysia, Singapore and Brunei, standards of hygiene are almost always equal to, if not better than, back home.

As for fruits and vegetables, the guidebooks say if you can cook it, wash it or peel it, it's ok. I say that if it looks good and others are eating it, it's ok. Your body needs fresh foods for vital nutrients that are lost in the cooking process. The noodle ladies in Cambodia, Laos and Burma always have lots of fresh veggies to add to your bowl. Green beans, bean sprouts, mint leaves, lettuce and cabbage will become your friends. Take advantage of this. Go to the market and buy some apples and oranges (or durian and lychee) to enjoy on a hot day. Your body will thank you for it after a few weeks of hard traveling.

A typical, hearty "foe" noodle stand, Laos.

malaria

Everybody freaks out over malaria. You hear so much about this potentially deadly disease, but I really think that's the problem. Yes, it is potentially deadly. Believe it or not, hundreds of thousands of people (mostly children in sub-Saharan Africa) die of malaria every year. However, it doesn't kill everybody. I met many locals in West Africa and SE Asia who claimed to have had malaria for most of their lives! The symptoms come and go, depending on your bodyís immune system and the severity of your infection.

You need to get some things straight before you start letting all this affect you. First of all, malaria is transmitted by mosquitoes, but not every mosquito out there in the tropics carries the bacteria that cause malaria. I was bitten several times while not taking prophylaxes (see below) and do not have malaria at the moment, nor have I ever exhibited symptoms of malaria. In fact, there aren't really that many mosquitoes to begin with. Those of you who have been to the Sierra Nevada Mountains of California in the spring (June to July) will know the meaning of a "swarm" of mosquitoes. Generally I would come across a few annoying ones every few days, but certainly not each night.

It is recommended by health professionals that travelers to high-risk regions (West, Central and East Africa, Central America, the Amazon Basin, South and Southeast Asia) take a preventative prophylaxis before, during and after your visit. The number of successful prophylaxes on the market is always in flux, but the current standbys are mefloquine/Lariam (250mg once a week) and doxycycline (100mg per day). Other common prophylaxes are chloroquine and fansidar. Which one is potentially right for you depends upon the doctor you consult and the size of your wallet (mefloquine is a hefty $8 apiece in the US). The idea is that if the drug is used correctly, your body will be able to take care of any malaria that comes along. It does NOT prevent you from getting malaria, it simply prevents it from getting serious.

But what if you're going to be on the road for several months or more? I think it's important to think about the potential long-term affects of taking these drugs. Many travelers have reported that mefloquine gives them headaches, bad dreams, insomnia, and much more. Doxycycline is an antibiotic. New understandings of antibiotics indicate that they should only be taken in very serious cases (see below). Many strains of malaria are now resistant to chloroquine, so perhaps you shouldn't consider that one at all. For more details on malaria prophylaxes and possible side effects, visit www.geocities.com/TheTropics/6913/lariamlinks.htm or www.travelhealth.com/mefloqui.htm.

I came to realize all of this stuff after a couple of months on the road. In talking with those who had been out longer than I had, I learned that many travelers just stop taking the stuff after a while. Did anybody even get malaria? Yes, just one Swiss guy I met in Ghana. He described violent fever, achy joints, profuse sweating and insomnia for four days. He went to a local quack in town, who prescribed chloroquine after a blood smear under a microscope revealed malaria as the culprit. Sure enough, it worked, and my friend was fine a few hours later. The price? Free.

What you should understand from this is that taking these drugs all the time as preventatives is unnecessary. Go to your local pharmacy and purchase enough to TREAT the malaria if you get it. Better yet, wait until you're on the road to do this, since pharmacies everywhere sell doxycycline at incredibly cheap rates. Mefloquine is available in larger cities (Bangkok, Singapore, Kathmandu), usually for around $4 each, expensive compared to doxycycline, but much better than back home. If you develop any of the symptoms described above, get a blood smear examined under a microscope from the local doctor or pharmacist. The people who live in the tropics are no strangers to malaria, so you can get this done virtually anywhere. If the results indicate you have the malaria parasite, purchase the drugs from the local pharmacy, or use the ones you're carrying with you.

diarrhea

Diarrhea should be looked at as a fact of life on the road. You are bound to get it at some point, so it's best to just accept this fact and deal with it as it comes. While I can't say for sure what will cause your runs, there is certainly a good amount of diarrhea in this world which is caused by less than perfectly sanitary food and water. Does this mean you should avoid eating on the street? Certainly not, and I think you'll agree that a few rushed trips to the toilet once in a while do not negate the benefit and pleasure of experimenting with local culinary delights.

What need to be addressed are the cases of serious runs that you may or may not experience. When I was in India, I developed a case of dysentery that was so bad that blood and mucus (slimy gray or green stuff) began to be mixed into my watery stools. The great thing about Asian toilets is that your stuff sits in the basin until you wash it down, so seeing what's in there is pretty easy. After a few days of this, I was fed up, went to the local hospital (which in India is quite good) and was given a prescription of antibiotics after a stool sample revealed to the doctor that bacteria were to blame. Sure enough, within a couple hours I was feeling much better.

Antibiotics may be one of the great miracles of modern medicine, but they need to be used with caution. DO NOT take antibiotics every time you have diarrhea, as it is not necessarily a bacterial infection that is to blame. The use of antibiotics has led to the spread of resistant bacteria strains. The less you use antibiotics, the easier your diarrhea will be to treat when a real infection comes around.

If you get a serious case of the shits (at least five days will let all but the worst run out), try to get a stool sample analyzed from a local hospital to determine if antibiotics are necessary. Generally this test will be quite cheap. If no professional is around to give you a decent assessment, you may want to consider taking a general spectrum antibiotic such as ciprofloxacin (available in pharmacies in the larger towns and cities of Asia). Carry a full prescription of this with you if you're worried. Three 500mg tablets per day for five days will do the trick. Once you start the prescription, take the entire run, for five days. Not doing so lets the more resistant bacteria fester and grow into a nastier case than you started out with.

What I've tried to convey to you in this health section is that although you will almost certainly get sick, the chances are that it won't be serious. This assumes that you've taken the proper vaccinations (see 4. before you go). Most remaining cases can be dealt with as they come. You don't need to carry around an entire pharmacy when you travel to remote regions.

On the grounds of the Royal Palace (Bangkok, Thailand).