We were sitting in a swank little chain style bistro restaurant and I was people watching. Hip young adults sat about sharing plates of appetizers, groups of guys watching the sports on the TV having a beer, couples were chatting alone in the establishments corner tables drinking wine, and one large table of six young women dressed for a night out, all made up, drinking cocktails fawned over one ladies child that sat with them in a stroller, all the while Top 40’s music blared forcing everyone to either talk loudly, or lean closely to one another to be heard. It was a typical late April Friday night sitting outdoors in the “Al Fresco” dining area, and the place was jumping. The wait staff attired in their particular chain issued uniforms scurried about with trays full of drinks and food orders trying to keep up clients requests.

We had been out walking on this beautiful evening trying to decide where we wanted to stop for a quick drink and a light snack and this place seemed to fit the bill, and judging from all the activity a locals favorite to do likewise. Her statement brought me back from my ruminations and a strange feeling took hold of me, and I’m not sure this has ever happened when I’ve been abroad. For a moment I had actually forgotten where I was. So alike was this scene to my home in the suburban United States that I had totally gone into some sort of a daydream watching the crowd that I had almost forgotten I was in Antalya Turkey and not the New Jersey shore.

Now I know resort towns are similar in many respects no matter where they are, and maybe we could be accused of gravitating to establishments and services just like the ones we have at home, but in this scenario that most definitely wasn’t the case, though I won’t lie I do get a kick out of occasionally visiting American institutions like Burger king or Starbucks in far off locales, but that’s more for entertainment purposes than for reasons of homesickness. Again my companion repeated her statement.

“Talk to me.”

“About what?” I replied in my patented response to this oft stated request.

“Anything!” she said starting to show her frustration.

“Well” I said, calculating how this next statement was going to go over.

“You know this is exactly the kind of place that terrorists and crazy fundamentalists love to blow to pieces just to make a point; you know to show everybody the evil of our ways.”

“Oh Steven, why do you have to say such things?” she questioned worriedly.

“Well you DID say talk about anything didn’t you?”

While my proclamation may seem a tad dramatic and exaggerated, I couldn’t help feel that it wasn’t ridiculously off the mark given precedents like Bali, Sharm-al-sheik and a few other quiet resort spots that have fallen victim to terror spawned violence, and while Turkey isn’t exactly a *Hot spot* for Al-Qaeda’s operations, the Turks haven’t been exactly immune from these types of acts either. While the odds were infinitely small it was a notion that while spontaneous in inspiration, had started to possess me with each additional moment I sat there drinking my tea.

With my last sip finished I looked at my friend and said, “Shall we meander elsewhere?” She looked at me with an expression that would be the equivalent of a big fat “Duh!”

Needless to say I didn’t have to ask her twice, then off we went to the local shopping mall.

The usual things like travel insurance, first aid kit, flashlight with extra batteries, camera, and copies of important documents like flight tickets and itinerary and contact numbers for those at home and in country. Certainly passport information would seem like a proverbial “No brainer”. This is especially true in places where the normal course of life tends toward routine chaos due to civil instability or simply this most fundamental institution of civility termed infrastructure and the intrinsic lack thereof.

While the phrase “Shit happens” has more than just a firm grasp on reality (more like a stranglehold) there is often a jaw dropping lack of respect for this all to often sucker punch type of reality check. When it’s most inconvenient, and cruelly compromising, when we tend to be at our most vulnerable, when unfortunately one couldn’t possibly be any farther from home, their friends, and their most influential and most powerful of assets, cold hard cash, that’s invariably when “Shit happens”.

This played out in front of me most recently in the check in counter at the airport in Lima Peru. While my companion and I waited in line, a twenty something young man with a panicked, not to mention outright desperate demeanor that attracted everyone’s (security included) attention stated to the counter clerk unabashedly and for everyone around to hear “I was robbed last night in a taxi cab and they stole everything from me even my passport!” This was in the predawn hour of about five in the morning so it was very possible the cruel irony was that very same taxi might have dropped him off at the airport as one last gesture of local hospitality. It was obvious that this young man was out I’d suppose having one last night on the town and then planned to fly out early the next morning as we all were, instead somehow he had been dealt a bad hand on this particular evening, and so what’s the point of this little soliloquy? Shit happens, and while it’s all too easy to be an armchair (or inline in this instance) critic, I couldn’t help as a very first thought to myself say “ He didn’t make copies of any these documents?” doesn’t everyone do this? Well apparently not, at least in this case. Maybe they stole the copies too. I doubt that would be likely though because only the original would have any intrinsic value. Whatever the case I did see the guy, looking either hung over or harried most likely a combination of both on the plane ride back to Miami, so whatever beneficence they were able to work out at the check in counter it at least got him on the plane, but in our post 9/11 era I have my doubts that his ordeal was over as he still had US customs and immigration to deal with in Miami.

What does this have to do with the title of this article though? Actually not very much, except for the main idea that no matter how much we prepare, research and strive to stave off any circumstance that we might be dealt while traveling abroad, there will in fact usually be something contrary to our wishes that will occur. It can range from the most obvious to the most sublime, but at some point during our adventure, holiday or vacation, it will have you either scratching your head (or something else) or perhaps even smacking it saying “Duh why the hell didn’t I think of that?”

This too was the case recently for me while in Peru, though arguably and fortunately it was of minor consequence unlike the aforementioned gentleman, and in the fact it was somewhat indelicate, it turned out kind of humorous in a sophomoric kind of way.

Peru is known for lots of things potatoes, llamas, Pisco, cocaine and most obviously Machu pichu but the one aspect of the country that preoccupied me most before departure was the altitude of many of the places we’d be and the potential effect it may have on us and how it may impact us during the trip. I poured over the web and asked questions on internet forums, questioned health care professionals that I know and got a wide variety of information that if I may sum it up simply stated was “It affects everyone differently, there’s an approach to minimizing it’s effect and if your not careful you might get sick and could potentially die.” In a way this was somewhat disconcerting because you’re hearing everything from “You’ll be ok” to “It was horrible and I was sick as dog for days and almost died”.

I was going to cover all the bases as best I could because usually in these situations I tend to worry more about my companion than myself, and seem to always develop a worse case scenario where I will have to be the functional one taking care of the other individual, so if this scenario happens at least one of us will be ok and I’d rather it be me.

I started taking my course of medication (Diamox) and despite all the negative affects that I was told it would cause (look them up yourself) and because of course my partner couldn’t take it due to a sulfa allergy (that would figure of course, wouldn’t it?) plus I had quit smoking a few months previously so I figured I should be good to go, even then though some people told me that even that lifestyle change might not matter much. I planned on drinking coca tea which was of course is the holistic local remedy for minor cases of altitude symptoms. I figure I pretty much had all the bases covered right? Wrong.

It didn’t take long for the symptoms to start to make their presence known. The short walk across the tarmac from the plane to the baggage claim of the Cuzco airport was all the time it took. No problem breathing for me just a tad lightheadedness and everything looked bright and shimmering. My companion though was laboring and made sure to let me know in no uncertain terms this was the case.

We would experience varying degrees of this during our stay and strangely enough the there really wasn’t too much acclimation. There was one point outside of Cuzco at the ruins of  “Sexy woman” or some such that my partner was really hurting but a sweet tamale and some fluid went a long way in providing some comfort. Regularly we’d wake up during the night gasping for breath after falling asleep, it was then our limbic brain would take over. During the day while awake it was easy to regulate activity, while asleep that function was left to this area of the brain.

These symptoms where easy to deal with and were in fact expected, it was the unexpected ones, the ones that weren’t in the guide books or the travel web sites that were the most uncomfortable and disconcerting. By the time we had gotten to the hotel and I was sitting down to my very first cup of coca mate was when I felt my whole lower gut make a quarter turn to the left. I thought this was curious, as I had only had a light breakfast due to the early flight and the need for an even earlier arrival to the Lima airport. While I could feel this change occurring and I was trying to pretend to be listening to everything our guide was telling us, not to mention in his thickly accented unreasonably fast speech not helping, I suddenly felt like I had something the size of a football lodged in my gut that needed immediate expelling. Very strange that’s for sure, I’m usually pretty attuned to my body and rarely suffer any GI disorder when on the road, but this wasn’t the usual quickstep type thing we all dread. This was something different. Finally Ruberio finished his litany of information he felt mandated to subject us to, and also at that very moment our room was ready. We were told to rest a few hours to acclimate. It couldn’t have come a moment too soon as I felt ready to explode. I made a beeline right to the bathroom and prepared for the worst.

I’ll spare you any graphic details not because I’m kind, but mostly because there weren’t any. As with any gas at altitude it expands and that’s just what had happened to us. My companion probably stated it best “This is not a trip for people who are just starting to get to know each other.” especially if they are prone to being shy about bodily functions around strangers or the other gender. We were able to derive great entertainment and laughter out of it all. It was rather indelicate at times in public places all depending of course on how much you care about the sensibilities of others.

While this should have just been common sense and easy to figure out beforehand, and while I read and read all about altitude and it’s effects on us not one place or with one person I read or spoke with did I get one clue about this harmless yet very unsubtle symptom. This will allow me to give you all the one little gem that I wasn’t able to glean for myself anywhere except through personal experience:

Pack some Simethicone; you’ll be glad you did.

Apart from our own due diligence in preventing exposure from the main vector of transmission (the venerable mosquito) this is usually done through the use of repellants, caution and prophylactic medication. Sometimes, depending on the area you may be staying in, and the length of time there, the odds unfortunately will go against you and the likelihood of contracting this scourge can become more then just a concern they turn into a reality.

Then the critical issues become many. How long since contraction do the symptoms start to manifest themselves? From that point, how long before the correct diagnosis is made and the proper treatment is started? Is it a common strain, or a multi-drug resistant type? Lastly, and hopefully on a minimal level, what will be the resulting and lasting effects of contraction and exposure and will the resulting effectiveness of the treatment have been optimal?

I don’t know about you, but the fact of the matter is (maybe I’m just hypersensitive) after spending a good part of my life working in a medical environment (a hospital) these are the kinds of issues that freak me out and make me go all obsessive compulsive when I go abroad, especially to malarial zones. I read up, and get my scripts and shots, cross my fingers and hope for the best, and as I’ve written here before, I tend to worry about my travel partners commonly much more then I do about myself. Low and behold my worries are usually well founded, not malaria thus far (inshallah) but most recently altitude sickness. But I digress (I’ll write about that in another entry) back to the war.

This year has been nothing less than a banner year for progress in this epic struggle, mostly for folk’s (developed world) who have been unfortunate enough to have contracted this disease. Some post exposure treatments have been not only found to be effective in killing this bug, but have also been approved by various governmental and legislative bodies for treatment of the malaria parasite. Quinine has long been known to be an effective treatment, yet in the United states it was never approved by the FDA until recently in the form of Qualaquin (quinine sulfate) though admittedly to read about all the contraindications and various drugs interactions it can cause you begin to realize just how bad the disease it’s treating is. Maybe the most important advance though on a global level is the Artimesia based medication Coartem (reg) (artemether-lumefantrine) considered to be the most effective treatment for many of the more common resistant strains of malaria. The only real down side at this point looks to be availability, mostly because the plant varieties of Artimesia used in production are only mass farmed in a few places most notably China. The other notable advance has been made in the realm of diagnosis. As I stated earlier, the sooner you find out you’re infected the better off you are because treatments that start early are not only more effective but you’ll more than likely suffer far less from some of the more debilitating symptoms. Binax NOW has been developed to give a positive blood test result in minutes as opposed to days as in the past. Unlike a skilled technician making a diagnosis from a blood sample utilizing a microscope this product will not only allow a quicker diagnosis (using microscopic analysis after the fact) but will also be able to differentiate whether the strain is a resistant one or not!

Though this is awesome news I’ll have to brush up on just how that is actually possible. Something along the line of a pregnancy test I suppose.

Regardless in these particular circumstances let’s certainly hope that the old adage of “If it sounds too good to be true it must be!” couldn’t in this day and age and in regards to the subject at hand be proven at least for once wrong.

http://www.drugs.com/mtm/qualaquin.html

http://www.medicalnewstoday.com/articles/23629.php

http://www.fda.gov/bbs/topics/NEWS/2007/NEW01659.html

Some things are just made for each other, or at the very least they compliment each other. They dance the dance together in a weird and at times with a dysfunctional symbiosis. At best these separate entities can compliment each other’s weaknesses or strengths. Like caviar and champagne, or chocolate and strawberries, a shot of whisky with a beer chaser. On a sensual level they seem like the proverbial “No brainer”. Sweet and salty, sour and bitter these are basic elementary components.

There are combinations that seem intuitive, sometimes they compliment or negate each other’s essential qualities. Man and woman, fire and water, summer and spring, these are the very components of the Taoist concept of Yin and Yang.

As usual you’re more than likely thinking “Ok what is he yammering about this time?” Honestly I really am trying to go somewhere with these analogies, but as I always do I’m taking my usual circuitous path.

Humans and the and impact they create among the natural world here on Earth and with the inhabitants of the plant and animal kingdom, and with very few exceptions, most don’t benefit by sharing this planet with us. There is a few no doubt that do. Cats and dogs are the obvious ones that come to mind. In fact for all the suffering that some cats and dogs endure at the hands of humans and nature alike, some actually get treated better by humans than humans treat some of their own. Even following the idea and concept of the “Covenant of the wild” and that animals have over the centuries chosen life (domestication) and death (getting eaten) at the hands of humans as opposed to dying on mother natures terms and by her methods, very few living entities have directly benefited from the advent of mankind. There does seem to be one however.

Readers let me present to you the definitively annoying bane of man throughout the ages, from time immemorial the humble yet none too insignificant fly. Yep very few organisms have so flourished because of the presence of man than the fly. Yeah yeah I hear the voices of derision already muttering under their breath and maybe even a bit more vehemently saying “Yeah what about the rat? Or the cockroach or the mosquito?” And to that I’d offer yes it’s true these pests have benefited from mans presence. On the other hand almost to a one, each one of those creatures has had some sort of significant human guided campaign to either control it’s presence and population or to eliminate it completely. I do plan somewhere down the line to more closely examine each of those pests a bit more individually and generally. But for now it’s the fly I’m interested in.

I know one of you smart people are already saying (and if you didn’t know this fact already you will now) “Well mosquitoes are flies!” and you would be correct. Volumes could be (and have been) written on the mosquito and how it and the diseases it carries have ravaged (and continue to do so) man over the eons. Malaria of course is the main scourge the mosquito is known for spreading, and probably the single major reasons humans have wanted to not only control, but also as a species eradicate them. I’m quite sure there is some statistic out there floating around that will state something to the effect that “Malaria has been responsible for more human deaths than motor vehicle accidents and old age combined!” and it’s probably closer to the truth than we might imagine.

Since mosquitoes, Malaria, and how this disease may have an impact on you as a world traveler are well documented I’ll get into a few brand new aspects and innovations that have recently hit the scene a in another entry. For now I’d like to run over a few basic and maybe lesser known aspects and diseases in relations to flies and trouble that clings onto their hairy little bodies like the malevolent hitchhikers they are.

I’m somewhat stunned (and repeatedly so I might add) that every three to six months or so a news story hits the wire usually coming out of central or South America or even North America about some innocent and unwitting tourist, more often than not, from Canada, the United States or Great Britain being cruelly mistreated and brutalized by the mouthparts and segmented eyes of the most graphically known of these little winged monsters, fit to terrify even the steeliest reader of the “Weekly world news”, I present to you the Bot fly! This little guy gets more press at times than all the snake bites and crocodile or shark attacks combined. While there is no denying the primal fear of being eaten alive, there is also some degree of intrinsic safety that staying out of the water in areas populated by these creatures also affords. On the surface it seems pretty easy to avoid, simply put “Stay out of the water!” On the other hand, take the notion of just being outside amidst all the other airborne critters that abound around you, birds and bees and such, and this bugger not only lands on you but he isn’t even sublime enough to inject a microbe into you. No, he proposes to use you for a growing medium of sorts for his kids. Not only as living space but you also become daycare until they’re ready to pupate and then leave home as it were.

The visceral nature of this never fails to horrify and disgust even the most hardened traveler. I actually had some people I know say that they’d almost even preferred contracting malaria. It really kind of astounded me. Well maybe not really. Obviously those folks were acting more on an emotional level not a logical one. Spirochetes that are potentially fatal or subcutaneous maggots that want to eventually leave and see some of the world? I know what I’d prefer anyway. Surgically remove my maggots please.

On one level I always feel bad for the folks that end up getting maggots dug out of their bodies from various areas, on the other hand, and I know the odds are against you the longer you stay in an endemic area, that anyone with a lick of common sense knows that whether mosquitoes, gnats, black flies (and on and on) that proper clothing (a hat for instance) time release repellent containing DEET and pre-treatment of clothing with a commercially produced substance known a premethrine can go a very long way in preventing a multitude of fly-borne parasites and diseases carried by a wide variety of fly species over vast areas of the earth that are both heavily and sparsely populated with humans.

This is the one irrepressible quality of flies whether it’s the tundra of the far north or the trash dump of a tropical urban environment they will usually be there en masse. Flies are really pretty ingeniously simple in their design. They have only four stages in life, egg, larva, pupa and adult, they don’t actually grow they’re born full size. Humans have been complaining about them forever, ancient Egyptians carved them into hieroglyphs and they were one of the plagues of the Bible, and they’ve made journeys on the space shuttle. They are also incredibly varied in size from the 120,000 species they can range from anywhere from 1/20th an inch to up the three full inches! They also have flying abilities that far exceed that of any bird or other flying insect skills for instance like landing on ceiling or an inclined surface, yet rarely do they live longer than 20 days.

Not all flies have the same type of mechanism for mouths. Though most flies like those such as house or blow have mouths that function on suction, some flies like deer and horse actually have knife like mouth parts and will bite and like mosquitoes put a saliva like material into the wound preventing the blood from clotting, feeds, leaving a small welt like wound that itches like crazy but usually heals within in a day or two, providing it hasn’t been scratched profusely thus leading to what can an become an infected troublesome wound.

Flies are also pretty flexible when it comes to reproducing and feeding. Flesh flies don’t even need flesh to be rotting as a medium to feed or lay eggs, they can even lay eggs in fresh, freshly cooked meat or in even in wounds of still living animals. Apart from just contaminating food with eggs and maggots, they can carry bacteria on the sticky hairs and pads of their feet that can cause intestinal diseases, these commonly being from fecal matter.

While flies are primarily an annoyance for most of us in the developed world they are widespread and significant problem and a disease carrying vermin in the developing world, affecting millions of people with an astounding variety of diseases and afflictions.

Bacteria, viruses and parasites as common and well known as Malaria and Dysentery, (which unfortunately mutates all the time and constantly becomes resistant to many of the treatments developed) to the lesser-known diseases like Myiasis and Bartonellosis. Myiasis is carried by the Cheese skipper fly and though rare in humans it has no treatment (animals are treated with insecticide) except to let it leave of it’s own accord or to entice it and then remove it. Bartonellosis is primarily endemic to South America and carried by the bite of the Sand fly.

Among the others are Leprosy, West Nile, Yellow fever, Typhoid, Leishmaniasis, African Trypanosomiasis, Japanese Encephalitis and Onchocerciasis not to mention a number of others that vary in severity and commonality. The main ideas in the control of flies lie in four major concepts:

Sanitation: Minimize the factors in allowing flies to feed and reproduce. For Mosquitoes this would include all standing water sources.

Exclusion: Minimize access to buildings shelter and housing, exposure to humans and animals and mediums of food or reproduction.

Mechanical control: Tools such as doors with tightly fitted seals, screens, sticky traps and Ultra violet light traps which when properly positioned near doors or windows but away from food sources are very effective. Devices that utilize Ultra sound are not considered to be effective.

Insecticides: These are most effective as a control for sever adult fly problems in the forms of mists, baits, and aerosols. Directions for usage must be strictly followed and the utmost of caution should be followed when around animals, humans or food sources. As previously mentioned for individuals this can be applied with regards to repellants for skin and treatment of clothing.

Flies have been around since the dawn of time and it doesn’t look like they’ll be going away anytime soon, so do everybody a favor,

Don’t encourage them; if you give them an inch, they’ll take a mile.

Some source material used for this article:
http://www.flypower.com/facts.html
http://.thaibugs.com/Articles/flyfacts.htm
http://library.thinkquest.org/CO117442/html/diseases.html

You might be wondering just what it is I’m on about. My answers to those questions were a except to the “Do I like having my picture taken?” I don”t. That may be because I am a photographer by trade. I”ve come to terms with having my photo taken over the years and am better in those regards now, providing I have at least some creative control over the portrait. The look of the photo (how bad I look and the aesthetic) tend to be the most important overall factors to whether I think the photo has any worthy  merit at all. The whole notion is actually pretty simple in those regards, on the other hand as a photographer I realize for most people it isn’t so simple, they almost always hate how they look, thus we get to the crux of the biscuit. For myself the mystery is twofold. Why is it some folks can’t stand to have their pictures taken, and some cannot get enough of it, especially while traveling? Travel photos seem to be the sole exception when it comes to how your average “Joe” feels about how good or bad they are represented. They can wear the stupidest looking outfit but because they were on vacation somewhere it seems to make it somehow more palatable. If they had the same picture snapped at home with the same stupid rags on it would be tossed post haste into the trash.

It stands to reason that the folks who don’t relish being on the subject end of a camera have some fairly simple logic. Shyness and modesty aside, there is some basis for how folks perceive themselves as most are only used to seeing their image in a mirror and when they do see an image of how they truly look, they more often than not initially have a negative response. There is some basis to this behavior being gender driven i.e. women are more predisposed to this phenomena. That being said it dumbfounds me greatly to the opposite end of the spectrum, these are the folks that never seem to get enough of their smiling mug. This opposite end of this scale of behavior has literally seen an explosion over the past few years with the advent of digital cameras and websites such as Facebook and Myspace. It seems as though the main content of these self-absorbed portals is (at least photographically speaking) the “at arms length” or the “helicopter shot” or the”in the mirror” type of self-portrait. An endless succession of marginal quality less than original self-portraits that’s only real difference is the faces involved. This brings me to the travel context of this examination.

Ultimately this may be my issue and not everyone else’s but when it does start to affect the day-to-day existence of others (myself included) it becomes everyone’s issue, or I’ll make it so. By extension why when people travel do they feel they need to be photographed in every conceivable act and type of pose? While I completely understand why you may WANT a photograph of yourself riding on a camel or an elephant (scam though it may be) I’ll never be able to figure out why you NEED a photo of yourself with the Eiffel tower protruding out of your head, or why you NEED to mar the beauty of a place like the Taj Mahal with your moronic grinning mug and bad fashion sense. Why isn’t it enough to just take the picture and buy the key chain to prove to people that you’ve been there and seen it in person? A good friend of mine that I’ve done quite a bit of traveling with always used to say “Ok and now a shot for Mom.” Whether or not he ever sent his mother these pictures is something I always wondered about, though knowing him I’m dubious that’s she’s ever seen them. There may in fact be some truth to it though as many times the pictures (much to my chagrin) that people always enjoyed the most were these types. Never were they the high composition artistic photos of the seven wonders of the modern world complete with deep azure blue polarized skies, or of the weathered face of the old man, or the third world child smiling amid the squalor. It was almost invariably a photo of my friend and I posed in some innocuous (and poorly composed by the guide might I add) way smiling uncomfortably.

I’ll take this a step further. To acquire this much cherished photo I’ve witnessed people profane the sanctity of a multitude of holy places, manhandle monks and other elderly folks, risk life and limb, and seen more than one temper flare and in one particular instance almost witnessed fisticuffs, all for the luxury of posing in front of the Giant Buddha. It was in Thailand and it must have been a very popular place to have ones photo taken as a line of tourists developed waiting their turn. One woman and her friend obviously wanting more than the one allotted photo of each were taking far too much time as deemed by the gaggle of German tourists waiting their turn. Angry snarls of “Schnell! Schnell!” were hurled their way. Not that these English speakers had the faintest clue at what was being tossed their way, this only made the situation worse. As an observer it was pretty entertaining to watch. Another unfathomable act is standing precariously near the edge of a cliff or some perilous ledge or dangerous precipice to get that invaluable “Me standing there” photo. I’ve witness people nearly killing themselves just to procure this type of photo.

You might think I”m obsessing a bit too much about this and perhaps I am. But in the last couple of years I’ve been traveling with someone who’s majority of travel photos are of her posing here and there. I call them her “Cardboard cut out” pictures, if it wasn’t for the mind numbing variety of her ever-changing fashion wardrobe you’d think that’s just what she was, a cardboard cut out. Her smile and pose is almost always uniform, only her clothes and the backgrounds change. When we’re home again and we look at our photos together she’ll say to me (content and technical merit thrown to the wind) “Other than the pictures I took of you, there is nothing for you to remember the trip, you take pictures of ugliness and shit, see how nice mine came out!” Then it all comes back to me in one vast flashback all the photos I had to take of her posing when she asked me, sometimes in the very same place,and with a veritable audience watching me, she’ll order me to “Take one more, hold the camera the other way, is it focused, make sure my feet are included!” the only minor a difference being a blouse or a pair of slacks. Lord knows one might compliment this or that element of the scenery better than the other outfit did.

National Geographic and combat photographers have nothing on me!

I think you’ll find the real beauty of “Moz’s” approach to travelers diarrhea is it not only lays out the physiologic mechanisms of the affliction but also gives some very pragmatic and logical solutions for curing this all too common woe abroad, and some really viable treatment options so you won’t be “Shit out of luck” if you didn’t pack Immodium or can’t get your hands on any Cipro, or worst of all contract one of the new anti biotic resistant strains of bacteria that are becoming more and more common throughout the world.
Enjoy!

By Dr. Dave Mozley M.D.>

Palliative Treatments of Dysentery

Purpose: As Napoleon observed, diarrhea has defeated more armies than all of history’s great generals combined. The specific aim of this prescription is to review some of the steps that stricken travelers should take to get back into combat as quickly as possible.

Background: Most travelers’ diarrhea syndromes are caused by pre-formed endotoxins. The “loudest” of these proteins tend to be resistant to degradation by stomach acid, bile salts, and the alkaline environment in the small bowel. No medication will destroy them. They must be eliminated. Once they bind receptors in the gut, they produce secretory diarrheas. Simply put, the gut tries to defend itself from invasion by what it assumes are live organisms by flushing them out with water. This is the key point from which all rational treatments follow logically.

Methods: the treatment of vomiting. The water for the gut’s fire hydrant comes from the extra-cellular fluid. Water in the extra-cellular fluid comes from the blood. Water in the blood comes from direct absorption across the gastric mucosa (and the distal colon). So point one is to put as much fluid as possible into the stomach. It does not matter how much you are vomiting. It’s virtually impossible to throw up more water than you put down. If you don’t get lots of water in, then the water going out will leave you dehydrated. Dehydration is pathological for a variety of reasons, not the least of which include the shunting of water from the muscles other internal organs to the gut, leaving you weak. Your brain suffers, and in its attempt to cope with the situation, tries to put you down on your back. Water is good medicine and exactly what you need for a variety of reasons. It’s relatively easy to regurgitate. Barfing up undiluted gastric juice is harsh on your esophagus, and bad for your teeth. Adding a lot of water to your stomach is a good way to wash out any remaining food as well as the offending agents in them. You should engorge yourself with water until you are regurgitating only clear, non-bitter tasting fluid. Some physicians like to prescribe clear sodas, like 7 Up. They taste good, and the bicarbonates in them are great buffers for gastric acids. The sugar in them can mitigate the feelings of lassitude. Colas are not favored because of their caffeine content. Caffeine tends to sustain and prolong the signal transduction caused by the binding of the endotoxins, so it can be thought of as relatively contraindicated. Dentists, of course, are appalled by the prescription of any sweet soda waters. Tooth decay is greatly promoted by stomach acid, and they would argue that any kind of sugar water in the oropharynx adds insult to injury. Apple juice is a reasonable compromise that is endorsed by many pediatricians. Orange juice is contraindicated because it is very acidic. Teas are worse because the solute loads in them cause the kidneys to loose more water excreting the solutes than the amount of fluids in the brews that are absorbed by the gut. Complex solutions like Gatorade or the electrolyte packets you add to water are unquestionably beneficial for the subchronic stages of major dysenteries, but free water is all that’s indicated during the acute stages of almost any diarrhea, and all that most travelers ever need. And, it’s often all that’s available when these syndromes wake you up either 6 or 12 hours after ingesting the problem.

Methods: treating diarrhea. Back in 1983, the family practitioners in rural North Carolina taught me that the psyllium they usually prescribed for constipation was the treatment of choice for these kinds of diarrheas. Their rational was so clear and compelling that the white haired physicians in Center City Philadelphia didn’t take more than a minute to convince that this was also useful on the urban wards when I interned in 1984. Products like Metamucil and its competitors work because they cannot be digested or absorbed by the gut. They are hydroscopic, meaning they absorb water. But, they hold the water they absorb within the lumen of the gut, where it forms a slurry, that is, a sort of mud. That’s nice for people who suffer from the constipation caused by hard, compact, water deficient feces. The same phenomenology applies to diarrhea. The psyilium mixes with the secreted water and forms a mud. Even nicer, whatever is dissolved in the water moves into the mud with it. Most endotoxins are water soluble proteins that are easily trapped within the mud. Live bugs are stupid, and get trapped in there too. As a consequence, the endotoxins are not able to bind the receptors on the brush border of the gastrointestinal (GI) tract. In this way, the offending agents are removed from the compartment that causes harm before they are eliminated from the intra-luminal space. When they are eventually eliminated from the terminal end of the GI tract, evacuating a slurry is gentler on the rectum than passing water. It’s also less messy, which might explain why some of the Philadelphia nurses were as enthusiastic as this kind of treatment as some of the physicians and patients. (And that might be an important point; anecdotal as it might be, patients almost invariably agree these maneuvers are helpful.)

Methods: re-feeding. The time to start eating again is before you feel like it. Practically speaking, with either a 6 or 12 hour lag time between ingestion of the offending agents and the start of their repudiation, most bouts of dysentery start during the night. As a consequence, you should plan on eating breakfast. Pediatricians usually recommend a BRAT diet: bananas, rice, applesauce, and toast. A multivitamin (with lots of water) is generally all that’s necessary to replace depleted electrolytes, such as the potassium that’s lost with vomiting. Gatorade and packets of electrolytes are nice if available, but unnecessary. Whatever you eat, select foods that are relatively easy to digest (and regurgitate in case you’re not quite done). Cereals are perfect. Avoid most fruits; they taste good, but are generally hard to digest. Nuts are difficult to digest under ordinary circumstances, and not recommended except as an unavoidable component of granola bars and trail mixes. A lot of thoughtful people recommend local yogurt for a variety of reasons. Whether or not the big bacillus in yogurt can really reach the colon and help establish a new and improved equilibrium is not really clear, but it tastes good and is easy to digest.

Drugs: Medications are available to terminate any and all of the symptoms of dysentery. But, none are recommended for travelers’ diarrhea, and most are contra-indicated. Food gets trapped in the stomach due to a healthy reflex that sends the pyloric sphincter at the gastroduedenal junction into spasm. You want to eliminate this food, and since there’s only one way out, puking is a physiological, i.e., healthy, response to the insult. Similarly, you want the offending agents that already made it into the small intestine out of there, and since the only way to get them out is through the back door, you want to avoid the anti-diarrheals. Save these for 12 hours after the last episode of vomiting if you need to be on the move. Otherwise, a second dose of Metamucil will serve you better.

Summary: Plan on coming down with a case or two of dysentery. Carry individual packets of psyllium fiber (about 0.4 oz or 12 grams per packet). Push fluids hard once stricken whether you feel like it or not, and keep hydrating yourself as much as possible between episodes of vomiting. Avoid medications for symptomatic relief until you’re sure the acute episode has passed. Carry multi-vitamins, as they’re always good for you and extremely beneficial in situations like these. Anti-bacterials like Cipro are not the first line of treatment for classic episodes that start 6-to12 hours after ingesting nasties. In most cases, you should wait at least 12 to 18 hours to see if hostilities end on their own before starting a chemical war.

On any given day there’s a blitz of signs that we receive from minute to minute, day after day, and it shouldn’t surprise anyone that more often than not they’re ignored. Or at the very least not given adequate consideration for their existence. This can often have grave consequences. Are these consequences always a given if warning signs are not heeded? Are warning signs just common sense, or are they also a useful tool, helping to prolong and enhance your statistical likelihood of putting off for just a little while longer your inevitable demise?

Obviously, the variety of warning signs can be as subtle physically, as a mere twinge in your back, or a rumble in your abdomen. It’s telling you something for sure, but just how meaningful is the message? Or they can be as overt as a gun in your face, the message quite clear.

One of my favorite warning signs in Asia is the “No Durian!” Generally this is a white placard with a green, thorny, vegetable, fruity-looking thing on it, somewhat resembling a pod from “ Invasion of the Body snatchers.” A red circle with a slash through it advises you against possession of this fruit in said building. So what’s the big deal with bringing one into your hotel? Go to the local market anywhere in Asia, pick one up and take a nice healthy whiff. Now ask yourself, “do I want 50 of these things being stored and eaten in the building I’m staying in?”

More often than not the trend is to make “warnings” as accessible to everyone as possible. Campaigns, icons and symbols are placed everywhere. “Stop!” “Stay out!” and “Slippery surface!” are among the many.

On a recent trip to Asia, Thailand specifically, I saw why heeding warnings and signs in general is very often a prudent way to approach travel and life in general. In one day a group of people I was around could have lost three amongst them in less than 24 hours; if they’d been really unlucky, that is. It’s not enough sometimes just having to try and survive crossing the street on a daily basis. There are times you just have to stare ahead, go for it, and hope you’re lucky today. There are also the times when the trouble comes seemingly from nowhere.

The other morning my companion and I saw a member of this group in severe pain. His wife was consoling him while he was writhing in the back seat of our sturdy, touring, air-conditioned ride. We asked what was wrong and she said he’d developed a sharp pain in the abdomen at about 3am (Had he had any previous warning?). After taking some antacids and Motrin it continued to get worse. He wasn’t throwing up or having to go to the toilet any more than usual, so this was something other than food poisoning. My friend is a nurse and I, a healthcare worker. We thought about it and agreed this could be any of a number of serious health complications. I recited them: Appendicitis, pancreatritis, gallstones, gastritis, diverticulitis, kidney stones, and more besides. As I rattled them out, my companion nodded all the while, stating in a thick accent “It could be no joke!” “You never know.” and “If it’s getting worse you should do something!” We both strongly endorsed getting to an ER urgently and for him to forget about travelling today. The tour was offering a ride and to catch up with the rest of the group, pending diagnosis. Even though he was a tough Canadian and despising the direction this all was going, it really was a “no-brainer” His wife would continue on.

In Phitsaniluk the following evening, his wife and he came up to us and said “We really want to thank you for pressing us the way you did. It would have been a bad idea to continue on in the condition he was in.” It was a kidney stone and it was passed painlessly into a cup later at the hospital.

The other incident occurred amongst a large group of folks from Mexico and Los Angeles. It was at the Temple ruins of Ayuttaya where near calamity was next to befall. It’s a site somewhat similar in nature to Siem Reap in Cambodia but very much smaller in size. It’s also dissimilar in that its “Chedis” are more in Sri Lankan in style than Khmer. The one thing both places have in common though is their stairways. Small steps, sharp inclines and narrow stairways are the rule. They are also very far off the ground when at the top. The ground below is commonly strewn with many rocks and much debris; so there is a very good reason that routinely placed around the site are signs saying. “Do not climb on structures” with a stick figure that looked to be falling forever.

Ironically, the day before I had been in a discussion with some folks, amongst them some of the Mexicans. When I had related a story about Angkor Wat (an optional side trip) and my fear of falling there, one of the Mexican women said that they were used to such things as these stairways, as the temples they often visited in Mexico were rife with them. “We have a special way we walk them,” she said to us demonstrating with her hands in a zigzag type motion. “Yeah well special technique or not, I’ll look for the way down with the railing.” I said.

It was brutally hot out and we had been walking around yet more Chedi’s and Buddha’s in all manner of poses and postures, when there was talk around the complex of some people having fallen. Ok say what you will, but really I was thinking Germans, not Mexicans. As someone who had seen the accident happen said, they went to the top of some stairs to pose for pictures. So when three zaftig, middle age women, perching 40 feet off the ground, in the blazing heat of the day, on a set of stairs six feet wide with no handrails, (It sounds like the “Care facility from hell.”) was it any wonder they all tumbled down when one lost her balance and grabbed her friend, taking out the third? Down they rolled, miraculously not killing themselves, but sustaining some wicked abrasions and contusions on their heads and legs. Ambulances arrived, crowds of locals (still selling stuff) formed, backboards appeared. They were driven off for treatment, treated and returned later, bruised and bandaged. Only a mere two days into the trip, with many more stairs yet to climb and already this happens. It was a true testament to the usefulness and efficacy of purchasing travelers insurance, especially if you are predisposed to ignoring warning signs in your effort to get the most out of your vacation.

I didn’t see the Mexicans much more after that, usually only as a nuisance. Clogging a line here or creating a crowd there, the women always shopping and the men always drinking and creating some type of gridlock in an already crowded area.

I’m still really wondering how they liked Angkor Wat.

Author - Steve Strommer.

These types of guests seem to be a given in life. Whether it’s someone you can’t stand crashing your BBQ or the taxman paying a surprise visit to your place of business or the drunken relatives during the holidays season, these encounters will never be void from your life. The only question that might remain is whether or not you had any hand in deliberately or inadvertently bringing these instances upon yourself, and by the time you per chance come upon that particular answer more than likely the damage has started to fully precipitate itself or it’s already been done. The best you can ever hope for is to minimize these scenarios from ever happening again…good luck with that.Recently I had the disturbing fortune to read an article in the NEJM (New England journal of medicine 10/8/05) about the increasing occurrences of infections of a bacteria called Clostridium difficile. The most disturbing part is it’s manifesting itself now in a strain that is showing resistance to some of the most commonly effective antibiotics that we travelers use for what is termed “Travelers diarrhea”, most notably Ciproflaxin (Cipro) and Levoflaxin (Levaquin). I don’t know about you all, but I feel all but naked without one of these two in my kit. This disturbed me. It also intrigued me to look into what this might bode for all of us who enjoy going to developing countries for our shits (pun intended) and giggles. So I decided to dig deeper and utilize some of the resources available to me and I learned quite a bit. More than I ever really wanted to know, but informative all the same.The smaller but more serious issue of drug resistant bugs is usually due to two major factors, drug overuse and the simple fact that most people who take the drugs never finish the complete course thus enabling the microbe to mutate into a more virulent strain. The larger issue though is the subject of “Travelers diarrhea” in general, cause, effect, prevention and all it entails. I’ll focus primarily on these subjects.

China
If completed, the $24 billion Three Gorges Dam on China’s Yangtze River will be the largest hydroelectric dam in the world. It will create a reservoir of 600km long and will be one of the largest man-made structures ever. China is hoping the dam over the high limestone cliffs of the Qutang, Wu, and Xiling gorges will provide for the country’s ever-growing electrical consumption needs. The dam’s hydropower turbines are expected to create 18,000mw of power; and as powerful as 18 nuclear power plants. It may end up providing one-ninth of the nation’s electrical production, and environmental benefits would be high given that China currently uses 50 million tonnes of coal annually. The Three Gorges reservoir would benefit China’s export business as well by enabling 10,000-ton ocean freighters to sail directly more than 2200 kilometers inland up to the city of Chongqing, transforming it into a major business hub. A lock system will increase river shipping from 10 to 50 million tonnes per year, and cut transportation costs by up to 37%. The reservoir’s 22 cubic kilometers of flood storage will lessen the frequency of big downstream floods from one every decade to one every century. Work on the project started in 1993 and is expected to span 17 years. The first phase (1993-1997) focused on the diversion of the Yangtze River, which took until end of 1997 to complete. The first set of generators started generating power in 2003. Also in 2003, the sluice gates were closed and the reservoir started to fill with water. It is expected to reach its capacity by 2009. More than 20,000 people work, sometimes around the clock, to complete the project. Construction should continue until at least 2008. Official numbers put the cost of the Three Gorges Dam at $24 billion; unofficial rumors speak of numbers closer to 75 billion.Mozambique
Red tape, archaic laws and corruption are seen as major threats to Mozambique’s reform agenda, which has won the country stable economic growth and acclaim from international lenders, analysts said. The former Portuguese colony, which emerged from civil war and ditched Marxism in 1992, has implemented stringent reforms advocated by the International Monetary Fund, World Bank and bilateral lenders, helping put it on a path of stable economic expansion. But analysts say a growth average of 8% annually over the past decade has yet to deliver a solution for poverty, and further reforms and investment were required to bolster the southern African country of 18 million people.Myanmar
Myanmar’s military junta says the country is taking a big step toward democracy with its constitution-drafting convention, but residents in the tea shops and markets of the rundown capital said they think it’s a sham. The junta has invited more than 1,000 delegates — including politicians, leaders of ethnic groups, workers, businessmen and government employees — to meet at a convention center about 25 miles north of the capital to continue work on the much-delayed document. About a month ago, Myanmar’s government began relocating its ministries to a planned new capital, Pyinmana, about 250 miles north of Yangon (Rangoon). Some analysts said the move is being driven by irrational fears of a U.S. invasion, while many in Myanmar believe it is due to worries about possible internal unrest. Still, most analysts say the junta is firmly in control, noting there have been few public protests. The country also has the economic and political support of neighboring China and India — two of Asia’s biggest powers.

Of course the answer to that is a resounding yes, but just the same, the preventatives seem to be pretty harsh in all sorts of ways in their own right. I got a call from my travel pal who had gotten the brilliant idea of maybe taking a trip to Borneo. I slapped my self in the face and said “What?” She said “Yeah I found a pretty good deal on the Internet.”
“You really want to see Orangutans that bad?” ”You know the place isn’t exactly chock full of the four and five star accommodations you hold so dear.”
She said, “Oh, it will be ok, we will think about it.”And that was what I started to do. I had read somewhere that there were parts of that island where at least 120 mosquito bites and hour had been recorded, which then got me to thinking about malaria prophylaxis. It hasn’t been an issue for the last couple of trips I’ve been on, but it certainly has in the past. There’s a huge difference of opinion on what is the best and most effective course for staying malaria free. Obviously the basic one comes to mind. Don’t get bitten by mosquitoes, duh. But just in case you may have forgotten here are some others.· Limit time spent outdoors at dawn and dusk, when many mosquitoes are most active
· Wear light-colored protective clothing such as long-sleeved shirts, long pants, and a hat when outdoors in areas where mosquitoes are present
· A long sleeve shirt with snug collar and cuffs is best. The shirt should be tucked in at the waist. Socks should be tucked over pants, hiking shoes, or boots
· Light colored clothing is best because mosquitoes tend to be more attracted to dark colors
· When going outdoors use insect repellents that contain DEET or other approved ingredients
· Make sure that door and window screens fit tightly and have no holes that may allow mosquitoes indoors
· To avoid insect bites, do not use scented soaps, perfumes or hair sprays on your childrenAnd then there are the medications. This tends to be where the real debate comes up. It’s not bad enough that depending on just where it is you’ll be going the varieties of Plasmodium can be resistant to certain medications, but then you have to consider positives and negatives of the medications themselves. Some are very expensive (Malarone) others make you kooky (Lariam) and others affect your skin and if you’re a woman and on birth control pills knock down their effectiveness (Deoxycycline). And for all of them there is a limit as to how long you should take them. A vaccine is in the works but it isn’t quite there yet and there are also some new drugs in the works. Almost all you would ever really want to know can be read on these two very good sites.