Pursuant to a series of articles about dangerous diseases, animals, toxins and other maladies that can inflict a person in a tropical or subtropical environment, we now continue with a series of observations about less well-known or less understood infections and problems that can arise for the traveller operating in environments where there may be concerns as to standards of healthcare and hygiene and it may be necessary to self-medicate in the absence of access to reliable medical facilities.
Irritable bowel syndrome
Irritable bowel syndrome has long been recognised as a digestive tract complaint distinctive from any specific microbiological or viral infection of the digestive tract, but potentially connected with such infections. Scientists and doctors are divided as to what causes it and how to treat it, but in fact it is a fairly simple condition to understand, this author having suffered from it on several occasions. Contrary to the conventional wisdom, it is not a condition that may last lifelong, save in the most exceptional cases; in fact it is fairly easy to clear up.
Irritable bowel syndrome is a sort of spasm of the digestive tract, in which much or all of the digestive tract from the stomach all the way through to the intestines and sphincter develop and irritation, almost like an allergic reaction, to the food they are processing. The digestive tract therefore seeks to expel food as quickly as it can from the digestive system, typically in the form of repeated acts of very watery diarrhoea as food is reduced to liquid without the usual uptake of nutrients and expelled via the anus. You can find yourself going to the toilet as many as 12 times a day, on each occasion expelling predominantly brown liquid via the anus. This is accompanied by a dramatic reduction in urination. From time to time you may also vomit, as the stomach expels food intake without processing it and you suffer from reverse peristalsis. Stomach cramps, flatulence and burping are also common.
This condition, which can be dangerous over an extended period if not treated because you dehydrate and suffer from malnutrition, should be distinguished from at least five other common diseases of the tropics, all of which are the result of infection whereas irritable bowel syndrome is not (or not directly):
Travellers' diarrhoea. This is typically the result of mild microbial infections and/or the body getting used to eating different sorts of food. It is particularly common in southeast Asia and on the Indian subcontinent, where food is not what one is used to and particularly where it includes spices that the body is not used to. It consists of loose stools that may be of an unusual colour. One may find oneself using the lavatory three or four times a day and, although unpleasant, travellers' diarrhoea typically clears itself up within a few days without treatment. If it continues beyond then, persistent microbial infection may be assumed and it should be treated with a small dose (250 to 500mg) ciprofloxacin, a broad spectrum antibiotic.
Bacillary dysentery (the most common variety of which is shigella). This is a very serious disease that causes acute diarrhoea and vomiting and often leads to death if not adequately treated. The symptoms are the same as irritable bowel syndrome save that in addition, bacillary dysentery lays the patient out flat: they cannot get out of bed, save to go to the lavatory. Bacillary dysentery will not go away on its own; if untreated, the patient will progressively deteriorate after an acute onset time of 12-24 hours and death may occur within a few days. Bacillary dysentery has been used as a poison by some less salubrious Eastern European security and intelligence agencies to harm, disable or kill victims, and it can be carried in phials or secreted into the water supply. In some countries with low rule of law, it can even be purchased. Like all these conditions, bacillary dysentery is easily treated with the right knowledge. The treatment is typically 1,000mg ciprofloxacin as an initial dose, then 500mg every 12 hours for a few days. Within two to three days, 90% of symptoms should have abated.
Amoebic dysentery. This is a viral infection and unlike bacillary dysentery its onset is not acute: it develops over days or weeks. However it is every bit as dangerous as bacillary dysentery and it will kill a patient progressively if left untreated. The symptoms are much the same as bacillary dysentery, save that they come and go: one day a patient may feel better, and the next day they may be bedridden. The distinctive feature of amoebic dysentery is dark red streaks of blood in the stools. (With irritable bowel syndrome one may experience bright red blood in the stools, something we will explain below.) Amoebic dysentery is not easy to manufacture or to handle, and because its onset is gradual it is not used as an intentional toxin. It is just a very unpleasant tropical diseases. Its treatment is metronidazole (traditionally sold under the brand name Flagyl), an extremely powerful medicine that exterminates most unwelcome organisms in the body. A typical dosage might be an initial intake of 500mg and then 500mg three times a day until a day after symptoms have subsided. However as with all these medicines, doctors are likely to recommend overdosage. You do not really want to be taking metronidazole for ten days, as some medical websites will advise you. Metronidazole leaves a metallic taste in the mouth, which is nothing to worry about. You should not drink alcohol while taking metronidazole, or you will want to vomit. However if you have amoebic dysentery, you are unlikely to want to do so.
Giardiasis. Giardiasis might be characterised as a distinctive form of dysentery caused by the Giardia Lamblia parasite (seen in the photograph at the head of this essay). It is not as serious as either bacillary or amoebic dysentery; its onset is gradual and a patient may live with the condition for weeks or months without diagnosis. Dark blood will typically appear in the stools from time to time. Treatment is with metronidazole at relatively low doses. Ciprofloxacin will not eliminate the Giardia Lamblia parasite.
Cholera. Increasingly rare, cholera is a bacterium that infects the water supply. It is rarely used as a toxin because it is dangerous to manufacture and handle and highly contagious. It causes symptoms similar to bacillary dysentery but even worse, leaving the patient virtually completely bedridden and reliant upon third parties to assist him or her with toilet and eating facilities. Cholera can be very dangerous indeed without treatment and it often requires hospitalisation. You know when you have cholera; it is in an altogether different league from the other conditions described here. Treatment is typically with specialist antibiotics, in particular tetracycline and erythromycin, although in countries that still have significant problems with cholera (such as Bangladesh) the microbe has developed an element of resistance to antibiotics so an antibiotic cocktail may be required under specialist medical supervision. Cholera is a case where it is necessary to go immediately to a specialist doctor. The good news with cholera is that with a few days of heavy and constant rehydration, the microbe is typically destroyed by the body of its own accord and the patient recovers. Deaths in cholera cases are typically the result of the patient not being rehydrated sufficiently with an appropriate electrolyte, often because they cannot afford the hospital admission fees.
Irritable bowel syndrome is distinct from all the above conditions that have similar symptoms, and we have set out the different symptoms and treatments in each cases in order to assist the reader in self-diagnosis because this is very important. Irritable bowel syndrome is not the direct product of a bacterium or a virus at all, but rather the consequence of the body developing an allergic or irritable reaction to the consumption of food. Its causes can be any of the following:
One of the above diseases of the gastro-intestinal tract, particularly if suffered more than once in a short period (for example over a few months).
A dramatic change in diet, particularly if one is used to eating fresh fruit and vegetables, or lactose products, and then suddenly one moves to an environment where these things are less available. Lactose intolerance is common in large parts of East Asia, and therefore dairy products may not be available. Sudden removal of dairy products from one's diet may contribute to irritable bowel syndrome.
Stress or anxiety are believed by many medical practitioners to contribute to irritable bowel syndrome. Although these factors are unlikely alone to cause the condition, they may prolong or exacerbate it.
In some cases medicines common in the tropics to address high blood pressure, heart disease and moods, such as acetylcysteine, may exacerbate irritable bowel syndrome, although it seems unlikely from anecdotal evidence that they cause its initial onset.
Nobody really knows how to treat irritable bowel syndrome, and some patients continue to suffer the symptoms of the ailment for a substantial period after returning home. However going back to a familiar environment where food is prepared and served that one's body is comfortable with will undoubtedly assist. Irritable bowel syndrome is essentially a shock reaction by the digestive system to the presence of diseases, parasites or unusual foods, and it will gradually fade as exposure to those things is taken away. In the intervening period, this author has found his own innovative solution: bananas. Bananas are high in potassium, one of the principal salts the absence of which causes malnutrition associated with irritable bowel syndrome and a number of the other conditions listed above. They are also a mild constipation agent. And they are smooth and calming to the gut. This author has lived on a diet of as many as 15 bananas a day and it has proven remarkably effective at ameliorating the effects of irritable bowel syndrome. Avoid foods that are likely to make you go to the toilet. Stick to bananas, bread or other thick carbohydrates (where you can find them), and well cooked meat (badly cooked meat has all its own problems in tropical environments), and you should find that the symptoms of irritable bowel syndrome ease.
The standard medicinal treatment for irritable bowel syndrome is loperamide hydrochloride (usually sold under the brand name Imodium), that prevents peristalsis and works as an anti-convulsant. A short course should clear up irritable bowel syndrome, as long as one reverts to a conventional diet and thereby avoids the unusual foods that are serving as irritants in one's digestive system. Start with a 4mg dosage of loperamide, and then continue with 2mg doses if symptoms recur. Do not use loperamide for any of the other microbial or viral conditions discussed above, as in constricting peristalsis loperamide will prevent expulsion of the harmful bacteria or viruses from the body using natural mechanisms. Loperamide is generally only appropriate where there is no infection.
Finally, irritable bowel syndrome can be very painful as whenever you pass water via the anus the sphincter becomes increasingly lacerated. The water being passed is highly acidic and hence it hurts. Try not to be horrified if substantial quantities of fresh (that is to say, bright red) blood accompany your expulsions. Your sphincter will heal as the irritable bowel syndrome subsides. Irritable bowel syndrome does not necessarily cause you to feel bad in the course of your daily activities, although the times when you can feel yourself needing to rush to the lavatory can be highly inconvenient. Nevertheless it is a very unpleasant ailment, and you should address it immediately when you realise that you have it. What you should not do is just keep on eating the same things, or the condition will continue. Go home as soon as possible, and in the meantime eat bananas and other very familiar foods.
It is very easy to acquire miscellaneous infections in tropical environments. Three of the most common you may come across are:
Infections of the skin after a cut. Virtually any cut in the skin will become automatically infected in a tropical environment.
Dental infections. It is easy in tropical environments for teeth to become broken, or for a microbe to enter the mouth and to infect the gum. This may cause acute gum disease, which can be agonisingly painful, particularly if one has a history of dental complications.
Eye infections. Rubbing your eye with dirty hands (virtually inevitable in a tropical environment, as sweat pours down your face in the hot and humid weather) can cause microbes on your hands to enter the eye and produce painful swelling and loss of vision. In the most serious cases, there may be a loss of eyesight.
Thankfully all these miscellaneous infections can be easily treated but they should be treated straight away. At the first sign of a cut or infection, treat the cut with alcohol (you can typically buy denatured alcohol in pharmacies, but a glass of vodka - without ice - will be just as effective) as an immediate antiseptic and then place a bandage over the injured part of the body as soon as possible. Then follow up with a prophylactic broad spectrum antibiotic; ciprofloxacin is the usual one. Yes, ciprofloxacin can be used to treat dental caries, although the treatment should be continued over several days as dental infections can be particularly resistant to antibiotic treatment. In particularly severe tooth infections, a course of metronidazole is indicated. Seek competent dental treatment once home.
Do not rub one's eye with alcohol - this is extremely painful. Instead purchase an antiseptic eyewash. There are several available. Boric acid is appropriate although in emergencies iodine solution can be used with care and sparingly. Tincture of iodine has all sorts of purposes as both an antiseptic (apply it to a wound if you have it available) and to clean water although in larger doses it can be toxic so carry iodine tincture if you have it but use it carefully.
Incidentally, many of the various medicines mentioned in this article are unavailable in Europe and the West without a prescription; and it can often be hard to persuade a doctor to provide you with one for prophylactic purposes. However in the tropics most of these medicines (save for the psychoactive ones, as to which practice varies by country and rules are always changing) are available over the counter and without a prescription.
Strange and unusual swellings are a common occurrence in the tropics. They may be the result of infection but as a rule this is only so where there has been some sort of cut or abrasion allowing infectious organisms to enter the body. You will be aware if there is an infection related to a swelling because liquid will typically amass under the skin that you can feel; it will be exceedingly painful to touch; and the skin may change colour. In case of an infection-related swelling, treat with broad spectrum antibiotics as discussed above, the most effective of which is almost always ciprofloxacin. (The beauty of ciprofloxacin is that it is almost completely harmless and extremely difficult to overdose on.)
Other sorts of non-infectious swellings are also eminently possible, as the tropical weather causes joints, muscles and other parts of the body to seize up. This is particularly the case if you are doing a lot of walking or other exercise. There are many local treatments for swellings of this kind but the most effective treatment is the conventional anti-inflammatory medicine ibuprofen, available without prescription in the vast majority of the world.
A course of ibuprofen over several days should eliminate any swelling, such as a swollen hamstring. Such a course should be started immediately; do not wait for the condition to desist on its own or it will simply get worse. The maximum safe prescription dose is typically regarded as 3,200mg a day but you are unlikely to be taking this much. The usual dosage is 400mg every four to six hours. The immediate release variety of ibuprofen should be used to reduce and eliminate swelling, not the slow release variety. If you sleep for eight hours a night you are unlikely therefore to take more than 1,600mg of ibuprofen a day. There is no clinical evidence to suggest that taking a dosage of more than 400mg in a single instance has any marginal benefit. The effect of ibuprofen in reducing non-infectious swellings is gradual and good timing must be maintained with the dosages. Do not go without food while on a course of ibuprofen or there is the potential for liver damage, particularly in vulnerable people.
It is our experience that things like ice packs, compression socks, taking rest, sleeping with one's legs up in the air, tiger balm, and various other things you may read about on the internet as to how to deal with swollen joints and muscle pain, are ineffective. The solution is a steady course of ibuprofen. Within five to seven days, the problem is likely to have disappeared completely; but it is advisable to continue taking ibuprofen for a few more days to prevent recurrence, particularly if one is reasonably active.
Fungal infections are caused by parasites in the fungus class of organisms that live in the soil. These parasites get everywhere, including in the air, on one's hands and in one's sweat. They typically create infections either between the toes or on the bottom of one's feet; or around the genitals.
The key to avoiding fungal infections is to wear open toed sandals, if that is possible (it is not if one is spending a large amount of time tramping through jungle areas); it is less easy to expose one's genitals, so keep changing your underwear frequently and making sure it is always washed. Severe fungal infections are commonplace amongst soldiers and other people marching in heavy boots across long distances in tropical climates. Fungal infections can cause lacerations in the skin that then lead to infection almost inevitably, so any sign of a fungal infection needs to be treated immediately or it will transmute into something worse. Tropical pharmacies will typically sell you all sorts of anti-fungal treatments; some are very strong but you should not need those if you catch the fungal infection quickly (as you should if you are constantly observant as to your health, which you should be when operating in any tropical environment). Fluconazole is a reliable mild anti-fungal treatment, that should dispatch any fungal infection with a few days of treatment.
Malaria and other insect-born diseases
These days the conventional prophylactic for malaria is doxycycline, an antibiotic that you start taking 24-48 in advance of entering a malarial area and for four weeks afterwards. Doxycycline is very effective in combatting malaria, and it is less susceptible to the phenomenon of malaria becoming resistant to it, such as its predecessors chloroquine, paludrine and mefloquine. Mefloquine proved to have unpleasant psychoactive qualities to it; it would increase the vividness of one's dreams to the extent that one would wake up and be unable to tell whether the dream was reality. This author took it as a form of malaria prophylaxis on a number of occasions and the experience was invariably unpleasant. All those problems have now abated with the use of doxycycline, so this is your prophylactic of choice if entering a malaria zone.
Malaria is much less the killer than it used to be. Although perhaps half a million people a year die of the disease, that is perhaps 40% less than it was some twenty years ago; and the reason for this is not because everyone who lives in tropical regions is now taking doxycycline. The more likely reason for the reduction in prevalence of the disease is probably increased standards of habitation. Malarial insects and other insects carrying diseases tend to come out at night and are often particularly associated with stagnant bodies of water. As infrastructure has improved, and air conditioning has become more prevalent, malaria has decreased in frequency. Doxycycline can also be used to treat malaria if you contract it, but if your travel anticipates staying in hotels with air conditioning then query whether you need to engage in malaria prophylaxis at all. Air conditioning is a near-universal panacea for insect-born diseases, because air conditioned rooms are sealed and hence the various crawling animals and insects that carry diseases cannot enter and it at night that these animals bite you.
If you cannot sleep in an air conditioned room, or - even worse - you must sleep out in the open - then you need to carry two things. One is 95% Deet (N,N-diethyl-meta-toluamide), a highly effective insect repellent but only really effective at very high concentrations. (Many pharmacies will sell you lower concentrations, such as 50% or 75%; you need 95%.) The other is a large canister of industrial insecticide with an aerosol propellant. Raid produces these products and they are very reliable. At night you spray yourself with Deet and everything else (including the bed and the floor around the bed) with Raid. Use a mosquito net, preferably suspended above you (several insects can bite you through the net so the net needs to kept at a distance from you, not used as a blanket) and, if sleeping outdoors, endeavour to sleep in a hammock (although that may not stop all sorts of crawling things from climbing up the connecting trees and getting into the hammock with you).
Doxycycline is an antibiotic used to treat infection and its effectiveness in malaria prophylaxis was discovered only by accident. In the West it is typically available on prescription only, and it can be expensive and inconvenient to procure. However in tropical environments it is usually available over the counter in most major cities (and large cities are undoubtedly the most likely place where you will begin your tropical adventure). So if you need doxycycline, arrive in a large city (where malaria risks are typically low due to higher accommodation and infrastructure quality) and give yourself 24-48 hours there (advisable anyway to acclimatise) to buy your doxycycline before heading out into the wilds.
If you are bitten, it will itch. Do not scratch it, or it will bleed. When, ignoring this advice, you do scratch a point where you are bitten (and it is perfectly routine in tropical environments to find oneself bitten from head to foot), apply alcohol or another antiseptic and then consider taking a prophylactic antibiotic such as 250mg ciprofloxacin.
Wear long trousers close to bodies of water, particularly at night. It may seem excessive given the heat, but insects love biting legs above other parts of the body for reasons we do not understand.
High blood pressure
Constant exposure to high temperatures and high levels of humidity can cause elevation of blood pressure. It is unrealistic to carry around a blood pressure monitor with you in a tropical environment unless you are a particular sucker for punishment in carrying large amounts of irrelevant luggage (as is this author); but if you are over 40 or you smoke, or you have a history of high blood pressure either personally or in your family, then take blood pressure pills with you or buy them when in the tropical environment and then take them. The standard pill against high blood pressure is propranolol. Although some Western medical websites will tell you that an overdose is dangerous, this is not true; in the words of a distinguished doctor and a friend of this author, you could take an entire packet all at once and nothing would happen to you.
Propranolol is often treated as a prescription medicine in the West so buy it when you arrive in your tropical environment as it will be available cheaply and without prescription.
Contrary to a lot of bogus advice, propranolol is not an anxiolytic and does nothing to assist with anxiety, stress or relaxation. It has no psychoactive properties at all. It is a blood pressure drug, and that is all it does. It has virtually no side-effects in people of good health, and it is a good medicine to start taking in your early 40's in any event. By all accounts, taking propranolol daily adds several years to a person's life.
Prolonged periods of presence in tropical environments can cause high levels of stress and anxiety, particularly as these environments are difficult to live and work in. There are constant concerns about illness and ailments; the weather is often unaccommodating, hot and humid; people tend to focus upon their own day-to-day survival; the environment can be confusing; sometimes nothing ever seems to work properly and there is a lingering sense of day-to-day chaos.
Although it has been (in this author's opinion, unjustifiably) blacklisted in a number of Western European countries (but not in the United States), the most effective anxiolytic to combat general anxiety of these kinds is alprazolam (Xanax). Like all medicines in the benzodiazepine class, it is dependency-forming (dependency tends to kick in after approximately four weeks) but that is true of many things, including caffeine. It is a mild anti-depressant and it can be effective for insomnia. Unlike some stronger anxiolytics in the atypical anti-psychotic class of medicines, it does not cause weight gain. It should be taken at night. The appropriate dosage depends upon body weight of the individual but Xanax dosages should be fixed and under no circumstances increased.
Xanax is used recreationally by some people along with unlawful recreational stimulants, to calm them down. It is essential to keep Xanax away from such people or they may steal them.
For acute anxiety, the preferred medicine (also used on the battlefield, in prisons and in other environments that typically cause panic) is lorazepam, an acute benzodiazepine. However lorazepam should, if carried, be used only with great care as it is acutely habit forming.
Xanax and lorazepam are available in some tropical environments without a prescription but in others you need one. Check the rules before you travel, if you are able to. (Sometimes these things are quite hit-and-miss). And never use any psychoactive medication unless you are experienced in the pathways of action of these various medicinal classes, as it can be disconcerting to find that a medication has an effect upon one's mental state unless you are prepared for it. Most psychoactive medications (but not all) are best taken at night, just before sleep.