Staying Healthy When You Travel, New Edition E-Book

Dr. Jane Wilson-Howarth

• Herausgeber: CompanionHouse Books
• Kategorie: Lebensstil
• Sprache: Englisch
• Veröffentlichungsjahr: 2023

Seitenzahl: 686

Beschreibung

The ultimate guide to research, plan, and prepare for your next vacation abroad, Staying Healthy When You Travel is filled with over 300 pages that will prepare you for anything! Author Dr. Jane Wilson-Howarth is an expert in parasitology, vector ecology, and child health, and she's also traveled around the world to treat the sick. She condenses all her years of medical experience into this incredibly helpful guide that's packed with international travel tips and crucial case histories, advice on immunizations and other precautions to take, tables and maps that match disease risk to countries, health tips to protect yourself from insects and worms, and so much more. While the author wrote this book with the world traveler in mind, it is also an excellent source for anyone who spends time outside camping or hiking or traveling locally, with helpful advice on protection from mosquitos, treatments for minor injuries, and first aid for cuts wouldn, dehydration, fainting, snake bites and more! So before you prepare to travel in a post-COVID world and head to the airport, do your research with this travel book and you'll be good to go!

Leseprobe

Staying Healthy When You Travel

CompanionHouse Books™ is an imprint of Fox Chapel Publishing.

Project Team

Editor: Diana Kern

Managing Editor: Gretchen Bacon

Design: Wendy Reynolds

Index: Jay Kreider

Proofreader: Jean Bissell

Wildlife Drawings © Betty Levene

Map design (disease risk areas): Tracey Ridgewell, adapted by Stephen Dew, Pete Gwyer, and Angie Watts Photo on here and author photo courtesy of Simon Howarth

Text and other photographs Copyright © 2023 by Jane Wilson-Howarth

Staying Healthy When You Travel, New Edition (2023) is a completely revised and updated edition of The Essential Guide to Travel Health (2009, Cadogan Guides), which was a revised edition of Bugs, Bites and Bowels (originally published in 1995, 1999, 2002, and 2006). Staying Healthy When You Travel, New Edition is published by Fox Chapel Publishing Company, Inc.

All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of Fox Chapel Publishing, except for the inclusion of brief quotations in an acknowledged review.

Print ISBN 978-1-62008-378-9

ISBN 978-1-62008-379-6

The Cataloging-in-Publication Data is on file with the Library of Congress.

This book has been published with the intent to provide accurate and authoritative information in regard to the subject matter within. While every precaution has been taken in the preparation of this book, the author and publisher expressly disclaim any responsibility for any errors, omissions, or adverse effects arising from the use or application of the information contained herein.

The views expressed in this book are the author’s own and do not necessarily represent those of Fox Chapel Publishing.

Disclaimer: This book should not be considered a replacement for professional medical treatment; a physician should be consulted on all matters relating to health. While the information in this book is believed to be accurate, the publisher cannot accept any legal responsibility for any injury or illness sustained while following the given advice.

Images used as inspiration for infographics from www.Shutterstock.com: Andrei Minsk (16); Billion Photos (27); D-sign Studio 10 (58); In-Finity (59); Dmitry Lobanov (64); Iryna Melnyk (65); George J (88); Vector Mine (90); Piscine26 (94); Freepik via www.Freepik.com (165); elenabsl (168); rktz (198); Mediantone (263); Tartila (283); inspiring.team (285); GoShiva (286); Pepermpron (204)

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DEDICATION

To three compassionate and inspiring physicians:Dr. Julie Draper, and the late Drs. Jim Waddell and Hugh Dawson.

ABOUT THE AUTHOR

Jane against a Himalayan backdrop. Photo by Simon Howarth.

Jane Wilson-Howarth BSc, MSc, BM, DCH, DCCH, DFSRH, FFTM RCPS, trained first in zoology (in Plymouth), then parasitology (in Oxford), and then medicine (at Southampton). Her 17 years living in Asia honed a particular loathing of parasites. She’s worked on various health promotion and child-survival programs overseas, with refugees in four countries, as well as acting as a family physician to expatriates in Asia and in her native England. She is SCUBA-trained, has been a cave diver and whitewater kayaker, has done a couple of parachute jumps, and loves cycling and wild swimming. She organized expeditions to the Himalayas, Peru, and Madagascar (twice) and has enjoyed over a dozen treks in Nepal with children from the age of three months. Her travel memoirs Lemurs of the Lost World and A Glimpse of Eternal Snows describe some of these experiences. She has written a regular medical feature for Wanderlust magazine since it was first launched and contributes on occasion to the Independent, Telegraph, and Guardian national newspapers. She served as a partner in General Practice for 15 years and also as medical director of the Travel Clinic, Cambridge and Ipswich, for 11 years. She conducts health briefings for VSO International and currently divides her time between Kathmandu and Cambridge, UK. Further information, details of her other books, and photos relating to her travels are in Jane’s author website, www.wilson-howarth.com, and on Instagram, @longdropdoc; she also tweets, albeit occasionally, as @longdropdoc.

CONTENTS

Introduction

BEFORE DEPARTURE

01 Preparations

Planning

Insurance

Homework

Fit Enough?

02 Medicines

What to Pack

Sharp Objects

Taking Medicines Abroad

Useful Medicines

Reasons for Not Taking Medicines

Blood Transfusions

03 Immunizations

Immunizations

Regional Health Risks

Non-disease Hazards

04 Special Travelers

Special Health Risks

Therapeutic Travel

Traveling While Pregnant

Taking the Children

Senior Travelers

05 Flight

Coping with the Flight

Pressure Effects and Reduced Oxygen

Food, Drink, and Exercise on Board

Motion Sickness

Sneezes and Colds

DVT and Flying

Jet Lag

ON THE GROUND

06 Culture Shock

Coping

Reverse Culture Shock

07 Responsible Travel

Traveling Responsibly

08 Bowels

Travelers’ Diarrhea

Safe Drinks

Water Treatment

Natural Remedies

Preventing Diarrhea with Medicines

Treating Diarrhea

Filth-to-Mouth Diseases

09 Worms, Guts, and Nutrition

Worm Heaven?

Problems from Bad Food

Nutrition and Tonics

10 Malaria

What Is Malaria?

Where Is Malaria a Hazard?

Diagnosing and Treating Malaria

11 Bites, Biters, and the Diseases They Spread

Mosquitoes

Insect-borne Diseases

Ticks and the Infections They Transmit

12 Hot Places

Hazards of Heat and Sun

Jungle, Forest, and Scrub

Desert

13 Water

Hazards of the Sea

Dangers of Rivers and Lakes

14 High, Cold, and Dark

Hazards in the Mountains

Other Mountain Hazards

Caves

15 Skin

Skin Infections

Rashes and Itches

Other Skin Problems

Bathing and Bathrooms

16 Sex and Genitals

Embarrassing Bits

Sex and Libido

Men’s Health

Women’s Health

17 Animals

Skin Invaders

Small Biters

Other Small Bad Beasts

Snakes and Nasty Reptiles

Dangerous Large Mammals

Threats from Domestic Animals

Small Wild Mammals

18 Ailments

Exotic Diseases

Evacuation and Medical Treatment

Fever

Coughs and Chest Pain

Hepatits and Jaundice

Abdominal Symptoms

Muscle Cramp

Head, Ears, Nose, and Throat

Eyes

Dental Problems

19 Accidents

Collapse

Unconsciousness, Fit, or Faint

Allergic Reaction

Strains, Sprains, Bruises, and Wrenches

Cuts, Wounds, and Bites

Fracture or Dislocation

Something Stuck...

Swallowing Things Accidentally

20 Expatriates

Health and Hygiene

Other Considerations

Psychological Welfare

Babies and Children

ARRIVING HOME

21 Return

A Post-Trip Checkup?

Psychological Issues

Resources

Selected Bibliography

Acknowledgments

Index

MAPS

Yellow fever

Japanese encephalitis

Epidemic meningococcal disease

“European” tick-borne encephalitis (TBE)

“European” tick-borne encephalitis (TBE), Europe detail

Rabies

Malaria

Dengue fever

Chikungunya

Zika

Leishmania

Schistosomiasis

River blindness

TABLES

Health risks:

Europe

Central America and the Caribbean

South America

Africa

Asia

Australasia and the Pacific

Preparations to counteract motion sickness

Sizes of microbes responsible for travelers’ intestinal infections

Microbes frequently found on microscopic examination after a tropical trip

Common antimalarial tablets

Geographical distribution of vector-borne diseases

Diseases transmitted by small biters

Animal hazards and where they occur

INTRODUCTION

We travel for different reasons—for work, adventure, a break, to escape, to invigorate ourselves—but mostly we travel expecting the change to be stimulating, fun, and refreshing. Perhaps the last thing we imagine is a health problem . . . But picture this: you’ve woken up in a hotel bed. Hours before, you flew into a town you don’t know, where you don’t speak the language. You don’t feel good. Your belly aches and there’s a horrible watery sensation in your mouth. You sit up. The room spins. You are ill, certainly. But how ill? Is this a simple stomach upset or do you need a doctor or a prescription? Should you go to hospital? What do you do? Where will you find reliable medical advice? Or is it safe to self-treat?

Do you know how to self-treat the commonest afflictions of travelers? Perhaps more importantly, do you know how to sidestep Montezuma’s Revenge or Mediterranean Tummy-Rumbles? The answers are all in the pages of this accessible, comprehensive guide. Information about any health concern that you might have is here, as well as information on many you won’t have thought of. There is also advice on when and how to seek out a local doctor. All the exotic horrors people love to talk about are included too—not because you’re likely to encounter them, but just in case you want to know and because knowledge should help stop you worrying.

Leafing through these pages, you will see that many hazards from tropical diseases and noxious animals are overstated. The candiru “willy fish,” for example, is just not worth worrying about (see here), and bites by venomous creatures are rare. Some people enjoy discussing the plagues that they have narrowly missed, yet the diseases that afflict travelers are mostly short-lived, like colds, sore throats, and diarrhea. Even so, this book will help you avoid all these diseases. The advice will work as well in Minneapolis or Mauritania as it does in the Maldives or Manchester.

I’ve offered advice on what to do rather than providing lists of long medical names. Treatment suggestions are given, but only where there is good scientific evidence that they are effective. Alternative remedies that work are mentioned, but untested remedies are not listed. This is not, though, a do-it-yourself doctor kit, and it isn’t intended to replace a consultation with a doctor (if you can find one). The first aid guidance is of the kind needed in situations where secondary aid might be poor, distant, or absent. Ideally this book will supplement first aid training, so if you are going somewhere remote, ensure that you or a traveling companion are trained at least in bandaging and resuscitation.

Styles of medical practice vary even between English-speaking countries. Most of us are used to physicians offering a diagnosis and explaining the purpose and possible side effects of prescribed treatment. Globally, though, doctors may be unused to patients who know enough about their bodies to intelligently question medical conditions and treatments. Tactfully ask what you wish to know, and be aware that linguistic and cultural difficulties may make the doctor (or you) seem rude. Then use this book to discuss alternatives, and check that the doctor’s prescription makes sense.

For the last five years I have been mentoring young clinicians in Himalayan health posts up to six hours’ walk from the nearest dirt road. This experience has reminded me and re-reinforced how challenging it is to deal with medical problems when far from a decent hospital. A lot is possible with very few resources, though, and this book is based on decades of my own clinical experience working as a family doctor in Cambridgeshire and in five continents. It has been tough condensing my expertise into a portable reference, so if, due to my simplifying the information, you find deficiencies or omissions, do message me.

Stay cool; have fun. Take care, bon voyage, salamat jalan, and pheri betau la!

Dr. Jane Wilson-Howarth, Kathmandu, Nepal

Naming medicines

Generally, medicines are given two names: the trade or brand name, which tends to vary a great deal from country to country, and the longer, less easy to pronounce or remember generic name, which should be similar everywhere, even in different languages. It is usually written in small print somewhere on the packaging, perhaps beneath the brand name. This generic name is what you should look for when buying medicines overseas. Throughout this book, the generic names of all medicines I suggest are given in italics.

Preparations

01

Planning

Is it safe?

Is it legal?

Insurance

Homework

First aid

Clothes

Fit Enough?

Summary

• There’s more to ensuring a healthy, enjoyable trip than immunizations and malaria tablets.

• Arrange adequate health insurance when booking your trip so that you are covered for accidents, illness, or bereavement even before departure.

• Travel agents and even travel magazines won’t want to scare you, so seek reliable, independent information about health and security risks. Certain internet sites under-emphasize health hazards. Equally, some expert sites might scare the pants off you. Face-to-face consultations are usually most reassuring.

• Specialist travel clinics probably offer the best personalized information and will give you time, but there is a cost.

• It is common to experience slight soreness and mild fever for up 10 days after an immunization, so try to organize jabs well before departure.

• Arrange a dental checkup to reduce your chances of needing treatment overseas (and thus the risk of HIV and hepatitis B infection), especially if you are over 50.

• Sort out any niggling health concerns; an exacerbation could ruin your trip.

• Pack a note of the dose and generic name of any medicines you take or may need to take, and of any antibiotic allergies.

• Travel with a copy of your eyeglasses prescription in case you need a replacement.

• Become safety conscious when traveling; of those few travelers who die overseas, about half succumb to accidents.

• Insurance is usually invalidated if you travel against medical advice or your government’s advice.

Planning

Is it safe?

There is more to traveling than booking a flight, and it is crucial to check current restrictions. For example, although most destinations no longer require COVID tests, vaccine certification, and quarantine on embarkation or arrival, at the time of writing (mid-2023) some such requirements are still in place in around 30 countries; be sure to check well before departure.

News travels fast, yet a surprising number of travelers are caught up in riots and civil unrest; some are held by armed robbers or even terrorists. It can be difficult to sort out whether your destination is dangerous, but your first pre-trip task should be to check as best you can. Some travel clinic printouts include security warnings. The US State Department and UK Foreign, Commonwealth and Development Office websites carry useful advice; diplomats are sometimes over-cautious, but that is because they bail out innumerable foolhardy adventurers. Good sources of information are recently returned travelers, as well as newspaper websites, consulates, and embassies. Advice can also be obtained through the Expedition Advisory Centre of the Royal Geographical Society, organizations like the South American Explorers club, and smaller bodies like the London-based Anglo-Malagasy, Anglo-Peruvian, Anglo-Indonesian, or Britain-Nepal Societies. Restrictions, such as whether an HIV test is required before entry, will be detailed in visa application paperwork.

CASE HISTORY

Pakistan kidnapping

Some keen Japanese venturers set out to canoe the Indus. They were kidnapped by dacoits (armed robbers). Had they inquired, they would have been told that this was a lawless area where foreigners are seen as rich and vulnerable. They were released once a ransom was paid. In Pakistan, kidnapping is common.

If 100,000 people visit a resource-poor region for a month:

• 50,000 (half) will develop some kind of illness.

• 8,000 will visit a doctor.

• 5,000 will be confined to bed.

• 500 will require repatriation by air.

• 300 will be admitted to hospital during their trip or on return.

• 1 will die.

—Prof. Robert Steffen, International Society of Travel Medicine

Wherever you are, don’t advertise your wealth, and don’t travel with items you’d fight for if robbed. If you identify as LGBTQI+, be aware that some countries will be hostile and Uganda is even trying to introduce the death penalty for homosexuality. Be especially careful about how accessible your social media profiles are, consider adopting stricter privacy settings, and check out the atmosphere before travel.

Resources and further information: PLANNING RESOURCES

World Health Organization (WHO), www.who.int

US State Department, https://travel.state.gov/content/travel.html

Foreign, Commonwealth and Development Office, https://travelaware.campaign.gov.uk and www.nhs.uk/using-the-nhs/healthcare-abroad. For official UK advice.

Royal Geographical Society, www.rgs.org/in-the-field/advice-training

WHAT COULD KILL YOU?

Would-be travelers who consider the risks to their health abroad tend to think of infectious disease. Of those who die on their travels, more than half succumb to issues that would have taken them wherever they were (e.g., heart attack). Less than 4% of those who die abroad succumb to communicable infections. Most health problems overseas are due to accidents. Tens of thousands of people die and perhaps two million are injured on European roads every year. The countries with most fatalities within Europe are Germany, Poland, Italy, France, and Spain, with Britain coming in sixth. The first five countries each have more than 5,000 deaths per year. Most nonnatural fatalities in US citizens abroad are due to road accidents, and Americans are eight times more likely to die in a road accident when overseas than in their homeland. It is also worth noting that 93% of deaths and serious injuries on the roads are in emerging nations.

An estimated 300 people are killed on the world’s roads every day. In low-income regions, vehicles may be poorly maintained because spare parts are expensive and difficult to obtain, legal controls may be lax, and some people drive while tired or intoxicated. Inside buildings, electrical equipment may be dangerous, so burns and electrocution are not uncommon. Drowning takes many travelers’ lives. Poisoning from stoves in tents or badly maintained gas or kerosene fires and barbeques can also be hazardous.

Nonnatural deaths in US citizens overseas

Average annual deaths: 882 (out of an unknown number of people)

Cause of death

Percentage

Road accident

30

Homicide

19

Suicide

14

Drowning

14

Other accident

12

Air accident

3

“Terrorist” action

3

Drug related

3

Natural disaster

2

Execution

0.3

Source: https://travel.state.gov/content/travel/en/international-travel/while-abroad/death-abroad1/death-statistics.html

Hotels may not have adequate fire alarms or well-marked escape routes, so there is some sense in choosing to sleep on lower floors—those with a fire escape ladder. It is wise not to stay any higher than the sixth floor—indeed, if visiting a destination in a politically unstable region, multistory hotels may be worth avoiding as they are more likely to attract terrorist attacks than smaller accommodation. Check the position of fire escape doors—sometimes these are locked. Be aware that hazards may not be signposted in the way you are used to at home. If you realize there is a fire in the hotel, check the door handle with the back of your hand before opening it. If it is too hot to open or the corridor is filled with smoke, call reception and say that you cannot leave your room. Fill the bath with water. Close windows and turn off air conditioning. Pack wet sheets and towels around door cracks. Await instructions.

If you are unlucky enough to experience a significant earthquake, keep away from stairs and external windows with glass. Try to take shelter in an inner doorway or the corner of a room. Alternatively, dive under a table and hang onto it so it doesn’t move away from you. Afterwards, be aware of the danger from dangling electricity cables that are still live. Any communication with loved ones will be most effective through texts, as mobile telephone services are likely to be overwhelmed for around 12 hours after the earthquake.

Accident prevention is especially important abroad. Jet lag, culture shock, not understanding local signs and signals, interesting distractions, being drunk, wandering animals, unfamiliar vehicles, and vehicles on the “wrong” side of the road all contribute to the risk of mishap. In emerging nations, accidents can be a double disaster, because rescue services may not exist and emergency medical facilities may be poor or distant. Do not attempt a dangerous sport for the first time in a place where they do not seem geared up for beginners. If, for example, you wish to learn to scuba dive, check that the instructors are properly qualified. Travel with safety equipment as appropriate, such as helmets if you plan to cycle or hire motor bikes, life jackets if you will be trying any watersports, or a car seat for the baby.

Is it legal?

UNEXPECTED DELAYS

According to Hansard, nearly 6,000 Britons are arrested or detained abroad each year. It is foolish to assume that foreign laws are similar to our own. Possession of pork (including bacon), for example, is illegal in many Muslim states. Some prescription medicines may not be imported into some countries even for your own use, even in your bloodstream. It is important to check these things before departure.

Over a million Britons visit the United Arab Emirates annually, and many flights to South and Southeast Asia transit through the oil states, so travelers might find themselves with an unscheduled stopover or are even sometimes sent back to the Middle East if there are visa problems at their destination. It is therefore worth knowing how strict laws are in most Middle Eastern countries. In Dubai, for example, you can be arrested for kissing, having sex outside marriage, making obscene gestures, being gay, cross dressing, being drunk, and drinking alcohol in public. Since ignorance is no plea in the eyes of the law—even an exotic law—travelers should beware.

DIFFERENT COUNTRIES, DIFFERENT LAWS

Drugs in the bloodstream count as possession according to Dubai’s courts, and what is illegal in one state may be permissible elsewhere. Codeine can be bought over the counter in the US and the UK as a component of pain-relieving remedies, but a British visitor was held in prison for seven weeks because a urine test showed she had codeine and temazepam in her system; the prosecution said that she should have been carrying a prescription justifying her need to take these medicines. Fortunately, she managed to avoid a prison sentence, which could have been four years. An unfortunate German citizen was arrested on arrival in Dubai and—surprisingly—jailed for four years for possessing the jet lag cure melatonin.

Expatriates often have brushes with the law. Many drive their own vehicles and so they are at high risk of a road accident, and some are accused of infringing local regulations. In Indonesia, expats were most likely to be given random on-the-spot fines in the days just before policemen’s salaries were paid.

Very strict Muslim states—like Saudi Arabia—have religious police who may club people who show too much skin—or even hair. World travelers must respect local sensibilities. A 37-year-old American businesswoman was arrested, strip-searched, thrown in jail, threatened, and forced to sign a false confession by the mutaween, Saudi Arabia’s religious police. Her crime was sitting with a male colleague at a Starbucks coffee shop in Riyadh. Fortunately the woman’s husband was able to use his influence to find her and secure her release, but she was bruised and crying when she was set free. In Saudi Arabia, people die in prison, and there are lashings and on average more than two executions a week; most victims are foreign nationals, albeit mostly from neighboring Middle Eastern countries.

Imprisonment isn’t great for your mental health, or your career, either. Some regimes encourage “trusties” (inmates who are used to control other inmates). This happens in Nepal and Thailand (where there are stories of unexpected deaths among prisoners). Prisoners in places including Colombia and Venezuela suffer violence. It is sobering to realize that 59 countries still impose the death penalty, including China, Indonesia, Iran (one of seven countries who execute children), Japan, Malaysia, Nigeria (which has the highest number on death row: 2,359 in 2018), Thailand (especially for drug trafficking), the United Arab Emirates (UAE), and the US. Thailand, Mexico, and Guatemala are the three countries where US citizens have been executed recently. It is estimated that up to 70 Britons are facing possible death sentences abroad.

It is crazy to cross borders carrying drugs; innumerable people are incarcerated all over the globe for trying, and they are the lucky ones. The death penalty is likely for anyone entering Thailand with illegal drugs, for example. Carrying hypodermics and syringes can result in you being misjudged as a drug addict unless the items are obviously part of a first aid kit or, as with insulin for diabetes, certified with a doctor’s letter.

BLOOD ALCOHOL LIMITS BY COUNTRY

Getting drunk reduces defenses, which can land you in dangerous situations. Alcohol limits may vary by state, age and driving experience. *Data is a guide and subject to change; check a country’s laws before travel.

THE DOWNSIDES OF DRINKING

Enjoyable as intoxication may be, it reduces the defenses, encourages risky behavior, and, if you are in an unfamiliar environment, can be more likely to lead to rape, robbery, a road accident, or drowning.

Britain has unusually lax drinking laws, and behavior that is permissible in the UK or some US states may be illegal elsewhere. Note that blood alcohol limits may depend upon who you are and what you are driving, and be aware that people are more likely to fail breath tests even the morning after a night of heavy drinking in some countries.

DON’T SKIMP

Dressing sensitively and behaving soberly allows travelers to better merge into the background rather than standing out and perhaps attracting violent crime or robbery. Contravening informal local dress codes can attract trouble. Travelers can experience sexual assault, and sometimes this is precipitated by wearing skimpy or inappropriate clothes. It pays to understand your risks and know how much of a target you might be in certain regions.

TIPS

• Check the rules for your airline, your destination and at any stopovers.

• Ensure you are carrying any relevant test or vaccination certificates bearing your name as spelled on your passport and any further entries, e.g., your date of birth.

• Carry a doctor’s letter if you have packed prescription medicines or hypodermics; there is often a fee for such a letter.

CASE HISTORY

Travel insurance for the US

UK–based Joe, aged 81, keeps active and bicycles to the pool twice a week for a strenuous, fast-lane, quarter-mile swim. About seven years before this story takes place, he’d suffered “funny turns” due to night epilepsy. He was put on treatment and had no further problems. He had not needed even to see his own primary care physician (GP) except for repeat prescriptions. He decided to visit his son in Washington, DC, and also do a bus tour to enjoy the fall colors of New England. Since his home in the UK was insured with Saga, he phoned for a travel insurance quote. Saga, who specializes in coverage for people over 50, said they have no upper age limit, yet they refused coverage: with his epilepsy, America was too risky for them. Joe phoned around and found that most insurance companies would not cover someone over 80, although several said that cover might be possible if he obtained a medical certificate confirming fitness to travel. Surprisingly, Joe’s doctor didn’t feel he could provide such a certificate because of Joe’s “heart block” that had been fully investigated six years before and was causing no symptoms. The doctor suggested a private referral to a consultant cardiologist and for an echocardiogram. Reluctant to pay the fees for this, Joe tried Age Co; once he could confirm that he had not been seen in any hospital during the previous year, they offered coverage for himself and his 75-year-old wife for £309 (about $375); the policy was valid for up to 31 days’ travel any time during the following 12 months. What insurance companies need to know is whether travelers are medically stable. The fact that Joe hadn’t been hospitalized for six years demonstrated that his epilepsy and heart problems were well controlled; he was not a high-risk traveler. People with other medical conditions would be well advised to shop around for insurance or consult a patient support group for advice or special deals.

Just a slip—the importance of good insurance

I still don’t know how it happened, but there was torrential rain and I either slipped or some land fell away and me with it. It was a freak accident; we were just trekking in to the Manaslu region of Nepal on a MEDEX expedition. I fell about 60m down a scree slope head over heels. I have no memory of this, nor the helicopter evacuation the next day, nor the week in ICU in Kathmandu. After the fall, the team (most of whom were doctors) took amazing care of me overnight in a nearby medical center. They kept me alive until the helicopter could pick me up the next morning. Dr. Sarah Wysling accompanied me in the helicopter to the private hospital in Kathmandu. I had de-gloved my head (I needed over 100 stitches), broken my nose, eye orbit, neck (C2), and two ribs. I also sustained multiple lacerations on my legs and face. Dr. Sarah was amazing liaising with my husband, Tim, in the UK every day. After a week in ICU, I was transferred to a regular ward. Much was going on between MEDEX doctors and our insurance doctor about whether I was to be flown home or to Delhi to have surgery. Doctors were on standby to receive me in Bristol, but the insurance doctor insisted I was flown to Delhi. With an open sinus, the Delhi flight would not involve much change in pressure, whereas to fly me back to the UK would be risky, especially with a broken neck. It took poor Dr. Sarah a week to get me a visa for India. Meanwhile, Tim was waiting in the UK with his visa. Amazingly, I arrived in the Indian hospital only about five minutes before Tim walked through the door. The private hospital in Delhi was great and I received superb care. The Hilton hotel in Delhi took good care of Tim too and I spent a week at the hotel as an outpatient after my surgeries and before they would fly me home. One afternoon I asked Tim to stop kicking the bed. Tim replied that we were in an earthquake. Luckily, we were only on the second floor, but hobbling down the stairs to evacuate the building still took me some time. When we were finally let back into the hotel, we turned on the news and learned of the devastation in Nepal; this was 2015.

We often ponder how much the aftermath of the accident cost. The figure must have been at least £100,000. I was insured with DogTag and this covered:

• Helicopter evacuation to Kathmandu

• 1 week in ICU in Kathmandu

• 1 week on a regular ward in Kathmandu

• Air ambulance to Delhi (with doctor attendant)

• 18 days in Delhi private hospital with surgery to straighten broken nose, fix fractured eye orbit, and skin graft my head to replace dead tissue

• My husband’s flight to Delhi

• 4 weeks hotel accommodation in Delhi for Tim

• Our flights from Delhi to London

• Private car from London to our home in Bristol

• They also reimbursed the entire cost of the trip.

—Heather Bone, Somerset, UK

• Never carry items for others.

• Be wary of carrying white powders.

• Think carefully about what you take across borders.

• Do your homework; visitors can be targeted for political reasons.

• Travelers who look tidy and “respectable” will usually experience less hassle at immigration and customs.

• Think about the location and company you are keeping if celebrating with intoxicants.

• It is no longer illegal to be left-handed in Albania.

Insurance

Arrange insurance to cover medical care and accidents, including air repatriation. Evacuation by “air ambulance” costs the equivalent of at least three full-price seats, plus nursing care. You need to be quite well and medically stable to be medically evacuated, so if, say, you have a bad car accident, you may stay in intensive care locally until you are well enough to be evacuated. Your insurance must cover all these expenses. Make sure the worst case is covered: for people traveling into North America or who may be at risk of being evacuated there, $2–$5 million (£2–£4 million) worth of coverage is a sensible target. Other destinations should be cheaper. Be aware that if you choose to travel to a destination against your government’s official advice, this will probably invalidate insurance. Travel insurance is available through insurance companies, banks, travel agents, and tour operators, but check that the policy covers what you need for your particular trip, such as a helicopter rescue from Everest Base Camp. Many insurance companies impose an upper altitude limit of 6,500 feet (2,000m), which is easily reached even in the Atlas Mountains. Insurance for mountain rescue is not usually included in standard policies, even if they do cover hill walking. The UK is unusual in having free mountain rescue from volunteer teams or RAF helicopters. Some insurance policies include emergency administration of screened blood (see “Resources and further information: travel advice and insurance,” below). In addition to adequate insurance, have another backup (such as an extra credit card) in case of unforeseen events such as an earthquake or terrorist attack.

Many household insurance policies can be extended to cover trips abroad, but domestic and standard travel policies often exclude extended or remote trips and adventurous activities (such as skiing or diving), in which case you should arrange coverage with a specialist firm. Many sports clubs and even patient associations offer this. Conventional insurers often refuse even short-term coverage if you have any long-standing medical problems or are pregnant. Travelers with specific health requirements are covered in Chapter 04: Special Travelers, here.

Within the European Union, emergency treatment is provided free or at reduced cost to EU residents with a European Health Insurance Card (EHIC). This does not cover long-standing health conditions. Reciprocal arrangements (where certain countries share free or subsidized treatment) are unusual elsewhere. Countries without reciprocal agreements with the UK include but are not limited to Switzerland, Turkey, Cyprus, Canada, the US, Mexico, all South American nations, most Caribbean islands, all Middle Eastern countries, all African countries, all of Asia, and the whole Pacific region except for Australia and New Zealand. The US does not have any reciprocal agreements with any other countries. Note that many governments, including the UK, don’t want to make it easy to discover who is entitled to free health care. Know how to arrange treatment at your destination before you go.

Resources and further information: TRAVEL ADVICE AND INSURANCE

US-based insurance companies include: World Nomads (www.worldnomads.com), Travelex Insurance (www.travelexinsurance.com), and Allianz Travel Insurance (www.allianztravelinsurance.com). Search online for other highly rated options.

UK-based insurance companies include: Age Co (www.ageco.co.uk), Goodtogoinsurance.com (www.goodtogoinsurance.com), Columbus (www.columbusdirect.com), Saga Services (www.saga.co.uk/insurance), and Worldwide Travel Insurance (www.worldwideinsure.com)

For UK Department of Health advice, see www.nhs.uk/using-the-nhs/healthcare-abroad

Look at www.bloodcare.org.uk for how to obtain properly screened blood.

See also Chapter 04: Special Travelers, here, for firms offering travel advice and insurance to those with particular health conditions and older travelers.

Homework

First aid

If you are planning a remote or long trip, try to attend a first aid course before you go; in Britain, possible choices are Red Cross, St. John’s, or, for expedition conditions, Wilderness Medical Training (see “Resources and further information: first aid courses and supplies”). It might also be worth acquiring other skills that will be useful in remote places; reflexology, for example, relieves pain without medicines, and I have seen it used as a self-treatment to great effect in the mountains. Consider buying a local SIM card for your cell phone, and know the local emergency number: 112 is good for Europe, 911 for the US.

If you ask your British National Health Service GP (doctor) to prescribe medicines to take abroad, rules say that this should be a private prescription for which there is a charge, even if you are prescription-charge exempt. A specialist service like Nomad Pharmacy might be cheaper. Sterile medical packs containing needles may be purchased from Nomad or other travel clinics, Lifesystems, and BCB (see “Resources and further information: first aid courses and supplies,” below), as well as many others. Guidelines on medicines and first aid kits to take are given on here.

If you are going somewhere hot, pack one or two large (1-quart/1-liter) water bottles. Thermos flasks are also useful, even in the tropics (see here).

Resources and further information: FIRST AID COURSES AND SUPPLIES

Red Cross first air courses, www.redcross.org/take-a-class

St. John’s first aid courses, www.sja.org.uk

Wilderness Medical Training, www.wildernessmedicaltraining.co.uk

BCB, www.bcbin.com

Lifesystems, www.lifesystems.co.uk/products/first-aid-kits. Have a big range of first aid kits and travel products.

Nomad, www.nomadtravel.co.uk/travel-clinic

Amazon, www.amazon.com. Sell a range of first aid kits by companies such as Zerohour and Primacare.

Health Books International, www.healthbooksinternational.org. Sells rehydration measuring spoons and disposable thermometers, etc., and distributes books such as Where There Is No Dentist

Clothes

What will you wear? If you’re traveling to a hot region, I suggest packing at least one long-sleeved, 100% cotton shirt and long, loose trousers; these will help protect you from biting beasts, barbed vegetation, and the sun. Dark clothing attracts insects (tsetse-flies are especially fond of blue) and absorbs sunlight, so light colors keep you coolest. Clothes may be cheaper at some destinations than at home, and in much of South and Southeast Asia you can commission made-to-measure garments very quickly.

Jeans are unsuitable travel wear: they’re heavy, dry slowly, and are hot and clingy in hot weather and yet not warm enough in cold climates.

T-shirts are not particularly comfortable tropical wear either; they are hotter than ordinary cotton shirts and do not protect the back of the neck from sunburn. They are, however, very useful as additional layers if the weather is unexpectedly cold or you ascend to cooler conditions from a hot, low area. Layers are warmer than one thick garment and more adaptable if traveling through several climatic zones. Try to discover how hot it will be at your destination and decide which is the kindest season climatically for you to visit.

Even in tourist destinations, dressing modestly seems to be appreciated, and those who do so are treated with most respect. Ask people who have traveled to your intended destination about local dressing customs. Even men can offend by stripping off shirts, and if women dress as they would at home, they may unwittingly encourage problems and even sexual assault. In many cultures, it is unacceptable to be scantily clad, while figure-hugging clothes and leggings may not be appreciated (or, on women, may be appreciated too much). In some Muslim countries and many Asian cities, it would be considered almost obscene for men to go out in public bare-chested or wearing shorts: both men and women wear loose-fitting garments that cover all but the head, hands, and feet. In many places where outsiders are a rarity, stripping down to a bathing suit is never done and, if women bathe at all, they bathe fully clothed. Until recently, women in Malawi were forbidden to wear trousers.

In warm climates, my favorite outfits include long, wide skirts. These are especially good when on long bus rides, since, by spreading the skirt wide and squatting, it is possible to have a discreet pee. The long tails of the subcontinental shalwar kameez are also good for this purpose. Loose skirts allow healthy circulation of air, reducing the problems of thrush commonly experienced by women traveling in hot, humid climates. A tube of cloth sold as a sarong in the Far East or lungi in South Asia is also great for bathing in public, and a drawstring skirt can be pulled up under the armpits for a complete bath at the village tap.

It is common for the girth to shrink dramatically on tropical trips. Heat tends to reduce the appetite, there may be fewer tempting snacks, there may be a bout or two of diarrhea, and there is often more exercise. Pack a belt.

Fit Enough?

It is easy to be swept up by the excitement of travel while overlooking the fact that the body has to cope with what is to be thrown at it during the experience. A routine medical checkup pre-trip is rarely necessary in people who feel healthy. However, when planning any journey, consider whether you are fit enough for what you plan to do: a surprising number of ill-exercised people book trekking vacations in high mountains, which makes for a miserable as well as risky trip. Of the 1.5 million Britons who head for the ski slopes annually, just 0.3% will need medical attention for an injury; sprains are commonest in the unfit.

Inexperienced travelers and smokers are more likely to become ill abroad. Smokers are the group most likely to contract Legionnaires’ disease or other significant chest infection, and there are many countries where smoking in public places is illegal. Overweight people (with a Body Mass Index, BMI, over 30) are at higher risk of heat exhaustion and blood clots. Underweight people (BMI less than 18) may not weather a bout of travelers’ diarrhea well. Women whose monthly periods have stopped because they are underweight should take medical advice before undertaking extended trips to resource-poor regions. Backpackers and independent travelers also have a high share of problems. A survey by the UK Foreign Office found that one-third of British independent travelers experienced a “major problem” for which they sought help from an embassy: of these, 20% were ill but had no travel health insurance. About a third of skiers and snowboarders travel with no insurance.

Try to sort out any recurrent medical problems well before departure, as an exotic trip can make them a lot worse. Also be aware that previous injuries leave a joint susceptible to a new sprain. Once you are pain-free after any lower-leg injury, it is good to practice single-leg balancing. After any sprain or wrench, the brain switches off proprioception, meaning that when you plant your foot when taking a stride, you do not have a precise feel for its position. However, balancing on one leg reconnects that sense. Aim for a target of single-leg balancing for 30 seconds and when you can do that, try with your eyes closed. Revise any other rehab exercises you were supposed to be doing, and pack sports supports/braces if you have a vulnerable knee or ankle.

TEETH

Have a pre-trip dental checkup. Dentists may not charge much abroad, but the standard of treatment is variable, and if equipment sterilization is deficient, there is a risk of hepatitis B or HIV. Stones in rice and lentils often cause dental trouble, so consider taking temporary fillings or a dental “first aid kit,” especially if you already have a lot of fillings; travel clinics often sell them. Meat in the non-industrialized world may be very stringy, so pack dental floss too; you should floss daily wherever you are in any case. A tip for travelers who have lost their luggage: salt is a good substitute for toothpaste, although, of course if you swallow rather than rinse-andspit, it’ll make you nauseous.

EAR AND SINUS PROBLEMS

Those with active middle ear or sinus congestion or infection, or severe hay fever, may suffer from a great deal of pain if they fly. Anyone suffering from a middle ear infection (otitis media) should delay flying until they have taken at least 36 hours (several doses) of a course of an appropriate antibiotic. Anyone who has had an operation on the inner ear should avoid flying for two months. Wait 10–14 days before flying after a tonsillectomy or any operation on the middle ear.

EYES

Conjunctivitis is common on tropical trips, and contact lens wearers should travel with a pair of glasses so that they can manage without lenses in case of infection. Those with a cataract should pack a baseball cap to cut down glare. During surgery for a retinal detachment, a gas bubble is often injected into the eye, and it is necessary to wait for this to be reabsorbed before flying; the wait is two weeks if sulfahexafluoride or six weeks if perfluoropropane gas was used. Surgery for cataracts or corneal laser surgery is not influenced by air travel, but wait a week after any penetrating injury to the eye. Check with your eye doctor. Always travel with a spare pair of glasses and your glasses prescription.

RECENT SURGERY, SERIOUS ILLNESS, AND FRACTURES

If you have just had an operation, ask your surgeon when it is all right for you to travel. Most doctors will say that you should wait at least a week before flying. If you fly soon after laparoscopy you may feel very uncomfortable, as gas left in the abdomen expands by about 30% in low cabin pressures; this expansion can also stretch a surgical scar if you fly within 10 days of an abdominal operation. After an operation in the chest, wait at least three weeks before flying. Air travel should also be delayed for three weeks after significant bleeding from a stomach or duodenal ulcer, since pressure changes can stimulate another bleed, which could be life-threatening. People with colostomies may find that they produce more waste during a flight, so they should use a large bag and also travel with extra in their carry-on luggage. After a leg fracture, flying is not advised for 48 hours because of the risk of swelling within the cast; however, back-slabs and casts that are split in two are designed to allow for swelling. If there is a full-length or above-knee cast, or if the leg needs to be kept raised up, it may be necessary to travel first class or to buy tickets for two seats. Fractures or other significant injuries or operations on the leg, including to varicose veins, carry an increased risk of blood clots. Some kinds of surgery also increase the risk of a clot (see “DVT and Flying,” here; also see “Fit to fly?” box, here). Anyone with their jaw wired after a fracture should either be accompanied by an escort with wire cutters or with some means of self-activating quick release in case of vomiting.

PEOPLE WITH MOBILITY PROBLEMS

Whether mobility problems are temporary or permanent, the biggest challenge, especially during flight, is likely to be the toilet; airline facilities can be very difficult and travelers usually need to be able to manage alone (see also “Tips for wheelchair travelers” box, here).

Resources and further information: ACCESSIBLE TRAVEL

Society for Accessible Travel and Hospitality, www.sath.org/disability-travel-websites

Access-Able Travel, www.accessibleurope.com

Access Africa: Safaris for People with Limited Mobility, by Gordon Rattray, Bradt Travel Guides, 2009.

Medicines

02

What to Pack

Dressings and bandages

Carrying hypodermic syringes

Thermometers

Sharp Objects

Taking Medicines Abroad

Beware of injections, drips, and “strong” medicines

Useful Medicines

Painkillers

Antibiotics

Mixing them

Reasons for Not Taking Medicines

Blood Transfusions

Summary

• Medicines are widely available the world over. City pharmacies are likely to be better stocked than those in small towns.

• Some medicines that can be purchased without a prescription in the US need a doctor’s script in Europe, and vice versa.

• Most remedies and many antibiotics are available over the counter in southern Europe, Asia, Africa, and South America.

• Medicines that have been banned in the West are sometimes sold in low-income countries.

• Counterfeit medicines are on offer in some tropical countries. Be especially careful in Asia and West Africa. Buy properly packaged tablets made by drug companies whose names you recognize and reject packets with spelling mistakes.

• Take medical advice from a doctor where you can.

• Know which medicines upset you and find out their generic names as well as their chemical cousins. Trade names vary.

• Only self-medicate if you understand what you are taking and are aware of potential side effects and disadvantages of the preparation.

• Check what you are taking. In many regions, combinations of medicines are the norm, and you may get more than you bargained for.

• New formulations and some contraceptive pills may be hard to find in some destinations.

• Palatable preparations for children can be difficult to find. Pack Calpol (paracetamol suspension) or soluble acetaminophen (Tylenol).

What to Pack

People everywhere have health needs, so generally the right medications or a reasonable substitute can be found overseas. I carry less and less on my trips, although good dressings always come in handy. A list of what I consider a fairly comprehensive kit can be found on here, although some destinations may have better products on offer than at home.

If you wish to take a complete medical kit because you are going on a major expedition, seek professional advice. There are plenty of seminars on expedition planning, medicine, and independent travel. You may also buy custom-made medical kits from travel stores. Many organized tours and treks carry a comprehensive medical kit, so you need carry less medical clutter of your own.

Sharp objects in your hand luggage may be confiscated at airport security. Put tweezers, nail files, razor blades, and needles in your checked baggage.

Dressings and bandages

If you plan to do anything remotely athletic, adventurous, or dangerous, shop around for good dressings and bandages. In particular, people with recurrent tendencies to injure a particular body part should pack supports/ braces for their weak joint; these are available in pharmacies and take up very little room. Even better, see a physiotherapist for strengthening exercises and sort the problem once and for all.

For most wrenches and sprains, a simple crêpe or rayon/elastic bandage is excellent and is also perfect for first aid after a snakebite. Hydrocolloid dressings are great for healing blisters; they stay on until the blister heals. A condom filled with ice makes a good emergency cool-pack to be placed on swollen, painful joints or even piles.

Carrying hypodermic syringes

If you carry a lot of medical supplies and/ or your own needles (see here), remember that some countries, notably Malaysia, will assume you are a drug addict unless the syringes are part of a medical kit and/or you have a medical certificate. Diabetics and other legitimate syringe- and needle-users should carry an official-looking, rubber stamped doctor’s letter, ideally in English and the relevant local language(s), especially if traveling to a country where bureaucracy is complex.

Thermometers

Mercury-filled thermometers haven’t been allowed on aircraft for many years, and European regulations now forbid their use on the ground too. There are various electronic alternatives. The in-ear versions are accurate, if somewhat bulky. Another alternative is a single-use clinical thermometer; it can be used several times or for several people if cleaned adequately, but they are so cheap, small, and light, that each person could carry his or her own. They read from 96°F to 105°F (35.5°C–40.5°C) in 60 seconds when placed under the tongue or in three minutes when under the arm. Forehead strips are inaccurate and unreliable and shouldn’t be used.

Sharp Objects

Sharp objects are not permitted in carry-on luggage on board the plane and may be confiscated at the airport. They should be packed in your checked bags. Such objects include tweezers, most scissors, penknives, Swisscards, nail files, metal cutlery, corkscrews, and hypodermics (put your first aid kit in your checked bags). At present nail clippers and cuticle scissors and disposable razors are generally allowed, but airlines vary. Flammable materials (obviously), toy guns, catapults, knitting needles, and darts are banned from carry-on baggage. Cattle prods also have to go into checked-in luggage. Rules vary with time and airline, so read any instructions before check-in and follow them to the letter. That way you will be more likely to retain your belongings.

Contents of a first aid kit

Some travelers opt to put together their own first aid kit, so here is a comprehensive list of all possible contents for readers to consider and pick over. Most people need to carry considerably less. Asterisked (*) items are those that are scarce or difficult to come by abroad or may be of poor quality. Some destinations will, of course, have better products on offer than at home.

• *Antimalarial tablets—Paludrine is never available abroad.

• *Insect repellent, DEET-based; sticks or roll-ons are least messy.

• *Sunscreen and lip screen.

•Soluble acetaminophen/paracetamol (Tylenol, Panadol) or ibuprofen. Soluble tablets can be gargled when the throat is sore.

• A strongish painkiller containing codeine. Opiate painkillers (co-codamol and codeine phosphate) also calm abdominal cramps in severe diarrhea. Mixes of codeine and acetaminophen/paracetamol (Tylenol) are also good. Prescription-only Tramadol may also help. All cause constipation. Some countries demand a doctor’s letter to import codeine even for personal use.

• Sore-throat lozenges.

•Heavy moisturizer (e.g., white soft paraffin, petroleum jelly, or Vaseline).

•Oral rehydration packets or a *measuring spoon to make sugar and salt rehydration solution.

•Anusol or Sudocrem—bum cream especially if prone to piles.

• Drying antiseptic of your choice (see here).

• An antifungal cream such as Daktarin (miconazole) or Canesten (clotrimazole).

• *Calamine lotion or After Bite.

•Crêpe bandage and safety pins.

• *Band-Aids (plasters) (which stick and stay stuck when you sweat).

• *Nonstick dressings (e.g., Melolin).

• *Micropore tape to stick on dressings or to tape sore eyes closed.

• *Steri-strips or butterfly closures.

•Cotton buds for removing grit from the eye (ten is plenty; see here).

• *Dental first aid kit or temporary fillings if over the age of 50.

•Dental floss.

•Antihistamine tablets:cetirizine (e.g., Zirtek), loratadine (e.g., Clarityn), or less good is diphenhydramine (e.g., Benadryl).

•Fine-pointed tweezers for removing splinters and coral. Pack in checked luggage.

•Scissors. Pack in checked luggage.

•Artery forceps. Useful for pulling out thorns, clamping off spurting arteries, repairing tents, and removing fishhooks from people—and fish.

•Paperclip for releasing blood under a nail (see here).

• *Condoms and contraceptive pills.

• A flashlight (torch).

Extra first aid items for some particular conditions

•Thermometer: if traveling with medicines for self-treatment of malaria.

•Mouth ulcer gel (*Bonjela or Teejel): for travelers taking Paludrine or Malarone.

•Low-reading thermometer and space blanket: if going to cold places.

•Steroid ointment (e.g., 1% hydrocortisone or Eumovate): if you have eczema or your skin erupts badly when stung.

• *Aciclovir (acyclovir, Zovirax) cream: if a cold-sore sufferer.

•Adrenaline (epinephrine) injection (0.5% or 0.1% or 1:1,000): if allergic to stings, nuts, etc. (see here).

• Two different courses of antibiotics: if going somewhere remote.

•Acetaminophen/paracetamol (Calpol, Panadol, Tylenol) or ibuprofen syrup*: if traveling with children.

• An anti-motion sickness preparation (see here).

• A fine-toothed louse comb: if traveling with children.

Resources and further information: WHAT TO TAKE

Health Books International (formerly TALC), www.healthbooksinternational.org. For disposable thermometers and rehydration measuring spoons.

Taking Medicines Abroad

Some resource-poor countries lack adequate policies to control the use of medicines. This means it is sometimes possible to buy unsuitable, poor-quality, or even dangerous preparations over the counter. Buying medicines abroad is also confusing, as many trade names are very different from those you know at home. Try to note generic names (in italics throughout this book). Most drugs have at least two names: the trade name (snappy and memorable but often different in different countries) and the generic name (usually in much smaller print on the packet), which should be similar everywhere.

The next challenge is finding out what is available. Pharmacists may say that a drug does not exist, when what they mean is that they simply don’t have it and would rather sell you something they do have. On the other hand, some medicines, even common and very useful ones, are just not available in some countries. Pills containing medicinal combinations are best avoided, unless you have already been prescribed it by a doctor you trust. When buying medicines, check that the generic name is correct and that the expiration date hasn’t passed. Also make sure that you will take the correct dose at the correct frequency by checking the packet insert.

Very few out-of-date tablets are dangerous (an exception is tetracycline, which degrades into toxic products), but even out-of-date aspirin is likely to be ineffective. Syrups and liquids have a shorter shelf life than dry medicines, especially in hot climates, so opt for tablets if you can. When taking antibiotics, complete the course.

Buying medicines abroad: checklist

Before you buy, check that:

• The generic name is correct.

• The preparation contains only one medicine.

• The expiration/expiry date is still in the future.

• There are no misspellings on the packet.

What to avoid

• Do not take tablets containing steroids or corticosteroids unless prescribed by a doctor you trust.

• Try to avoid injections. If in a resource-poor region and an injection is needed, provide or buy your own syringe.

• Do not buy or use medicines that are more than a year out of date.

• Try to avoid taking others’ medicines.

• Never take chloramphenicol (called Chloromycetin, Catilan, Enteromycetin) except as eye drops or ear drops. It should only be used internally during hospital treatment.

• Enterovioform was banned long ago as a dangerous cure for diarrhea; avoid it.

• ”Mexican aspirin” or dipyrone, a “strong” kind of aspirin, is dangerous; avoid it.

• Avoid taking Mesulid, aka nimesulide, a painkiller available in Greece, India, and elsewhere (see here).

• Women trying to conceive should be wary of taking medicines. Some drugs are dangerous in pregnancy, especially in the first three months; take expert advice.

Most medicines you buy in North America, the UK, Europe, and Australasia will be of acceptable quality, but some medicines beyond our shores are made to poor specifications. Manufacturing standards are known to be patchy in Nigeria and Thailand, for example. Try to buy pills made by local branches of international drug companies, or, in Nepal, by the national drug company, Nepal Drugs Ltd. Spelling mistakes on packets sometimes betray counterfeit tablets.

Beware of injections, drips, and “strong” medicines

In all Asian countries in which I have worked, people like the powerful placebo effect of a hypodermic. I have seen Afghan and Nepali medics giving intravenous saline infusions to treat weakness, but in such small quantities that even if the patient was dehydrated it would not have helped. This treatment is considered very “strong,” earning paramedics high prestige. It can be dangerous to have unnecessary injections, though. There is a risk of abscess or infection from dirty needles and serious allergic reactions are more likely when medicines are given by hypodermic. In addition, serious reactions are more likely if the remedy is suspect: there were deaths in China, for example, after Siberian ginseng injections, which are claimed to treat thrombosis, weak liver and kidneys, coronary heart disease, and menstrual problems. Before accepting any proffered injection, ask if the medicine is available in tablet form. Unsterilized needles, including those for acupuncture, body piercing, and tattooing can give you hepatitis B or HIV. Beware.

Useful Medicines

Painkillers

Acetaminophen (which is the same as paracetamol) (Tylenol), or ibuprofen, a nonsteroidal anti-inflammatory (NSAI) medicine, are good painkillers which reduce inflammation and swelling, and control fever. Ibuprofen is especially good for treating aches and pains, sprains, strains, wrenches, and breaks, though this can cause indigestion and some people with asthma may wheeze on taking it. If ibuprofen (e.g., Motrin, Nuprin, Advil in the US; Nurofen in the UK) isn’t strong enough, move on to naproxen (e.g., Anaprox in the US; Naprosyn in the UK) or diclofenac (e.g., Voltarol). If you notice indigestion or nausea while taking these, stop and use a combination of codeine and acetaminophen/ paracetamol instead. The prime side effect of codeine, DF118, Distalgesic, and other opiate painkillers is constipation; they are also rather sedating.

Aspirin (acetylsalicylic acid) is also a good painkiller which reduces inflammation and fever. Those with stomach ulcers or a lot of indigestion should avoid it. Nor should aspirin be given to children under 16.

Avoid “Mexican aspirin,” dipyrone, which is sold as a “stronger” variety of aspirin but which can cause agranulocytosis: a fatal AIDS-like condition. The NSAI Mesulid/ nimesulide