A Traveler's Tales of Tummy Troubles

Betty the Bat made another circle through the latrine, this time dipping a wing in friendly recognition (or so I imagined).  I had been there four times already and the night was still young. The open-pit latrine was down a walkway lit by kerosene lamps, the smell of which brings a touch of nausea to this day. Another smell that haunts me is the disinfectant/deodorizer the lodge used in the latrine, because this night effluvia was coming out both ends of me, meaning at times my head was disturbingly close to the source of the odor.  The latrine was about 100 feet from the rooms in our lodge on the Amazon River in Peru, where earlier in the day we had arrived for a few days of exploring flora and fauna of the jungle.  In the afternoon we had gone fishing for piranha and the chef had prepared them for us to taste at dinner.  I, however, never got that far -- before I could take my first bite my intestines told me in no uncertain terms to make that first trip to the latrine.  Probably something I ate for lunch, but it was never clear. Whatever the exact cause, after a day in a hammock watching the Amazon flow by (while my wife had a great adventure trekking through the jungle),  I rejoined the living.

Over the 40+ years my wife and I have been traveling, we have both had a number of incidences of traveler's tummy troubles. When we relate stories like the one above to other people (usually in a bout of "competitive complaining") they often assume our intestinal problems occur more often in third-world countries and exotic locales within them.  Actually, our experience doesn't offer strong support for this.  A counter example to my upchucking along the Amazon occurred recently in Sweden, undoubtedly one of the most developed, squeaky clean places on the planet.  In this case some "Toast Scoggen" cleaned me out better than a colonoscopy prep. On the other hand, a trip to Zambia, Africa a few years ago included a meal cooked for us by local village women in open pots on the ground  -- no problems at all. And yes, it happens in the good old USA.  I once ran back to our motel after dinner at a restaurant in Maine, nearly leaving a trail of DNA as I went. 

Timid travelers also assume that if they stick to eating in upscale places they will be less likely to encounter problems.  Again, not our experience.  Many years ago I remember having lunch at the very posh Acapulco Princess hotel and then waiting outside a bathroom shortly afterwards for my wife's bipolar evacuation of it.  On the same trip, however, we ate a fish dinner at a local beach restaurant, selected from several as being the most upscale and clean-looking.  But as we left we discovered the food had actually come from the restaurant next door, prepared in a tiny shack where cockroaches seemed to be the dishwashing staff.  No intestinal distress at all.

Another of our observations is that there are definitely individual differences in susceptibility -- some people are just plain more prone to traveler's tummy than others.  Many years ago my wife and I started sharing our food in restaurants -- two or more dishes which we split between us. Since then we have discovered that even when exposed to exactly same food we have different intestinal reactions.  Perhaps the first time this was apparent was on our first trip to France, where I spent a good portion of time in the bathroom but my wife never had any problems. On this trip I did a very good imitation of a Bulimic, because even though I was sick a lot I kept on eating because the food was so good.  We later figured out that part of the difficulty was that in those days my stomach was pre-loaded with a high amount of acid from many cups of coffee, vitamin C supplements, and routine ingestion of aspirin for various aches and pains. Mixing all that acid with rather rich food was like a recipe for a volcano science project.  After cutting down on the supplemental acid, the next trip to France was much more pleasant, though far more fattening.

Although my problems in France were likely due to stomach acid, the most common cause of traveler stomach troubles is exposure to microbes.  About 80% of all cases are caused by bacteria of several kinds (mostly of the E. coli variety) and 10% or so by viruses (like the infamous Norovirus) and various protozoa (see Wikipedia). According to the CDC, intestinal problems are the most common travel affliction (other than walletus depletiosis) hitting 30-70% of all travelers, usually within the first week or so of their trip.  Although visitors to developing countries are at higher risk, all destinations have a significant risk level, even the most highly developed (as my personal experience attests).  Also, travelers from developed countries get sick more often than those from developing regions (Medicinet), and all visitors have a higher incidence than locals because the residents have developed resistance to the most common pathogens (Wikipedia) . Note, this often makes terms for traveler's tummy troubles like "Montezuma's Revenge" rather appropriate -- it is payback for germs invaders brought from Europe that infected the natives who had no natural immunity.

Traveler's intestinal problems nearly always last only a few days and go away on their own, though many people like to take antibiotics and anti-motility drugs like Lomotil.  (I love the double meaning of "anti-motility").  These treatments have their downsides, however.  Popping antibiotics may kill the offending bad microbes but it will also kill the beneficial ones that live in your gut and help protect you from other kinds of infections (see How About a Fecal Transplant?, Microbes for Breakfast!, and Fabulous Synthetic Poop!).  And male geezers with prostrate problems should be wary of the side effects of some anti-motility medications -- you may become plugged up in more ways than you wish (I speak from experience on this one).

So, is there any way to prevent this unpleasantness?  Being very careful in what you eat and drink is certainly good advice, but as the CDC notes, "Traditionally, it was thought that TD [Traveler's Diarrhea] could be prevented by following simple recommendations such as 'boil it, cook it, peel it, or forget it,' but studies have found that people who follow these rules may still become ill."  It is also the case that often a traveler can't follow these recommendations for practical reasons (like when traveling with a group or as a guest of a local resident).  The CDC is pretty blunt and realistic about this: "Although food and water precautions continue to be recommended, travelers may not always be able to adhere to the advice. Furthermore, many of the factors that ensure food safety, such as restaurant hygiene, are out of the traveler’s control."  My own experience, as illustrated by the examples above, is certainly in line with the CDC's conclusion -- being careful is prudent but hardly guarantees you won't still get sick at some point and predicting when or where is very difficult.

Besides trying to watch what you eat and drink, there is evidence that taking daily doses of bismuth subsalicylate, the active ingredient in Pepto Bismol, can cut the incidence of stomach illness by up to 50%. But there are a number of side effects and interactions that make its use questionable for many people:  "BSS commonly causes blackening of the tongue and stool and may cause nausea, constipation, and rarely tinnitus. BSS should be avoided by travelers with aspirin allergy, renal insufficiency, and gout and by those taking anticoagulants, probenecid, or methotrexate. In travelers taking aspirin or salicylates for other reasons, the use of BSS may result in salicylate toxicity" (CDC ). Sounds like the cure may be as bad as the problem. Likewise, preventative doses of antibiotics do seem to work, but they may lead to greater stomach problems down the road by encouraging bad microbes that are resistant to antibiotics and therefore very difficult to treat. Also, good microbes aid in digestion and help fight a wide range of diseases -- killing them may not be a very wise thing to do.  Speaking of good microbes, one preventative measure which seems to me like it should work is to ingest probiotics (like yogurt, kefir, and soft cheese), but so far the research is inconclusive (even so, I try to keep up my input of yogurt while traveling).

It seems to me we are left with two choices.  One is to buy some virtual reality goggles and experience travel electronically, without the messiness and risk of actually doing it. This certainly avoids traveler tummy troubles, but also removes some of the most rewarding aspects of real travel, like unplanned interactions with real people.  As you might guess, I heartily reject this option. The second is to accept that occasional tummy troubles are a small cost to pay for the life-enriching experiences that come from being exposed to cultures other than your own.  Traveling in total comfort and safety is not possible and even if it were, I don't think it would be desirable because the most beneficial aspects of travel involve a certain degree of challenge and adventure that can lead to surprisingly positive experiences.  Like making friends with Betty the Bat.