With the help of my new iPad, I have put together a collage of the smiles that I have collected and still remember from more than thirty years of travelling. I hope you enjoy the pictures … and the music.

Mark

Hey Mark, it’s (shall remain nameless!)

I have a question. I’m in Tanzania and taking Doxycycline 100mg for the
prevention of malaria. I think I’m having one of the rare side
effects that it lists. Something about ulcers or aggravation of the esophagus.
Basically it feels like I’ve got acid reflux every night. My stomach is always
bloated, I’ve got a pain in the upper part of my stomach  and I’m burping
constantly. Is it dangerous that I continue using it?

All of my patients, whether they are travelling or not, ask me “Do these pills have any side effects?” My answer is always the same, “Yes, all pills have POTENTIAL side effects. Most people don’t have most of them most of the time, especially if they take the medication properly. But here are the common side effects that you should know about .”

Let’s talk about the common side effects of antimalarials, since many of you will be taking one.

Firstly, doxycycline, the one mentioned above. It is an excellent antimalarial in that it is effective everywhere, it is inexpensive, and if taken properly, that is, WITH LOTS OF WATER WHILE UPRIGHT DURING THE DAY, it is usually well tolerated. If this precaution is not adhered to, then a “malignant” heartburn might ensue. I have had other e-mails and frantic “mother calls” from travellers about to undergo gastroscopy in the middle of Africa to try and figure out their chest pains! Other common side effects – photosensitivity, or, you might burn to a crisp if you don’t cover up and wear sunscreen, and yeast infections in women. For the latter group of travellers, take along some some curative treatment such as Diflucan or Monistat and take all the probiotics or yoghurt that you want.

Malarone (proguanil/atovaquone) is allegedly free of adverse effects, aside from the fact that it costs at least 5 bucks a pill. This is not the case (the side effects part). Gastrointestinal upset, or abdominal pains, nausea and diarrhea may occur in a small number of patients. Take it with a big meal! When travelling in Bangladesh, it may be difficult to know whether to blame the Malarone or your street food! Weird dreams, supposedly the domain of mefloquine (Lariam), is also reported frequently by those on Malarone. While I haven’t done a scientific study, these dreams seem less bizarre and disturbing than what one can achieve of mefloquine! Finally mouth ulcers are uncommon, but do occur, and perhaps more frequently in kids with braces. This is an old, well-known side effect of the proguanil component.

Finally mefloquine or Lariam. If ever there was a pill with neat side effects, this is it! The more benign side effects incluse gastrointestinal side effects – nausea, diarrhea – and dizziness and insomnia. The most common complaints are the dreams – They were really scary! Spiders crawling up my face and stuff. I feel like I was awake during the dream! They were exotic! They were erotic! These VIVID dreams are usually tolerable. What may not be is the anxiety, depression, paranoia or edginess that occurs in up to 15% of patients, especially young women. So, with respect to mefloquine, it is a good choice of antimalarial in that it is cheap and easy to take. Those who have tolerated it well in the past will hopefully do so again. But in spite of years of prescribing it, I am now hesitant to use it in young people (it is usually fine with “kids”), those with adverse effects in the past, those who have concerns about its adverse effects, and those who can afford Malarone or are willing to take doxycycline. Certainly those with a history of anxiety, depression or psychosis should not be touching mefloquine with the proverbial ten foot pole! If you do take mefloquine, take it with lots of food and water, and not with much more than one glass of wine or bottle of beer!

Chloroquine is a good, effective and cheap antimalarial. Unfortunately, its effectiveness is limited to rural Central America, Haiti, and rural parts of the Middle East – not alot of people going there! It is bitter, and may, in fact, cause some of the same neuropsychiatric side efffects as mefloquine, so it may not be for everyone. It can be dangerous in kids if the recommended dosage is exceeded. Keep safely away from kids.

With respect too this week’s frantic e-maiiler … I told him how to take doxycycline, suggested he use antacids or meds such as ranitidine or omeprazole, and if that didn’t work, change antimalarials.

On another note, if you like reading … and Cuba … consider the novel, The Beggar’s Opera, by Peggy Blair, and/or Bacardi: and the Long Fight for Cuba by Tom Gjelten.

Family Day in Canada this Monday. Enjoy yours.

Mark

Just back from a week in Cuba with my son Michael. No diarrhea, jet lag, STIs, dengue or anything else of note. So here are Ten Things To Do In Cuba.

1. Walk around Havana, or Habana …especially Old Havana, or Habana Viejo. It is full of life, colour, music and smells.

2. Try a mojito – lime, mint, sugar, rum and soda. They vary in quality from place to place, with each bartender claiming that theirs is the best.
3. Take a local form of transportation – an old ’51 Chevy. a horsedrawn carriage, a bike-rickshaw or a horse.

4. Go to the baseball game. Baseball is Cuba’s national sport. We went out to the Estadio Latinoamericano to see the team from Matanzas play the Metropolitanos of Havana. Really good baseball. Better than the Blue Jays, and a helluva lot cheaper.

5. Go to the beach … Varadero or wherever. We didn’t do that on this trip, but I have in the past.

6. Go to the Museo de la Revolucion, and learn about the history of this fascinating island…. Marti, Che, Fidel and Raul, Capone, the Bay of Pigs, the Cuban Missile Crisis and much more.

7. Visit Vinales – two hours to the west of Havana – scenery to die for. There, if you want to work off some calories from your mohitos and black bean soup, you can hike and bike, cave and horseback ride. Much calmer than Havana with friendly B and Bs to enjoy.

8. Attend Shabbat services at the synagogue or visit the local cathedral. We took down a suitcase of asthma and ulcer medication for distribution to the local community. While their medical system is free and allegedly excellent, there is a distinct lack of medications available in the local pharmacies. You don’t have to be Jewish! Anything you can take down – medications, pencils, soap, etc. is greatly appreciated by the Cubans.

9.Go to Coppelia in Havana for ice cream.This is an entire park devoted to the love of ice cream.While I would love to say it was the best ice cream I have ever tasted, that was not the case. But a great outing nonetheless.

10. Enjoy the music and the people. Light up a cigar. You don’t have to visit The Tropicana or The Buena Vista Social Club. There is music on every corner and in every restaurant and bar and on every taxi radio.

The local people are friendly and helpful. Yes, they would appreciate your business, because they are generally poor as well.

The news is just starting to seep in about a few planeloads returning from Cuba, Holguin to be more specific, full of sunburned Canadians with vomiting and diarrhea. While this story would always be of interest to me, it is even more exciting as I take off for Cuba with my son, Michael, of The Midway State, on Thursday.

It is not yet clear what the cause of this sudden surge in Traveller’s Diarrhea is from, though it might be clearer after some local or Canadian investigation and dozens of stool samples. But there are many possibilities …

Perhaps this group of Canucks was even more careless about the usual “Boil it, bottle it, peel it, cook it … or forget it” precautions that we generally recommend. Tourists at all-inclusive resorts tend to ignore the advice because they have already paid for their food and beverages, the resort has 5 stars, or because they don’t see anyone else getting sick (they are all in the bathroom!).

Maybe the resorts in question had a particularly contaminated shipment of fruit, vegetables, juice or ice.

Perhaps a local Cuban with poor hygiene was doing the cooking at all of the implicated resorts.

Maybe the airline was serving infectious mohitos at the airport.

In any case, it might take some time before we know the actual cause of today’s headlines.

So what can tourists do to prevent standing inline at the can on their return flight? Firstly, stick to the above mentioned precautions. Dukoral, the oral vaccine against E. coli provides moderate (30-40%) protection against Traveller’s Diarrhea. We do not know whether this current “outbreak” is due to E. coli. or another infectious agent. Carrying some loperamide (Imodium) and an antibiotic such as Cipro or Zithromax might also come in handy for self-treatment, as the majority of cases of Traveller’s Diarrhea are cause by susceptible bacteria.

Diarrhea can certainly ruin a holiday or a flight home from the tropics. While generally just uncomfortable and an inconvenience, the young, the elderly and those with underlying medical problems might be more prone to develop serious disease and even death.

Should Canadians stop going to Cuba? Absolutely not! This will be my third visit, and in spite of the current news, I still intend to have a mohito exactly where Hemingway had his!

But then a luxury cruise ship runs aground near Italy. Several people were killed and many were injured. They are still searching for survivors. So who am I to say what constitutes risky behaviour when travelling. I will leave that up to each individual traveller to decide.

Now for the shameless promotion …. a new website, SpringTern, where young and not so young skilled people can earn much needed experience even before they have a fulltime job, which isn’t so easy to find these days. By providing their skills, they gain experience, they might add something to their resume, and they might ingratiate themselves with a company that can use them on a regular basis. For the company on the receiving end, most likely a smaller one or a non-profit, they gain the benefit of some pro bono work, hopefully well done, and likewise, the chance to rub shoulders with enthusiastic and talented wannabee members of the work force.

My son Benjamin is the co-founder of SpringTern. He spent a year volunteering in Ghana several years ago, where he honed his humanitarian skills. After graduating from the Ivey School of Business and being in the workforce, he has also honed his business skills. SpringTern provides him with the opportunity to mix both worlds. If you are an individual looking to get some experience, or a company looking for some inexpensive expertise, give SpringTern a look!