Eric's Beijing Diary

Diarrhea. It's not a pleasant subject, I know. But it is something people want and need to know about. I am not a doctor, but I have tried to become as informed as I can be about this condition, because it is such a common affliction when you travel in Western China. Of course, the best treatment is prevention, so I have several means I have used to try to encourage good digestion. First, I am pretty picky about starting the day with some kind of whole grain cereal. They say middle age is when you choose your cereal for the fiber, not the toy. But if that's true, I have been middle aged since I was in college. Here in Beijing, I buy Muesli that comes from Russia, and I also get some very good Australian oatmeal. Right now I am in the process of trying to develop a combination of whole grains that I can cook up myself, but I haven't put that together yet--I'll let you know if anything comes of it.

In addition to whole grain cereal, I buy good yoghurt. In China, yoghurt comes in liquid form, in contrast to America, where yoghurt is pretty much a desert item. But there are many places in China where it is not readily available. You walk into a store, and they will tell you they have it, but the stuff they give you is mostly some sweet stuff with a little bit of yoghurt in the background. It is sort of a yoghurt pop, except that it is not carbonated. But here in Beijing, you can get fresh yoghurt from Inner Mongolia (the dairy of China). It comes in plastic cartons about the size of a half-gallon, with the yoghurt cultures printed on the side. It's good stuff, and very healthy.

I should note, while I am at it, that milk is not nearly as common in China as it is in the United States. In China, the yoghurt I mentioned is found in the cooler at the supermarket, but milk is found in the aisles in envelope-like packages of various sizes. It is UHT (Ultra-high temperature processing) milk, like the old United Nations milk cans we used to see on the mission field. UHT milk is not popular in the US, because there is some discussion about the extent to which the UHT process affects the proteins. But in my opinion, it is good milk and it is not expensive, so even though it is not packaged for high consumption, you can buy as many envelopes as you want. For a single person, it is not a problem. But you do get a constant reminder that milk consumption is obviously much lower here than in the US.

The last thing is good fruit juice. That you have to look for. Most so called "juice" in China is not juice. In that respect, China is exactly like the US. You walk into a store and find various varieties of "juice drink," but when you read the fine print, you discover that it is not really juice, or that it contains 10% juice. But here in Beijing, they also have the real thing in big cartons. And it is very good. Orange juice, of course. But also apple juice, and very good peach juice, probably my favorite. (Beijing is famous for it's peaches.) I usually pour some fruit juice in a glass, then pour yoghurt in on top of it (important, of course, to pour the juice in first). I drink at least a glass of this every day.

OK, so much for prevention. The fact is that no matter how hard you work to prevent the above mentioned problem, it is very hard to travel for any length of time in Western China without being visited at least once by the malady. So sooner or later we need to come to the subject of treatment. Medical people like to say that diarrhea is a symptom, not a disease. At first, it looks like that is a meaningless distinction, but it turns out that the statement is useful in helping us to remember that the condition can have various causes, and therefore various treatments depending on those causes. If you read up on this condition on the Internet, you will discover that most sources divide the condition into two basic causes: virus and bacteria. So all the discussion revolves around how to treat a viral case as against a bacterial case. But there is a third cause that is not often mentioned, but which you are sure to run into if you stay in China long enough. This is the case of your stomach rejecting something just because it is so completely foreign to your system, like the pork-fat stew I ate in Yunnan Province on my first trip to China that gave me the runs. You don't have a virus, you have not been infected with bacteria, you have just managed to eat something that your digestive system cannot accept. It is almost as if your stomach says, "forget it; I'm not dealing with this," and shoves it right on through. I call it "fast food."

So now, how do you treat the various cases? The first problem is that there is no "one fits all" treatment for diarrhea. To treat the condition properly, you need to determine whether it is viral, or bacterial. Problem: That is just about impossible to do. But though it is very hard to be 100% accurate, there does seem to be a distinct difference between a bacterial case and a viral case, but it's not easy to explain. Actually, I know exactly how to explain it, but I really don't want to. Let me put it this way: In my experience, if the diarrhea you have seems to be characterized by massive quantities of water being dispensed from your system as opposed to just having a bit of a loose stomach, that is a good indication that your body is trying to flush some poison out of your system. When that happens to me, I start taking Cipro right away. And if your body really is flushing poison out of your system, it really isn't good to take Imodium (loperamide), because Imodium tends to inhibit this effect, and that's not good for you if you really do have an infection. But Imodium can be useful for alleviating mild cases of diarrhea, and is certainly much better than an antibiotic if you don't have a bacterial infection, since antibiotics are powerless against viral infections, and have no positive effect on the third case I mentioned. You really should not take antibiotics if you don't need them. I actually read one source that recommended taking 500mg of Cipro a day just in case you get a bacterial infection. That seems like a horrendous approach. Nevertheless, I would advise that you never travel in Western China without Cipro, because if you do need it, you will really wish you had it. I got a very bad case in 2004 that disappeared within a day after I started on Cipro. And last year (2005), I was in bed for two days with a high fever at a youth hostel in Urumqi. Really good thing I had the Cipro. A year and a half ago, I was teaching in Zhengzhou for a week, and I got what was clearly a case of infectious diarrhea. Stupid me, I had forgotten my Cipro at home. It was a long week. Although I hate to say this, because of the behavior it might engender, the situation has always improved when I took the antibiotic. Improved to the point of having no symptoms whatsoever after two days. But that does not prove that the drug was always the right treatment, because viral cases usually don't last more than two days anyway.

So what to do? Well, unfortunately, I don't have an easy solution for the problem of how to distinguish between the three various causes of diarrhea. But if it begins to look like something that is going to last awhile, you should definitely take the antibiotic. Or if, as mentioned earlier, it is characterized by massive loss of pure (I use the term loosely) water, then I would also take the medication. It might also be well to heed the advice of the Italian tourist I referred to when I was traveling, who cautioned everyone in his group about eating local yoghurt. Perhaps I should stop and say something about this. When you travel through minority communities in Western China, you will often confront local yoghurt. This stuff is not pasteurized or processed in a regular dairy. It is made locally. It is very thick. You don't drink it, you eat it with a spoon. And it is very, very sour. At Leisha's, they always put a bowl of sugar and/or honey on the table. But it is also very delicious. And very nutritious. But the guy from Italy is probably right. Local yoghurt contains local bacteria that could give you a case of the creeping crud if you are not from the local area, and thus have not built up antibodies. I usually eat it, because I like it, but also because I do live in China, and I want to develop the natural resistance to local bacteria that relieves one of the constant need to deal with this miserable condition we have been talking about. In Beijing, I have pretty much accomplished this. The first year I was here, I had a lot of stomach trouble. Not really severe stuff. Just a slow, persistent stomach rumble. Off and on for a long time. Especially as the seasons moved toward Spring and Summer. What should I do, take antibiotic for weeks and weeks? No. I just rode it out. By the second year, it had disappeared. I am hoping the same will happen in Western China. This is one of the main reasons I avoid taking antibiotics. It seems to me that if you are trying to build up resistance to local bacteria, the worst thing you could do is to take antibiotics. You have to let your body heal itself if you ever want to get to the point where local bacteria doesn't affect you. I am not there yet by any means, but I will say that this is the first time I was able to go through the entire summer without taking Cipro. But what about travelers who don't live in China? Well, you still don't want to rush to an antibiotic, especially if the condition you are suffering could be caused by something like that bear fat stew I had back when I was a short term traveler from the US. But I would probably be quicker to use the Cipro if I knew that I wasn't going to be here long enough to build up resistance to local bacteria. And as much as I love the stuff, I would probably avoid local yoghurt. The only other thing I would say about this, is that if your body is giving up more than a usual amount of water, it is very important to rehydrate. It is very rare to find a town in China that doesn't have Sprite. Drink plenty of it. And avoid guided tours, where your schedule is locked in. If you are feeling a little under the weather, it is really good if you have the flexibility in your schedule to lay low for a day or so.