A new book on Israeli travelers' risks of contracting tropical diseases on their travels.
By JUDY SIEGEL-ITZKOVICH
They go to have fun, make friends, discover the world, test their abilities and learn about themselves – and some come back unwell or even rushed to an Israeli hospital. Every year, hundreds of Israel backpackers – including some middle-aged adults – return from Third World “paradises” not only with memories and memorabilia but also with serious tropical diseases due to apathy, negligence or bad luck.An infectious diseases specialist and an educational psychologist teamed up to write a book, in Hebrew, about these travelers and the malaria, bilharzia, dengue fever, leishmaniasis and other potentially fatal diseases they pick up.One hopes they pack up and read the 248-page, softcover volume along with their maps and travel guides so they can stay healthy during their treks in the Far East, Africa and South America.Titled Nosaya Samui: Sipureihem Shel Nos’im Veshel Mahalot Tropiot Nilvot (A Hidden Traveler: Narratives of Travelers With Tropical Diseases), the NIS 78 book was written by Sheba Medical Center Prof. Eli Schwartz and Dr. Orna Schatz- Oppenheimer and published by Ramot-Tel Aviv University. It makes an interesting, often fascinating read as the authors combine their talents to provide a lot of laymen-friendly clinical information intertwined with personal stories of Israeli victims.The main aim of the book, they write in the introduction, is to explain the risks of catching unfamiliar diseases that even many Israeli doctors have never seen. “For those who intend to go on a journey or trek, worried parents of backpackers, medical staffers, company workers involved in the Third World and just those who are curious and enjoy reading – to all these, A Hidden Traveler opens a window” on the relatively new field of tropical medicine.MALARIA, which is derived from the Italian words mala aria (because it was thought “bad” or polluted air caused it), is still one of the most fatal diseases, killing about two million people a year. It was in Israel’s swampland too, and whole settlements were abandoned due to the toll taken by Anopheles mosquitoes carrying the plasmodium parasite and spreading the disease. But in 1966, the World Health Organization declared it eradicated in Israel; since then, it has been diagnosed only in Israelis and foreigners bringing it from abroad.There are three million types of mosquitoes in the world, they write, and 400 belong to the Anopheles family. About 25 of these can carry the parasite and transmit it to humans. The plasmodium parasite come in four types – ovale, malariae, vivax and falciparum, but the last two are responsible for 95 percent of all cases. Charles-Louis Alfonse Laveran, a French military doctor, first identified the parasite in 1880 in red blood cells of a malaria victim; 27 years later, he received the Nobel Prize for his achievement.The female Anopheles mosquito needs blood for the protein “meal” the eggs she lays can feed on. She sucks the blood through a hole in the victim’s skin, and if she carries plasmodium, two weeks later the first symptoms appear – a high fever, weakness, headache, chills and possible pain of the joints and lower limbs. As these symptoms are influenza-like, doctors may misdiagnose the problem as flu, especially if it occurs in the autumn/winter flu season, the authors note.IF UNTREATED or unsuccessfully treated, malaria can result in severe headaches, epileptic attacks, respiratory difficulties, kidney failure, loss of consciousness and then death. Only a specific blood test can confirm the diagnosis – and unfortunately, in far-off Third World countries, such a test is not readily available. It is more difficult to diagnose if the Ovale or Vivax parasite is involved, as it may show some symptoms, then “sleep” in the liver and awaken months later. This has produced misinformation among trekkers that malaria can be treated, only to reappear later, but there is no scientific basis to this, insists Schwartz.The first effective drug for treating malaria was identified by the Indians of Peru, who used the bark of a local tree – Cinchona or Chinchona – to treat it.The active ingredient in Peruvian bark is quinine. It was synthesized at the end of the 19th century and called quinidine and shown effective as an injected drug not only against malaria but also against irregular heartbeat after heart attacks. But as the parasite developed resistance to the drug, there has been a constant search for new, safe and effective ones. A drug called mefloquine (Lariam) developed by the US army and taken once a week has proven very efficient; it sometimes causes dizziness and stomach discomfort and should not be prescribed to people with neurological disease, especially epilepsy, or psychiatric problems. Two other malaria drugs are malarone and a Chinese concoction named sweet wormwood.When visiting places where malaria is endemic, one must also take pills to reduce the risk of infection, but they don’t prevent infection, as they hinder the parasite’s development and halt the disease. Many backpackers believe that the pills’ side effects are more unpleasant than the disease, but this is untrue, according to the book. No protective vaccination has been developed so far, as the parasite “knows how to escape” from the immune system. Thus the best prevention is wearing long-sleeved shirts and long trousers, using mosquito repellant and sleeping in rooms whose windows are screened (as the bugs bite at night).The authors include a chapter taken from a book produced by the Foreign Ministry about how successful malaria treatment at Sheba Medical Center of Isaias Afewerki, the president of Eritrea led to diplomatic relations with Israel.In 1993, Afewerki visited disease-infested parts of his country and took sick with malaria that reached his brain and put him into a coma. The Americans, fearful that Afewerki’s death would end the peace process with Ethiopia, pressed for hospitalization in Israel, despite Muslim countries’ opposition. He was flown to Sheba along with senior ministers and advisers; excellent treatment was provided, and he recovered fully, even chatting with then-foreign minister Shimon Peres. He was able to return home in an Israel Aircraft Industry jet, and liked it so much that he bought it on the spot. When he suffered a rare complication due to the severity of his illness, he returned to Israel for a checkup and was successfully treated. In May 1993, two months after his second visit, diplomatic relations between Eritrea and Israel were declared.MICHAL, a 30-year-old Israeli who took very ill with malaria in India, gives a frank interview while in an Israeli hospital. A graphic artist, she decided to leave her routine and trek with a boyfriend and alone. The patients’ personal stories are printed in italics, with the authors giving helpful commentary on the medical aspects.She had been away for many months and returned for her birthday, but spent it in an Israeli hospital feeling awful. She had diarrhea, ringing in her ears and low blood sugar in addition to the better-known symptoms of malaria.“I presume it will be much more difficult to return to India after I got sick there,” she says, “but it was an incredible experience and I’m sure I will return.What is clear is that one has to be very aware that the minute one’s temperature rises and one can still travel, get on a train or a plane or hire a jeep for NIS 600 or NIS 1,000 and get to a hospital... and not some clinic.”Drora, a divorced woman in her 50s, is not the typical Israeli trekker. She spends many months traveling alone, making friends with people her children’s age and dancing and doing meditation in ashrams. Suddenly she felt she was losing her strength, but though the number of red blood cells in her body had dropped, malaria was not diagnosed. She became so apathetic that her daughter had to fly in to take her home. Yellow from the decomposition of blood cells, she was covered up in the plane going home so as not to frighten other passengers. She could hardly breathe when she arrived at the hospital, and was immediately admitted to intensive care. Drora thought she was dying – but was not alarmed. Only when a friend visited her and demanded that she fight the disease did Drora decide to get well.An Israeli who lived in Angola buying raw diamonds from local dealers and living in a well-guarded villa got malaria for the fourth time, but the last was very severe, harming his kidneys. Even though he was hospitalized there, doctors didn’t know what type of parasite was involved and gave him drugs on a trial-and-error basis. Fortunately, he got back to Israel in time, and his kidney function recovered. But he decided not to live in Africa any more.Bilharzia is a tropical disease known scientifically as schistosomiasis, produced by the trematoda worm that lives in water polluted with human excrement.The worm, only 12 to 14 millimeters long, passes through the skin to internal organs. The eggs are eliminated in the urine and stool and, when they meet up with a certain type of snail, breed inside and are excreted. A month after they enter the human body, the victim develops a high fever as an allergic reaction to the worms. When eggs are released by the worms, the disease spreads, producing itching, burning and blood in the urine. Some patients are misdiagnosed with a tumor. The eggs can wander into the prostate in men and genitals of women, causing more problems. A drug called praziquantel (Biltricide) is recommended when the worms reach adulthood.Bilharzia existed here in the 1920s, apparently brought by pilgrims, Beduin and soldiers who came from Egypt. In some Arab villages, nearly everybody was infected. Just bathing in the Yarkon was enough to infect 170 pupils in 1928. But ironically, the heavy organic pollution that developed in the Yarkon killed off the snails, and the cycle of infection was halted. Eventually, it disappeared from the country, only to appear in Israeli travelers and foreigners.Tali, a 30-year-old student, went to Africa for over a year and picked up bilharzia while bathing in a Malawi lake. She retells her experiences as a single woman travelling to Uganda and other countries, with the local married women protecting her from macho males. Feeling unwell, she returned to Israel and suffered greatly. “It was really scary; I was weak and couldn’t do anything.”It took months until she was correctly diagnosed and treated by a tropical disease expert, who asked for photos and a full description of what she did during her travels. Finally, she recovered.Dengue fever is spread by Aedes aegypti mosquitoes, their bites causing high fever, joint and muscle pain and sever headache. It is common in the Caribbean, Far East and Latin America but less so in Africa. The import by the US and European countries of cheap tires from the Far East led to the mosquitoes’ “import” as they lived in their wet hollows. The most serious type of the disease is dengue hemorrhagic fever, which is often fatal. There is no vaccine or specific drug; people are given supportive care to recover.Leishmaniasis is spread by the bite of the sand fly and is common in the Middle East, known in Israel as the Rose of Jericho because of the rash. But other types affect not only the skin but rather internal organs, membranes and cartilage. Various drugs are available, depending on the type, but the body can sustain serious permanent damage.At the conclusion of the book, Schwartz and Schatz-Oppenheimer note that every year, some 100,000 Israelis visit Thailand and 50,000 go to India. Latin America is also popular, with 55,000 trekkers, and 20,000 more go to Africa.Poor hygienic conditions do not deter them.Israeli doctors who treat returning trekkers are frustrated by the fact that the supply of drugs is minimal as companies have to go through much red tape to be scientifically tested, approved and registered; in addition, “only” hundreds of Israelis a year need them. With an inadequate supply of drugs, treatment that would have taken only a few days drags on.As the Third World is brought closer by travelers, a change in thinking is required, the authors conclude. “From the personal stories we have presented in the book, it is clear that diseases that used to exist in far-off regions of the world are coming here quickly. This book exposes some hidden travelers’ diseases that have become visible guests in our home.”
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