Pincushion Day

I thought I'd try to get in the habit of writing a bit before my trip starts this time. This will also be a better chance to see if Blogger will do what I want. Don't worry, these updates will get more interesting once I'm really travelling again. Hopefully some will find the pre-travel frenzy worth a read, especially if you're considering travel to a similar part of the world. At least we'll all be able to look back and see how much my plans and preconceptions change.

You're going where?

As many of you are aware, I'm off to India in less than 3 weeks. I get asked "Why India?!" a lot, so here's an attempt at answering. I'd like to say a lot of thought went into deciding to go there, and I guess it did, but not much of it was conscious. It's certainly been high on my list of places to visit someday (which includes pretty much everywhere, eventually - even Bratislava), but here are a few specific reasons:

• It comes very highly recommended. Many of the travellers I met on previous trips (Australia, New Zealand, Middle East) were in the midst of a year+ round-the-world trek (something apparently commonly done before or after university in the UK). Those that had already been through India almost always said it was their favorite spot. When I'd try to pin them down on specifics, they'd get kind of a dreamy, far away look, but couldn't come up with anything tangible. Curiosity piqued.
  
• The only place that India sometimes came in 2nd to was Iran. Relatively few round-the-world travellers make it there (usually just those trying to motorcycle around the world, or something, who didn't have much choice but to pass through), but those who had always rated Iran higher. Despite having been to a few places some might consider unwise (notably Syria and Lebanon, in calmer times), I got cold feet about going to Iran. This was reinforced by news reports several months back about specific invasion plans being in progress. Though armed conflict now seems much less likely, I'd rather wait a couple years, and maybe combine it with a grander trek across Asia.
• Timing - both the time of year (just post-monsoon) and duration I thought I had available seemed about right for India. Taking 6-8 weeks of vacation/sabatical seemed like the most I could push for, but adequate to see enough of India to be worth the long journey. Before I bought tickets, I'd decided to leave my current employer, so stretched things as much as I could without missing Christmas.
• It's a classic Gateway Country. By this I mean, like they say about "gateway drugs", it gives you a taste, and helps prepare you for the hard core stuff. Though I've been to a few places that some consider 3rd world (a characterization I don't agree with, after visiting them), none of them required any extreme precautions, especially on the medical front. I've especially avoided going anywhere that malaria is endemic. However, since this is common in so many places I want to visit (and visit before I'm too old to easily explore them), it was time to take the plunge.
  
• When asked where I'm going next, I've been saying "maybe India, or maybe _" long enough that it was pretty clear I'd made up my mind on India.

Travel medicine

As even the mostly sloppily written guide to India makes clear, you really must be up to date on your shots well before you go (at least 4-6 weeks, most say). Not that I'm a hopeless procrastinator (OK, I am, but that's beside the point), I did at least attempt to solve this more than 20.5 days from taking off. It turns out my "primary care physician", the one brief doctor visit I've had since I started work 9 years ago, has moved to Boston. It also turns out that most insurance plans (including the PPO plan I had to drop dental/vision coverage to upgrade to) won't pay a dime towards vaccines for personal travel. It'll cost you $250 just to visit the waiting room at Stanford, if vaccines for tropical diseases are involved (and that's nothing compared to the cost of the shots). They also don't stock the full complement, and 3 or 4 doses are involved for some, so you're looking at a bunch of pricey visits.

After researching other options, including a doctor 2 blocks down my street that gets most of his referrals from immigration lawyers, I finally put my fate in Google's hands. It turns out I'm very lucky to live near San Francisco (OK, I knew that). The Department of Public Health there is supposedly the best (only?) spot in northern California that stocks every possible vaccine. They sell the vaccines at cost, even if you aren't a resident, and their nurses are probably more familiar with what you do and don't need than anyone around.

I was just blown away by how thorough and patient they were. My nurse spent over an hour talking with me first (they'd already entered my 5 page quesionaire into their computers the previous week, which resulted in a lengthy, current risk analysis). She knew far more than their computers, down to this week's death toll of encephalitis for each Indian state I'm likely to visit! I wished I'd had a tape recorder so I could send the transcript to Lonely Planet to replace their current Health chapter.

It was all about helping you make an informed choice, though. One example was rabies. "Here's another case where the CDC and the WHO see things completely differently." She went on to explain how the CDC insists that even the most minor scratch from an animal should be given a long, expensive, painful treatment. The WHO argues this is a bad idea - rabies requires a substantial bite that penetrates a lot of nerve tissue. Even where money is no issue, it doesn't make sense to treat in cases there's zero risk. That said, rabies is 100% lethal if you come down with it (except for a single survivor in the last several hundred years!), and India has by far the most cases, so you have to get treated quickly if you get a bad bite. She even warned what to look out for if they try to give you the "old treatment". "If they try to stick 8 needles in your stomach, get the hell out of there, and get to a real hospital in a bigger city." Apparently it should involve a shot to the wound, and a shot to the shoulder.

I ended up having shots for pretty much everything I could that's common in India. Some were rather pricey, but if I don't ever have to think about that disease again, it's a small price (like encephalitis requires 3 shots at $120 each!).

• Flu - it's always flu season there, and the current rationing to those over age 50 doesn't apply to travellers. Though I've never had this vaccine, I always mean to, even though I haven't come down with the flu in many years.
  
• Chicken Pox (Varicella) - Since I'm pretty sure I never had it (though they say over 70% of the people who "never had it" actually had a minor case of it without knowing it, but getting the test is more expensive than the vaccine). Again, outbreaks of that are pretty common year round in India. They don't happen in the US anymore, now that the chicken pox vaccine is mandatory for kids.
• Japanese encephalitis - There's apparently a big outbreak of that there now, and it's a vaccine that they think protects you for life. So, even though it's pretty expensive (see above), I went ahead with it. One less thing to worry about.
• Hepatitis A&B - Though I don't consider myself at risk for B, this one is apparently better for A as well, and only costs a little more than A by itself.
• Tetanus/Diphtheria - I'm pretty sure that's the only one I've had since I was a little kid, and that was before going to college, so I was due.
  
• Polio - Like many vaccines, the childhood polio one is only 80-90% effective by the time you grow up. This is plenty to prevent it from spreading in countries where everyone is vaccinated, but not good enough when going to the country with the largest remaining number of cases.
• Typhoid - Apparently the oral version is better and lasts more than twice as long. So, they gave me four of these to put in the fridge and take 1 every 2 days. They suggested waiting a few days to start, to make sure I didn't get complications from the others.
  

Ones I didn't get included:

• Rabies - India has far more rabies than anywhere. Even though it's very expensive ($510 total) and only lasts 3 years, they recommend it there if you're spending much time outside of cities. Unfortunately, there's no accelerated schedule for this one, and I was a day late getting there to get my 3 doses in time (and they won't do it unless you can get all 3 on time).
• Tuberculosis - Though India is again one of the hotbeds for this disease, it's actually pretty hard to catch, and the vaccine is only somewhat effective (about 70%, and only for a year or so). So unless I decided to spend a few weeks volunteering at one of Mother Theresa's charities in Calcutta, it doesn't make sense.
• Yellow Fever - This one is only needed if you're passing through (or trying to leave) somewhere with a Yellow Fever outbreak. Though it has an ideal climate for it, India is free of this one, and would like to stay that way. So, it's the one vaccination they check for at immigration there, but only if you've been somewhere that has it (parts of South America and Africa).

Malaria:
Most importantly, I got my prescription for Malarone, my first choice of anti-Malaria drugs. Fear of malaria has so far made me unwilling to visit areas where it's endemic, and it took me quite a bit of research to get comfortable with the idea. It's made worse by the anti-malaria drugs themselves - none are anywhere near 100% effective, and the common side effects of some seem almost worse than the disease (one causes constant nausia and headaches in 40% of those who take it, another is known for causing suicidal depression). Currently, there seem to be two options that have limited side effects and provide pretty good protection:

• Deoxycycline - a common antibiotic that is also good at preventing Malaria. Taking it also helps protect you against many types of food poisoning, and other bacterial infections. It's also pretty cheap. It has some of the downsides of being on antibiotics long term (upset stomach, easy sunburns, etc.), but in general pretty safe.
  
• Malarone - currently the most effective anti-malarial, it's also the most expensive ($5/day!). It's a combination of two different drugs, each of which is about as effective as the others, but together give you better protection.

Though a friend of mine had good luck with Deoxycycline when travelling in Africa, I decided to go for the best possible protection this time. I'm also not a big fan of taking antibiotics when there's nothing wrong with me (and thereby helping create more strains of antibiotic-resistant bacteria, as my microbiology prof pounded into us). If I end up spending more than a couple months in Malaria areas in the future, I'll probably go with the cheaper option, as Malarone is my single biggest daily expense for this trip.

At least I feel prepared now!