Crises, emergencies and health management

Crises, emergencies and health management

This section is concerned with risk management. It is chiefly addressed to foreign nationals, so Peruvian readers may prefer to look elsewhere. It helps you plan to avoid crises, and gives you some guidance as to what to do if something unfortunate does occur. However, as we discuss in more detail in the legal section, we cannot help you to foresee everything, and what we have suggested here will need to be modified by common sense if it is to be useful. We cannot be held responsible for your misfortunes whilst traveling.

Please do note that a section in infirmities and problems is going to sound very frightening. We are trying to give you a realistic perspective on the worst that could happen, and on what to do if it does. We are not telling you that it will happen. Perú has its problems, but its is safer than many countries in the industrial world. Its rules are different, and as a foreigner, you do not know them. This section is intended to help you avoid problems. The advice is largely common sense, but it is amazing how long it takes one to work it out for oneself.

Traveling in the country and trekking is generally an extremely safe activity when one is well-prepared, and one is far more likely to be hurt in the urban environment of an industrialised nation than when walking in the wilds in Perú. This said, the country is not without its hazards and it is sensible to be aware of these.

This is a long section, written in a form which you can print out. There are quite a number of external links to subsections of it. We have divided this text into four chapters, as follows:

  Avoiding difficulties through awareness
  Responding to crises
  Health management and acute medical problems
  Difficulties with local people

Many countries publish status reports for countries. For example, the US offers an excellent service on Consular Affairs Internet home page. This is helpful in monitoring whether there are civil disturbances of which you should be aware. Equally, most of the industrial countries publish health assessments of the country, which we treat below. There is a vast amount of information available on the net, much of which is obviously more current than this Guide. Our web site, which you can access through the menu on the left, contains links to a range of these sources.

Avoiding difficulties through awareness

The best approach to crisis management is, of course, to avoid having the crisis in the first place! This may sound obvious, but experienced travellers will know of many instances where people have set out without even the most minimal of preparation or forethought, and come into difficulties as a result. The UK Mountain Rescue service regularly pick up walkers who have set off into the Scottish hills in winter wearing the clothes that they put on for a drive in the country.

The fundamental risk in Perú has little to do with trekking or the countryside. It is the risk of theft and, to a much lower degree, the risk of personal violence. We discuss this in a separate section, but it is worth noting that any travel the wild parts of the country will involve visits to the towns, where the issues are much more acute. If you have back-packed and camped in Europe, Japan or North America, however, you will have a false sense of security that it is wise to question. Guides are not always benevolent, children who gambol around your tent may well have their eye on the layout of the interior with a night raid in mind, and handsome men (or women) who find you irresistibly attractive may have ulterior motives.

Perú has a great deal of involvement in narcotics. There is a substantial street trade, where the two sides of the deal are first, that they sell drugs to (or plant them on) tourists and second, that the make money by reporting this to the police. We discuss this in more detail below.

Theft is conditioned by the opportunity that you offer by carelessness with your belongings, by the time of day, by the location and the vulnerability and attractiveness which you present as a target. Lima and Cuzco are the prime tourist destinations, and so tourist-related crime is at its peak there. The smarter districts are largely safe by day, whilst the poorer areas (including the old city centre of Lima) are not. Night changes everything, and trips back from a Cuzco nightclub by a drunk tourist is very much more dangerous than the same trip by day. This is particularly true for single women.

Your vulnerability is also conditioned by how you present yourself. Frightened and lost solitary figures excite predators. Tourist who hang a year's local income around their neck in the shape of an expensive camera, for example, advertise their vulnerability. Wearing a personal stereo in public or brandishing a mobile telephone is to paint cross hairs on your back.

To look like a victim is to be a victim. There are basic rules to be followed. Look confident, and walk briskly to where you want to go. Avoid eye contact that you do not want, but look in the eyes of people with whom you choose to deal and speak loudly and with clear diction. If you loiter, do so with purpose and confidence. If people approach you, be cool and distant until you know what they want and then treat this on its merits.

You will be categorised by your dress, and you should dress more formally than you might wish. Flapping pastel shirts and baggy shorts mark you as a 'tourist victim' and tank tops and dirty jeans as a 'backpacker victim'. Combat fatigues, ethnic knitwear, ski wear and buttock revealing shorts excite assorted responses, none of which you will want to draw on yourself without thought. In particular, do not ever, ever dress up as Che Guevara or Party Girl on Holiday if you go into the wilder parts of the country. You will be taken literally. Read the history section to see what that can imply.

The ideal clothing for a man in a town is clean long trousers and a pressed long sleeved shirt. Shoes should be clean and functional: avoid sandals, flip flops or smelly trainers. Women should seek the equivalent, avoiding impractical garments or locally-purchased ethnic clothes. Male or female, you should also avoid overly bright colours. The image of yourself that you should be projecting is of someone of modest income but serious intent. Think "missionary". Think old money being careful. Think good manners.

The foregoing may sound repressive and dull, but it is the fruit of hard experience. Cultures differ in how they interpret the signals which people give off, and this recipe for Perú helps you to signal that you are not to be crossed, or not worth crossing. Pack your ego with your medicine, and take out both only when it is appropriate to do so.

Now let's turn to the reason why you bought this disk. How should you think about travel to wild places? There are four basic forms of preparation:

Common sense is anything but common. When we lack experience, we usually focus on the details and miss the larger picture. If the details tell us little then we become stressed and we tend to make stupid mistakes. The key to avoiding problems is to do things thoughtfully, with adequate time, the right level of resource and the necessary support and equipment.

Responding to crises

We discuss what you should do if you have problems involving conventional travel in the section "difficulties with local people." Health problems are discussed in the section which follows this. Here, we are concerned specifically at what you do if you have problems whilst in the wilds.

Perú has various kinds of evacuation service. The area around Huaraz, the centre of trekking, has helicopters on standby for evacuation. In addition, there is a health infrastructure which builds up from the most humble village to regional and national centres. Each has health workers who are capable of assessing their capability to manage a crisis, and a mechanisms of evacuation up the chain should they feel themselves inadequate. In addition, every town with a road to it has transportation which can take you to the nearest Posta Medica. Naturally, all of this costs money, in cash, up front. If you live on your last penny, then there will be no emergency evacuation for you unless you can get onto your consul by telephone. As noted elsewhere, it is easy to establish a bank account in Perú, or have someone wire you money from overseas or from a base you may have established in Lima.

Some crises are best served by doing relatively little. If you get malaria, for example, you will not get better more quickly in Lima, and the trip may weaken you. Make sure that you take local advice and that you have access to medication, use a mosquito net so as not to give the disease to other people, and sweat it out - literally. Most commercial airlines will not accept you as a passenger if you are gravely ill, so put aside fantasies of the white sheet of home and form a realistic plan of action.

Health management and acute medical problems

It is impossible to summarise all potential emergencies in a few paragraphs. Here are some guidelines. We end with a suggested medical kit.

Prophylaxis - medical prevention - is better than cure. If you are going into a malarial region, take the pills prescribed for you to make you immune, and avoid mosquito bites with long clothing and by minimising you exposure at dusk. Make sure that the water that you drink is pure or sterilised, and that you avoid potentially contaminated foods. (It is possible to get typhoid from a single strawberry, for example, previously fertilised by excrement in the irrigation water.) If you are sexually active, make sure that condoms are used. It is best to avoid oral-genital contact with new people, as Hepatitis is commonplace. We describe some of these hazards in more detail in a moment. If you read nothing else, please do read the section on malaria, here.

If you have a chronic condition, take an adequate supply of the supportive treatments that you need and do not get them stolen. Not all drugs are available in Perú, and specialist needs should be well-covered, carrying sufficient medicine for perhaps twice the intended duration of your stay. Where a break in treatment leads to unfortunate outcomes - as with psychotropic compounds or drugs which are aimed to manage circulatory problems and the like - do not have one store, have several. Diabetics are particularly at risk of having injection equipment stolen, and also from unfriendly enquiries at borders. Consider a fall-back oral kit just in case. It is also sensible to have a copy of your prescription with you if you take chronic medication.

The chief acute medical problem suffered by trekkers is physical trauma - a fall, crushing or the like. It is, happily, rare,and the trip to the trek's start is usually more dangerous than the trip. This said, one needs to be prepared to treat trauma if it occurs. There is a fairly standard tree for first aiders to follow, which you can use to decide what to do with yourself if you are self-medicating. The assumption is that you are trekking in company, and that you are far from a road head. (As already mentioned above, singleton travel is not advisable in the wilder regions, and absolutely to be avoided if you are venturing into the wilds to live under canvas. )

Here is the decision tree, which is little more than common-sense, codified and pointing at some primitive diagnostic possibilities. This is categorically not offered as medical advice, but rather a way to help you to structure your thinking about possible difficulties. If you need to use this structure, you will also need to take your own decisions.

1 Is the patient prostrate?

1.1 No, they are mobile:

Can the problem be treated, or will it heal itself?

  Yes » Treat in situ (see 2)
  No » Walk them to nearest transport

1.2 Yes, they are prostrate

Can the problem be treated, or will it heal itself?

  Yes » Treat in situ (see 2)
  No » Organise a truck, porters or animals for evacuation.

2 Treatment in situ: is this a chronic condition which has flared up?

  Yes » Follow the patient's experience and medication
  No » Diagnose and prescribe for them (See 3)

3 What is the nature of the problem?

3.1 Non-penetrative trauma - typically, strains, burns, breaks or deep bruising. » 4.1
3.2 Penetrative trauma - wound, abrasions. » 4.2
3.3 Intense fever and shivering » 4.3
3.4 Light fever, skin rash to chest, prostration, perhaps gut complications » 4.4
3.5 Diarrhoea, perhaps with other symptoms » 4.5
3.6 Headache, personality change, lethargy (only at high altitudes) » 4.6
3.7 Lassitude, jaundiced skin, eye white and fingernails, diarrhoea » 4.7
3.8 Chest pains, shortness of breath, painful left arm and neck » 4.8
3.9 Major skin rash with pustules, fever, headache » 4.9
3.- Other » 4.-

4.1 Non-penetrative trauma - typically, strains, burns, broken bone or deep bruising.

The most common problem is strain, and jarring of the joins after long descents. These are best addressed with rest, massage and non-steroidal anti-inflamatories (NSAIs) such as asprin, ibuprofen and the like. Sprains are relieved by cold water baths and binding with tight bandages in order to reduce swelling. Breaks can usually be detected when the individual finds it painful to use their tendons for anything - to wiggle their fingers, for example, or to grip. Treatment should be immobilization of the affected region, by bandage and splint.

Injuries to the rib cage is particularly difficult to treat satisfactorily, notably if the individual is sleeping on hard surfaces, such as the ground. A break can be detected by pressing the shoulder on the injured side diagonally down toward pressure applied at the bottom of the opposing ribs. The patient will typically report acute pain, in somewhat less academic language. The chest should be bandaged tightly so that breathing causes as little movement of it as possible. Depressed chest fractures - where the surface can be seen moving in and out when the individual breathes - are no uncommon in mountaineering and require evacuation. These symptoms, associated with 'bright' blood in the mouth imply a punctured lung and double the urgency for evacuation.

4.2 Penetrative trauma - wound, abrasions.

First, if there is intensive bleeding, do your best to stop it. If the would is in a limb, this can be done by an arterial tourniquet: otherwise, you must use topical pressure . You can use a tourniquet only for ten minutes before you must renew the blood supply. A tourniquet is a cord pulled tight between the wound and the heart, reducing blood flow and hence bleeding.

It is, of course, impossible to generalize about wounds. "Sticks" - deep, narrow wounds from knives or tree branches - are extremely hard to treat in the field. Open wounds, by contrast, are more tractable. They first need to be cleaned with sterile water with disinfectant and salt in it - one table spoon per litre. Boiling is ineffective as a sterilant over about 3000m, and you should use water that has come from a pressure cooker if this is at all possible. Iodine is a good chemical sterilant, as are the standard proprietary compounds such as Dettol and TCP. Coca Cola and other sugar-containing drinks are innately sterile and they are good washing liquid once the fizz is removed. You can wash the sugar from the area around the wound once it is securely sealed.

After washing, decide if the wound needs stitching. Deep wounds need a drain if they are to be stitched and this is beyond the means of most camps. In extremes, use the tube which holds the ink in a biro, but sterilise it extremely thoroughly. Deep sticks (above) are best left unsealed and undrained in camp conditions. If you are going to stitch, make sure that the thread that you use is strong and sterile. Make deep stitches if you are inexpert. Too shallow ones will pull out, and make the wound edge ragged. If you are undecided, do not seal the wound.

Cover the wound with clean (sterile) cloth that has been coated with vaseline or a greasy antiseptic. This stops it sticking when you need to change the dressing. Now add a pad of absorbent material, and bandage the entire thing firmly. You will need to change the dressing after 24 hours. Administer oral antibiotics immediately, and increase the dose if the wound seems to be unduly red when you change the dressing.

Address odd smells immediately. If you encounter sepsis, wash the rotten material away with sterile antiseptic treated water (this will hurt a lot) and repeat the dressing. Evacuate the patient immediately. Increase the antibiotic dose. You are unlikely to carry injectable antibiotics unless you have medical training, in which case you will probably not be reading this. If the patient becomes unable to swallow, therefore, push the capsules up his or her anus, greasing the passage before you do this.

4.3 Intense fever and shivering

Fever can be caused by many things - the proper medical phrase for "I don't know" is probably "it's a virus." This said, extreme fever is unmistakable. It involves rigor - shaking, where the muscles can be stiff and sore - and copious sweating. Temperatures around 40°C (104°F) are not uncommon.

If the patient starts with a chest infection and then becomes feverish, suspect pneumonia. Antibiotics will usually clear this up, although viral pneumonia has to be treated supportively as antibiotics will do nothing except prevent bacterial invasion.

If the patient starts with a headache and then begins to shake, particularly if they feel alternatively freezing and hot, then they may well have malaria or dengue, both endemic to Perú. It is hard to catch either of these anywhere but in the jungle regions, and people who have not been there are unlikely to have either of these.

If the patient has not been taking anti-malarials, then they are unlikely to have any with them. In this case, antibiotics such as doxycycline or cephalexin may have some affect. Malaria is extremely serious, and people who recover even with the use of anti-malarials are going to be very weak for a long period. The chief supportive treatment is to provide fluids to counter the intense sweating that accompanies the "hot" spells, and warm clothing for the "chills". A natural course of self-healing takes 7-10 days, with potential relapses. Cerebral malaria, marked by aversion to light and intense head pains, later convulsions, can be swiftly fatal. Evacuate.

Dengue, which is caused by a virus, will not be touched by antibiotics. People with dengue may (or may not) become jaundiced. People suffering their second infection may experience agonizing pains in the bones: hence the former name for the disease, 'breakbone fever'. This may sound esoteric, recall that you may be treating your Peruvian porters as much as yourself . Evacuate.

Yellow fever is uncommon in Perú. It causes fever with extreme jaundice, and in the more serious cases, haemorrhages under the skin and in the internal organs. It, too, is a virus which is spread by mosquitoes, and it is an extremely serious disease. Evacuate.

4.4 Fever, skin rash

Typhoid

Salmonella infections can be benign, or they can cause typhoid. Salmonella infections are extremely common in Perú, and most cause gastroenteritis (see 4.5) which Peruvians call un tyfoidea. Virulent strains of Salmonella may invade the blood stream, causing typhoid. This causes a fever that is generally light, a blush or bloom across the chest and collapse due to toxins which the bacteria produce. It is usually rapidly cured by systemic antibiotics, such as doxycycline, ampicillin or cephalexin if these are used early.

Erysipelas

This is a skin disorder which is fairly widespread in the local population. It is a streptococcal infection often associated with poor personal hygiene, poor diet and lowered immune status. It causes local swelling and reddening of the skin. It commonly affects the legs and buttocks, but may appear on the face, where swelling may close the eyes.

Illness appears abruptly, with initial fever and chills followed by a painful rash which appears 1-2 days later. Penicillin V at a full adult dose of 500mg, four times daily combined with flucloxacillin 500mg four times daily is indicated as first line if no allergies exist to penicillin. Erythromycin 500mg four times daily is indicated where there is sensitivity to penicillin.

4.5 Diarrhoea, perhaps with other symptoms

Gut disturbances are very common amongst people to whom countries such as Perú are new. Most clear up spontaneously, or with the help of antibiotics - see 4.4. There are three relatively common problems that are less tractable.

Perú suffers occasional waves of cholera, often focused on the pig farms which ring Lima. The disease is spread by poor hygiene. Washing up facilities at many roadside inns may be done in a tub of black water, and travellers may be exposed to diseases through this. The symptoms are a complete inability to retain any fluid in the gut, and consequent dehydration. A cholera victim loses weight catastrophically and appears made of wax. The pass an odourless and colourless fluid which is, nonetheless, extremely infectious.

The disease was once very dangerous, killing around half of those it infected. It can now be stopped by antibiotics, but this needs to be supplemented by oral rehydration. Compound such as Dioralyte are available for this, and the sachets weight very little. Failing this, a teaspoon of sugar and one of salt dissolved in a litre of water will do the job. It is essential to rehydrate before giving oral antibiotics, as these will otherwise not be retained long enough to work.

The key issue in cholera management is to avoid cross infection, such that the nurses themselves get ill. Burn all infected clothing and bedding, and wash hands in antiseptic at each instance where there is contact.

Giardia is a protozoan which infects the gut of many people in the developing world without causing problems. Visitors may experience a new strain, however, which makes them symptomatic. The consequence is an intractable Diarrhoea coupled to a particularly smelly gas attack, affecting both ends of the digestive system. One burps and farts bag eggs. The specific is Tinidazole, one dose of which cures it.

There are other intractable gut infections, but this is probably a long enough horror story. If you maintain your normal standards of hygiene, you are unlikely to encounter them.

4.6 Headache, personality change, lethargy at high altitudes

Suspect altitude sickness. There is only one treatment that truly works, and that is to descend. Few people develop this under 4000m, but it is the young and fit who are most at risk. Intense rehydration plays a role in adapting to high altitude, and you should ensure that your urine is at all times quite colourless. If it is not, drink more.

4.7 Lassitude, jaundiced skin, yellowed eye whites and fingernails, Diarrhoea

Suspect one of the Hepatitis family of viruses. Hepatitis A is the most common, and is spread much as is Salmonella. It is common to get Hepatitis A and Typhoid at the same time. The infection creates deep depression in many people, and lassitude in all.

You can be immunized against the common members of the Hepatitis family (see below). However there is no effective treatment once you have become infected, although injections of Gamma Globulin may be helpful. It takes around three months to disperse, during which time you should avoid alcohol and think happy thoughts.

Hepatitis B is acquired through the exchange of body fluids. The symptoms are similar, but virus is not usually eliminated quickly and it can cause major long-term problems to those it infects. Use condoms for sex, and avoid oral intercourse with anybody suspect.

4.8 Chest pains, shortness of breath, painful left arm and neck

Suspect coronary problems. The patient should be kept calm and relaxed as far as possible, and evacuated with the minimum of fuss. Check for an irregular heart beat, as this is perhaps the only 'camp-site' sign that a heart attack has occurred. Cyanosis - blueing - of the whites of the fingernails and of the lips is a clear sign of reduced circulatory efficiency. The presence of either symptom proves nothing, but both together would be indicative.

4.9 Major skin rash with pustules, fever, headache

Measles and chicken pox are widespread in Perú, and if you did not get exposed to them as a child, then you may get them here. Neither are normally life threatening, although both are capable of unpleasant surprises. There is no treatment, save fluids, rest and isolation. Watch for photophobia, pain at exposure to light. This is a symptom of meningitis, where the virus is inflaming the membranes around the brain. This needs specific treatment (corticosteroids, perhaps diuretics) and can become extremely dangerous if unchecked.

4.- Other

This has been a sketch of the most common problems. A glance at a medical handbook will make it clear that they are far from the only issues which can arise. There is, however, no point in trying to replace such a handbook. What follows is a list of some specifically Peruvian horrors.

Leichmaniasis (la verruga)

This is a protozoal disease - meaning it is extremely hard to eliminate - that is spread by sand flies. These inhabit the dry valleys of the coastal Andes (and all sorts of other places, such as the deep jungle.) It is as well to keep yourself in a mosquito net if you are sleeping outdoors anywhere below 3000m in Perú, and to get your sleeping platform up off the sand if you are doing so in the dry gullies where the sand flies proliferate. Sand flies are anyway deeply irritating and it is no chore to get away from them.

The infection appears some months after infection has occurred. It creates initial inflammation around blotches of white or pink on mucous membranes, spreading inflammation and the formation of a brown crust. The tissue at the site of infection is destroyed, and this is particularly disfiguring when it affects the face - lips, nose, eyes - giving it the name "white leprosy". It can completely devour lips and nasal tissue if not treated. A more deadly strain infects the organs of the body and does the same thing to them. This form is even less tractable to treatment. Use your mosquito net.

Chagas disease

A blood-sucking beetle related to the bed bug (which also spreads a protozoal disease) creeps out of cracks in old plaster work while you sleep, defecates on the bite and gives you a disease which entails chronic fatigue and abdominal pains. Charles Darwin was supposed to have had it. So: really do use a mosquito net, and pick where you sleep.

Water beasties

The major waterways are very welcoming on a hot day. Visitors tend to have seen too many movies of pirañas devouring mules to have a rational view of their safety. Most of these fish actually eat fruit. Some do attack bleeding animals, but this is not common enough to deter tiny children from spending much of their life in the water. Much the same can be said of the cayman (crocodile), which looks fearsome but actually eats fish. River banks attract snakes and these are the chief large animal hazard of the water ways. Mosquitoes are, however, the dominant threat.

Clean, running water does, however, have two dangerous inhabitants. One is the candiru, the other the electric eel.

The candiru (Vandellia cirrhosa) is a tiny catfish. It is a parasite of other fish, which it attacks either through their gills or urethra. It is extremely thin and semitransparent, more an eel than a fish, but it has sharp spines attached to its body that both lock it in place and cause bleeding. It feeds on the blood, becoming larger and so locking itself further in place.

A gorged, swollen Candiru

The effect on humans is appalling. The candiru detects urine in the water and swims agilely up either the urethra or the anus, locking itself in position. It is then a permanent fixture, completely occluding the flow of urine. A person will die in a few days if it is not removed. Natives of the selva use the Xagua plant and the Buitach apple, which collectively kill it and dissolve the body. However, these have to be introduced surgically upstream of the animal, which is particularly hard to do with primitive tools if the person affected in female. Conventional surgery uses normal cut-and-find practice. This said, the animal cannot get through cloth and simply wearing 'jockey'-type swimming trucks offers complete security. Locals are not much affected because, even though the bathe in open-legged shorts, they never ever urinate when in the water.

The electric eel lives on the bottom of highly oxygenated stretched of the rivers, just below rapids. It makes its living by electrocuting fish, and its discharge is easily enough to paralyze a man, or stop a weak heart. These are genuinely dangerous, but the locals know where they live and seem to swim with impunity.

Creepers and slitherers

Vampire bats, snakes, vast but largely harmless spiders and a nameless myriad of arthropods exists in the jungle regions. The bats can give you rabies . But then, so can dogs. You should watch out for the dogs which display unusual behaviour, such as a wobbly gait, snapping at things which are not there or heavy salivation. If you get bitten, you absolutely much undergo an anti-rabies course of inoculations, as death is otherwise both inevitable and extremely unpleasant if the animal was infected. Most Peruvian dogs are, however, merry beings, never happier than when trying to bite the tyre of a twenty tonne lorry.

There is a species of tick to be found in lowland jungle which is minute, but which climbs up your leg to the intimate regions and there buries itself. The result is a bird-shot sized lump under the skin that endures for months, itching fiercely. Insect repellents such as DEET are helpful, but tend to sweat off. Happily, South America does not have widespread leeches.

There are, of course, snakes, scorpions and spiders. Some species of spider grow to the size of two boiled eggs and are never happier than when settled in the thatch of a tropical hut. They can drop off the roof spontaneously without seeming harm to themselves, but to be their landing ground is an unhappy way to wake up. Use your mosquito net. If you stick your hand into thick bush, or pick up a stone without looking to see what is under it, then you will get what you deserve. Check your shoes in the morning and be sensible where you put bare feet. People with experience of the humid tropics get into habits which mean that the incidence of snakebite and the like are very low. It is the unfortunate peasants, who absolutely must stick their feet into their crop if they are to eat, who get bitten.

Malaria and mosquito-borne diseases.

Essentially, almost all of these hazards are as nothing before the mosquito which, after humans, is undoubtedly the most dangerous animal on Earth. Use your mosquito net.

If you are going to the jungle region of Perú, you need malaria prophylaxis. This has to start a defined period before you visit and continue for a period after you leave. If you omit these brackets, you lose much of the protection. It is typical for tourists who travel for a relatively short period to develop malaria after they have gone home, due to its incubation period. The threat does NOT go away with the mosquitoes.

The second most deadly animal alive

What should you take for malaria prophylaxis?

First, take the advice of your doctor. This is particularly the case if you are pregnant or if you have high blood pressure. However, if you are already far from home, then you will need to select your own treatment. Here are some tips.

The standard combi treatment of Chloroquine and Proguanil are very safe, but malaria in Perú is largely immune to their effects and they are nearly worthless.

Some doctors recommend the effective Mefloquine (Lariam) which is taken weekly. It cannot be combined with beta-blockers, and it can make you clumsy. Its greatest downside is that it can, occasionally, produce anything from disorientation to outright psychosis in one in fifteen thousand users. Halofantrine is a related compound which must not be combined with Mefloquin, as this can cause cardiac arrest. It is usually reserved for curative rather than prophylactic treatment.

Fansidar (pyrimethamine-sulfadoxine) is still on sale in some countries, but can have bad side effects. It has been withdrawn in most developed-world markets. It also interferes with the red cell production that goes with adaptation to altitude, which is certainly something worth noting if you intend to go high. A related mix called Maloprim is still on sale outside of the US, but is an old compound of limited effectiveness. Neither should be taken if you have sulphanilamide sensitivity or suffer from kidney stones.

Doxycycline is an antibiotic which is used in high resistance areas in individuals who are sensitive to Mefloquine. It has to be taken daily. Do not take it for more than three months, or if pregnant or feeding a child. It is a penicillin derivative and cannot be used if you are sensitive to this family. It is, however, an excellent broad spectrum, systemic antibiotic, applicable to many of the problems discussed above. Cephalexin is also sometimes used for this purpose.

Prophylaxis: other diseases.

Hepatitis A is both common and debilitating, and it is possible to immunized against it. (Of course, if you have already had it, then you are probably immune.) There are two inoculations which you can get before you travel: Vaqta and Havrix. Neither are used on children younger that three. Two inoculations give complete protection, one around 95% cover.

Hepatitis B is associated with the transfer of blood and other body fluids. There is a vaccine that is largely effective and which covers Hepatitis A as well: TwinRix.

Yellow fever is confined to the coast of Perú and is rare there. However, in view of its seriousness and - for travellers roaming South America, its widespread nature - inoculation is wise. Some countries require you to have a certificate of inoculation.

Leishmaniasis is does not have a prophylactic treatment, or much of a curative treatment either. An infection can be managed with toxic heavy-metal based drugs. This fact brings forward an important lesson - that prevention is far, far better than cure; and that avoiding exposure is the best form of prevention. Please make a point of sleeping under a mosquito net which has been impregnated with Permethrin wherever there is risk of insect bite at night. Such nets are cheap, pack up into a tiny bundle and weigh next to nothing. They can save your life.

Sexually-transmitted diseases are neither more nor less common in Perú than anywhere else, and the risk factors are the same. The official HIV rate is also fairly standard. The chief local drug of abuse is not injected, which is a plus, but casual male homosexuality is relatively common, which is - in this context - a minus. STDs are chiefly diseases of poverty and, as a relatively wealthy country, Perú is much safer than, for example, Africa. You are advised to follow the standard safe sex practices: limit your enthusiasm, use condoms and choose your partners carefully.

Your medical kit

The following list is a generic one. One can buy many medicines over the counter in Perú that would normally require a prescription from a doctor in the industrial world. However, some of the more expensive or unusual pharmaceuticals that are available in the developed world are often simply not imported into Perú. If you take chronic medication, therefore, it is not safe to assume that you can top up locally.

A clinic. It offers surgery, cardiology, dentistry and obstetrics. Plus.

It is worth taking four categories of bactericide: a 'generic' topical antiseptic, two forms of systemic and one specific parasiticide. It may be well to worm yourself after the trek if you have been exposed to a high-risk environment, such as the prolonged exposure to school children. Mebendazole is the usual product of choice for round worm, and it can be purchased over the counter in most countries ("Ovex".)

Anti-inflammatory products and pain-killers can be helpful. However, many interact with existing medication and what follows is the most general guide. "Basic" products such as aspirin and ibuprofen - both sold under many brand names - are extremely helpful when joints become sore and muscles ache. One should note that ibuprofen can make some people accumulate fluid, which is extremely undesirable at high altitude. (Fluid accumulation is one of the key elements in the altitude sickness syndrome.) Topic application of ibuprofen is often both helpful and a way of avoiding this issue, and there are many creams which will deliver this that can be bought over the counter. It is also counter-indicated for people with asthma.

More serious pain - as with serious strains and broken bones - can be alleviated with stronger pain killers, such as dihydro codeine and its yet-stronger cousins. These should be obtained from a doctor and used only under advice. Pain killers taken against high altitude head aches can, for example, mask dangerous symptoms.

One of the most common problems on trek is Diarrhoea The best way to prevent this is, of course, good hygiene. However, people for whom this is a first trip to the developing world can hardly avoid a readjustment of their gut ecology. Most such attacks can be stopped with a short course of antibiotics.  However, longer sieges may leave individuals dehydrated and weak, and it is sensible to take one of the many cheap oral re-hydration mixtures that exist. These come in sachets, and should be mixed with boiled water before drinking. Few people are likely to need more than six sachets.

Boiled water is usually freely available, but one can empty one's water bottle on a hot day. Sterilisation tablets are available which are extremely effective. Those based on chlorine should be avoided, as must less powerful than the silver-iodine products that can be bought in most camping shops. These come in a tiny bottle that can be carried in the day pack against need. Once opened, however, a bottle lasts only a month of so. These tablets, whilst harmless to humans when used as indicated, have unfortunate effects on plastic water bottles and, if they leak, on clothes.

The diet on trek is as varied as cooks can make it. This said, long spells in remote areas may offer a diet that is deficient in vitamins, which shows up as a general loss of stamina when one is working hard. Vitamin complex tablets help to offset this. Tablets that offer extra Iron can be helpful when the body is making extra blood cells at altitude, but there can be awkward side effects amongst some women during menstruation. Medical advice is, once again, recommended.

It is also sensible to take assorted dressings. Adhesive tape has a dozen uses. The robust cloth-based tape is much better than micropore or plastic tapes. The single greatest need for dressings on trek is for blisters and abrasions caused by footwear. The kind of tape that stays in place under such repeated stress is robust, and not the sort that comes in different sized bits, packaged individually in a box. A single bandage, and some sterile gauze can also be useful. If you have the competence to use it, equipment to manage serious wounds is sensible to have, but almost never used. (In the authors' experience over twenty years, used once: and then for a porter who had been bitten by a dog, rather than a trekker.) In general, serious injury will need supportive treatment only until evacuation can be arranged: see below. It is advisable to take a pot of vaseline, which has a thousand uses - lip salve, leather softener, anti-adhesive for wounds, hair dressing - and an antiseptic cream.

Some travel writers advice you to bring syringes and needles with you in case you require injection. The concern is that you may be subject to second-hand equipment and so at risk from HIV and Hepatitis. This is certainly a valid worry in much of the world, but Perú tends to have the equipment that you need where you need it, and traveling with hypodermics in South America can lead to misunderstandings at the border. Make your own decision.

Individuals will have their own particular needs with regard to chronic medication and specific weaknesses. Some of these can be accentuated on trek: psoriasis through wind and dust exposure, acidosis due to a radically different diet, haemorrhoids as a consequence of altered toiletry conditions, bad backs from sleeping on the ground. One needs to think one's particular needs into a situation where running water is not on tap and where physical stress is increased. Thinking ahead - to potential relationships, ailments, accidents - can build both a prepared mind and a well-stocked bag. The disposal of female hygiene products and contraceptives may also benefit from some forward planning. Much the same is true of syringes and other diabetic paraphernalia.

If you plan to be sexually active, it is wise to bring condoms, lubricant, wet wipes towelettes and tissues with you. Local condoms are not altogether reliable and, for the well-endowed man, the condoms on sale in the highlands tend to be small. The paraphernalia is needed in that a convenient basin or shower may not be available, and certainly will not be if you are in a tent. Remember that oil based lubricants such as Vaseline almost immediately rot latex condoms, making them useless within seconds. Use KY or others in the same product family. There are non-latex condoms available but they are hard to find outside of Lima. Do not use products such as Viagra is you are at all affected by altitude or you will probably be blessed with migraine.

 

Difficulties with local people

The first section, 'avoiding difficulties through awareness', sets out how you should present yourself in order to minimise the chance of unwelcome encounters. It tells you to keep certain items close to you at all times. It tells you to avoid potentially dangerous situations. Please read it.

Contacts with the Andean peoples.

The section on history will show you that the native Americans of the highlands have had the stuffing kicked out of them for over three hundred years. Each apparent improvement in their lives has led to betray and disappointment. Their horizons are small, and they know that the only people with whom they have solidarity are their own. People crossing those horizons have, pretty reliably, brought with them rape, murder, disease, dispossession and contempt. It is astonishing that they even attempt to be civil to strangers.

One has, therefore both to expect a degree of distance and to have to exercise considerable discretion when dealing with these people. This is less of an issue in the North. Here, the Spanish influence was so extensive as effectively to have bred out the native American population in some areas. Southern and central populations can be volatile and potentially dangerous to outsiders if you behave stupidly. This is less of an issue around Cusco, where foreigners are commonplace, but is nonetheless something to keep firmly in mind.

This situation has major implications for how you should conduct yourself with these people. What follows should not be taken as a tract on the "weird and dangerous natives". Fundamentally, people are much the same everywhere, however different the surface manifestations of their culture may be. This said, it is easy to get into trouble in the Andes if you are bumptious, loud, flamboyantly dressed or in other ways seeking to impose yourself, or if you intrude uninvited into native ceremonies. Holiday makers tend to see "the natives" as picturesque bit players in their personal drama, and whilst you can get away with this in places where the locals have learned to smile and take the money, you absolutely cannot do this unscathed in the Southern and Central Peruvian Andes.

It is, of course, feasible to operate alongside of these constraints. Taking photographs of campesinas on their way to church in a rural market town will cause no offence if it is done impersonally and discretely.Do not start handing out presents to the children. Do not go uninvited into people's houses. Do not throw your weight around in the local bar-eatery. Mobs of obese tourists is garish clothes descending unannounced - "Ain't they just cute!" - may get a really nasty surprise.

Extrovert self-imposition is not appreciated, and you may get stoned for attempting it. With real rocks, intended to maim. Really.

Group celebrations which take place away from the towns, out in the countryside, are specifically approachable only with someone to play the ambassadorial role. You are then accepted as an honoured guest, and it is for you to behave with dignity and reserve. Status is very important, and this is displayed by posture and largesse. You must show your status with presents of money to key individuals - your "ambassador" will know who you should treat - but do not confuse these with payment. They are not acting for you, in any way. Do not lose your reserve, let your hair down and try to show that you are one of them: for you are not, and never will be. You may, however, get a good kicking for your trouble. What is acceptable is if you have an approachable performing skill - magical tricks, a good singing voice, a musical instrument - which you are able to deploy in carefully prepared circumstances. That is, you ask whether this would be welcome and the elders indicate that it would. They then prepare the crowd, you do your stuff and they thank you. Try your act out on someone safe first, as you will be standing before a volatile audience which may not understand your intentions. "Magic", for example, has rather different connotations in a society where malignant and beneficial magicians (brujos) and shamans are a part of everyday life.

Medical and related skills are always welcomed, but again these need to be properly framed if they are to be acceptable and effective. You confer status on the elders if you conform with this, and undermine their authority if you do not. This is of itself unlikely to cause acute problems, although your period of welcome may be shortened.

The peoples of the jungle regions are quite different: often open but timid, not at all sure of how the world outside works, but thoroughly convinced that strangers are potentially dangerous. The chief contact which the remote groups will have had with the outside world will have been through missionaries, rapacious traders and soldiers. The military garrisons behave neither worse nor better than soldiers anywhere else in the world where they have money to spend and are far from home, but the impact is obvious.

These people have learned to melt away when the noisy or the vulgar presents itself, and if you turn up dressed like a Martian - or treat them like Martians - you will see little of them. You are generally expected to take food or drink with them, at their choice, and as the drink is made by the women chewing cassava and spitting it into a vessel to ferment, you need to be clear of your limits before you start. (This is not true of the Shipiba people near Pucallpa, who have been rendered 'tourist friendly' by local missionaries, but is definitely the case elsewhere.)

Theft

Theft is as much initiated by the victim as the thief. There are three fundamental weakness that you need to avoid:

All three of these are obvious when you think about it, but many simply do not think.

The issue of how to maintain this awareness is covered in the opening part of this section. Remember one fundamental point, however. In your own society, you have a "radar" for what is risky and what is not. You do not have this when you are a newly-arrived foreigner in Perú. In its place, you must put conscious awareness of potential problems, the active search for intelligence, and self-management if you are to manage your exposure to risk. Luck has nothing to do with it: lucky people are those who understand the system, consciously or not, and manipulate it for their advantage. You now have to work at this.

So:

If you look like a victim, you probably will become one. Here are some examples of victim-behaviour.

Narcotics

The greatest single source of predators on low-budget backpackers are their peers. Theft is far from confined to Peruvian nationals. This is particularly so where drugs are involved. Beware of unusually old, battered looking backpackers with a drug habit, for they may - will - see you as a bank account. Never, ever accept a parcel to carry across a frontier from anyone whom you do not know personally and for a long time. Alarm bells should scream at the phrase: "I have just taken on too much - could you please carry this for me." (Variants - "I am too sick to travel and my friend needs this"; "I have to go back to La Paz but my sister in Lima really needs this sweater"; and so forth.) If you absolutely must comply, insist on looking inside. Do not let anyone less than an intimate or blood relation pack for you, and check any untended items before going near customs. One specialty is to offer to tend a backpack whilst the owner goes to the lavatory - for example, off a bus - and then to plant drugs. As noted above, drugs can either be smuggled for real, or simply planted in order to reap a reward from the police. Perú is extremely tough on people carrying drugs in even modest quantities, and its jails are not pleasant.

The narcotics industry in Perú is vast, ruthless and insinuated in all strata of society. If you involve yourself as customer or courier you can expect a thousand tricks, all of them new to you. This is true of cocaine, cannabis and opiates such as heroin, all of which are sourced locally. Other drugs such as amphetamines are largely imported, but by the same people. The ayahuasca circuit is distinct, and the use of the drug is not illegal. There are established tour companies which will take you to a curandero for the experience. It will not kill you, but people with any history of mental problems should be aware that it can precipitate psychotic episodes. It may also give you gastroenteritis, as the preparation of some of the ways of taking it involves ditch water. (See the previous section.)

Police and officialdom.

If your papers are lost, go to your consulate. Do keep a record of all major documents, from photocopies of your passport to lists of any credit cards and travellers Cheques which you may have brought. Consuls cannot help with anything financial except complete pennilessness, in which case most provide a loan to get you home. The Consulate is also your first port of call (or telephone call) if you get into trouble. They seldom are able to do more than advice you and to help you get legal representation, but they can set up a liaison between these people and any family or financial support which you may have at home.

If you do have something stolen, you can approach the police. How much effort goes into the matters depends on how you present yourself, how meaningful an investigation would be and - well - the phase of the moon. However, the police will certainly investigate serious crime, such as rape or wounding. Bear in mind that the identity of 'perpetrator' and 'victim' can easily switch, to your disadvantage. It is unwise to approach the police in respect of serious crime without legal representation. You must make it quite clear to this person just how far you are prepared to go in weighing the scales of justice in your favour. They will be happy to tell you the options.

Bribery is widely practiced across the whole of Latin America as a form of unofficial fine (multa). This is how it works. You have parked illegally, and find a policeman sitting on the car, smoking. Do not offer a bribe. Ask how his family is, and you will hear a tale of woe about the price of shoes for children. Offer to buy a pair - as a gesture of respect for the police, of course. (You get the idea.) This is not for those with weak Spanish.

The police are largely honest in their own light. That is, there is a proper way of doing things in Latin America which, as with the Middle East, puts a huge premium on avoiding contact with the official world. Bribes that are given over minor offences are really fines levied in accordance with the seriousness of the crime, the perpetrator's social status and so forth. They are seen as a way of acknowledging social disapproval whilst simultaneously helping a police force with a poor pay structure to operate. Major issues - and problems involving the army and other agencies - are much less tractable.

Junior police are expected to pay their superiors for their post. Perú is modest in this regard as compared to countries to the North, where highway patrolmen pay millions of dollars for the "rights" to stretches of freeway, or where humble traffic cops buy equivalent access to manually-controled traffic lights. Most bribery in respect of traffic is concerned with the passage of freight - which does not affect travellers - or for "franchises" for public transport which can, by contrast, have a sharp impact if the bus or collectivo owner has not paid.

Major involvement with the police absolutely cannot be resolved without a lawyer, who is both an advocate and a fixer. If you cannot afford this, then you are on your own. You may find that physical, rather than financial inducements are expected of you, particularly amongst the rural police. You may decline, of course, and take your chances with the system.

Officialdom covers a wide spectrum in Perú. There are assorted spook-and-narc agencies, which it is to be hoped will never have reason to trouble you. Civil policing is under one umbrella organisation, the Policia Nacional del Perú or PNP. This has many arms of activity, such as traffic management, border control, facilities security and the like. An important group with which you may have contact are the Policia de Transito, who keep an eye on the major routes. They use distinctive 4x4 silver land cruisers. Police who wear white - rather than the standard khaki green, a branch of the police whose job is looking after foreign tourists. All speak English, and some other languages.

Lima is seemingly saturated by Rentacops in assorted military-looking uniforms. Some are hired by specific companies, whilst others are paid for by municipalities. The municipal police (Serenazgo) have the job of watching the streets, and calling the police if they spot anything suspicious. They may ask you where you are going if you wander around the expensive districts such as San Isidro in scruffy clothes. The private security forces will affect you only if they suspect you of shop-lifting, or you are too scruffy to enter the establishment which they guard. Be nice: their status flows from the capacity to deliver focused violence when they feel it is needed. They are also poorly paid. They are, however, largely ubiquitous in the areas of the town with formal governance.

People who descend on you when you park, wearing official looking jackets, are franchisees who have bought the right to manage parking charges in sections of street. They cannot help you if you have been robbed.

The countryside is complicated by alternative systems of authority. As explained in the section on Perú's social framework, much of the farmland is collectivised (collectivo or SAIS.) These have their own courts, overlapping with the rural police. They have a militia, called rondas campesinas, which are used to maintain aggressive 'foreign relations' with neighbouring collectives. It is just possible that trekkers could get involved with this, in which case it is important to know with which agency you are dealing. Rural lawyers are sparsely distributed, but are profound fixers of problems.

Then there are the armed forces. Visitors are likely to come into problematic contact with these only if they have done something serious, chiefly narcotics or subversion, or have become involved with, for example, a traffic accident with a military vehicle. The military are extremely 'correct' in how they handle such issues and a formal resolution will be required once the engine starts to turn. Minor issues - a bumped fender - may be handled through less direct means if the approach is exactly right. Serious matters are, however, serious. If you political or religious views force you to preach a message of aggressive social change - or if you take direct action in Perú - then expect an acutely serious response to this. Read the section on the history of Perú to understand the forces with which you are dealing. The most deadly intersection lies between the guerilla groups, such as the Sendero Luminoso, the Colombian narcotrafficantes to which they provided services and the web of intrigue in the militares in handling this.

What to do if all else fails

You have been precipitated into a crisis. If this is a simple social confrontation, you should attempt to defuse the situation. For example, if someone is offended by something that you have done, apologize sincerely and profusely. Make it clear that the offence was accidental and that you intended no slight to their social standing or personal authority. If the matter is unprovoked, such as a street crime, then give them what they want. It is wise to keep a a separate stash of money if you feel that the risk is acute. Run away if the opportunity presents itself, but not if they are pointing a gun at you, or you are involved with a volatile crowd that looks as though it, too, could run quickly.

Screaming and shouting often deters attackers, but make sure that they do not think that they are being attacked by you. Pack away your ego. This is particularly addressed to young men: do not feel shamed into rash action by a thousand dimly recalled action movies when a quiet retreat would allow you to live another day.

You have got yourself involved with the officialdom. Be cool, and do not panic. Modest Spanish evaporates when you become emotional. Red-faced weepers look like victims. Try to understand the situation. What do they think you have done? It may not be what you are worrying about. Is the issue relatively trivial, such that you can talk your way to a settlement?

If the matter is serious, decide whether you can afford a lawyer, and whether you can afford not to have a lawyer. If this is a matter so serious that it will end your trip - a fatal car accident, a drug bust - then get a lawyer even if you cannot afford it with the money that you have to hand, and call home for help. Do not try to be heroic, as this system has chewed up much stronger people than you.

Moderately serious issues - say, an accusation of assault by one foreigner on another - are often resolved by putting matters on indefinite hold, and letting the parties leave the country. Getting to this happy state of affairs does, however, require more financial resource than most backpackers will have with them.

Once again, be careful of veteran expatriates who follow the backpacker life style, and particularly those who combine this with drugs. Many are larcenous and predatory: there is nothing explicitly Peruvian about this, but the type is omnipresent and particularly dangerous in countries which have a narcotics problem. Beware. too, the professional moles that Peruvian police use to infiltrate and keep an eye on backpacker groups. You 'best friend' can end up framing you, and also getting you pregnant.