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Staying Healthy in Rural India

Here you’ll find a collection of information and advice* on staying healthy in rural India, for the benefit of visitors and residents alike. It was written with visitors to Bir in mind, but most of it applies to all of India and to other places where food and water contamination create health issues.

This article is focused on prevention. For a directory of medical and healing resources in Bir (including allopathic doctors and clinics as well as natural medicine practices such as acupuncture, homeopathy, and herbal medicine), see the Bir Portal’s Health and Healing Directory.


Topics

Hygiene | Water | Food | Immunizations | No Malaria | Treating Diarrhoea


Hygiene

Washing one’s hands and face thoroughly with soap and water, and practicing good hygiene in general, is one of the best things one can do for one’s health in India. In addition to washing your hands with soap before eating, it is also important in India (or any other place where the tap water is often bacteriologically unsafe) to make sure your hands are completely dry before you touch your food. Thus, it is wise to get into the habit of washing your hands at least five minutes before you’re ready to eat, such as when you first arrive at a restaurant (rather than waiting till just before the food is served).

Washing is important, but avoid antibacterial hand sanitiser products (e.g. Purell, etc.) unless it’s completely impossible to wash your hands with soap, as these can do two very undesirable things. First, use of these antibacterial gels can depress your immune system (in the same way that the use of oral antibiotics does), and that defeats the stated purpose of the product (ostensibly to keep you healthy). Secondly, but no less seriously, these antibacterial products are now thought to contribute to the development of antibiotic-resistant strains of ‘super-bacteria’, which are becoming a serious threat to the public health in India and elsewhere. 

We recommend either or both of two alternatives to antibacterial hand sanitisers:

  • Use ‘Medimix’ brand soap (available all over India in most chemist shops and general stores that sell soap), which contains herbs said to neutralise bacteria.
  • Rub a drop or two of slightly-diluted tea tree oil into your hands after washing, as tea tree oil has been shown to have bacteriostatic properties (in other words, it renders bacteria harmless without totally nuking them, and your body along with them, the way the antibiotic products do).

Washing your hands thoroughly with such soaps (or tea tree oil) and water and then allowing them to air dry completely before touching your food makes your hands much cleaner and safer than antibacterial gels anyway, so if you use antibacterial gels at all, do so only as a very last resort (e.g. on a bus journey where there is no water to wash your hands).


Water

Most of the biggest threats to good health for travellers in India are to be found in the water. The water in Bir is cleaner than in most of India, but that doesn’t mean it’s always safe to drink out of the tap (or to use for brushing your teeth). Bir’s municipal water supply comes from a spring high in the foothills above the town and villages, so the source is pristine. The catch is that it has a long way to travel to reach the village, and occasionally can become contaminated along the way (due to leaks and breaks in the pipe, etc.). Bir’s tap water has been tested and is quite often safe to drink, with notable exceptions during heavy rains, especially in the monsoon when the groundwater can pollute the system. Bottom line: It’s always wise to boil or filter your water just in case, but especially when it has been raining.

Avoid bottled water: The water here in Bir is likely to be better than most commercial bottled water (the majority of which is simply filtered tap water from the big cities), so do both yourself and the environment a favour by not buying bottled water. Instead, get your own water bottle refilled with boiled/filtered water at your guest house or at one of the local restaurants, or carry your own quality filter so you can do it yourself. You’ll get better water this way, and you’ll avoid adding more non-biodegradable plastic to the unsightly heaps of litter.

Like most of India, Bir has no garbage collection, so whenever a visitor throws an empty plastic water bottle in the rubbish bin, the contents of that bin will simply be dumped outside and either burned (causing toxic smoke, often inhaled by children and others trying to keep warm or keep the fire going) or simply tossed out of sight, where the rains will eventually carry it to the nearest river, polluting the waterways and destroying India’s natural beauty. Please, for your own health as well as the planet’s, avoid bottled water by using boiled and/or filtered water instead.

Boiling and Filtering: The most reliable way to make water bacteriologically safe is to bring it to a full boil for about a minute (some say several minutes, but these days the general consensus seems to be that, at this relatively low altitude, merely bringing it to a full boil for a few seconds does the job). Another alternative (or complementary practice) is to filter the water with a high-quality filter, meaning one of the fancy expensive ones with a very small filter aperture (which aren’t easily available in India, so consider bringing one from abroad if you can). Note also that filtering can do one thing that boiling can’t, which is to remove particulate matter (e.g. dirt and excess minerals) that can contribute to upset tummies as well as some chemicals (the latter aren’t an issue at all in Bir, but are a huge problem in the big cities, which have notoriously contaminated water supplies.)

Note on Indian water filters: Please be aware that the typical, simple Indian water filters (the two-chambered steel drums with one or two white, porous filter elements screwed into their upper chambers) are virtually useless because the holes in the filter are too big, allowing many of the harmful parasites to go right through. Making matters worse, if these filters are not scrubbed thoroughly and often, the filters themselves can even become breeding grounds for parasites. So, as a general rule, unless you know with certainty that such a filter has been scrubbed clean both thoroughly and recently, you should consider water from these filters to be less safe than boiled but unfiltered water. (Of course, if you boil the water after filtering it, there’s no problem.) Having said that, there is also a new generation of fancy water filters that include activated-carbon filters and UV treatment. These filter systems (at least those made by trusted brands, such as Aquaguard) are dependable provided they are properly maintained (which usually means replacing the internal filters about every six months, give or take, depending on use).

Staying hydrated: Finally, once you have safe water to drink, the trick is to drink plenty of it. The recommended minimum for adults is at least two litres per day, and more if you are exerting yourself, if the weather is hot, or if you’re adjusting to high altitude. Note that coffee and tea don’t count as water for this purpose because they don’t help the body hydrate as well as plain water. If you prefer some flavour, try adding a squeeze of lime, or making hot water with ginger (and lime, if you like).


Food

As with most places in Asia, it is best to eat only food that has been properly cooked and is still hot, plus fruit that you peel yourself. If you want to minimise your chances of getting sick, follow the advice below as well as you can.

  • Salads: Avoid salads or any uncooked vegetables, even if they have been rinsed in boiled/filtered water, which is insufficient to make them bacteriologically safe (because millions of the invisible critters manage to remain in the folds of the greens even as they’re being washed). The only way to make a dependably bacteriologically safe salad in India is to soak the ingredients for at least 30 minutes in a solution of either iodine or potassium permanganate, neither of which are widely used in India (even at most restaurants that claim to have safe salads) and then rinse them in boiled (or properly filtered) water. Again, despite the popular misconception, simply washing salad greens in boiled/filtered water is not enough. One exception to this rule is cucumber salad, which is OK provided the cucumbers (a) were clean and dry when peeled, (b) were peeled with a dry, clean peeler/knife, and (b) were not then rinsed in unboiled/unfiltered water after they were peeled. Note: Uncooked tomatoes (which are sometimes included in the cucumber salad above) should be considered unsafe unless either soaked in one of the solutions mentioned above or submerged briefly in rapidly boiling water.
  • Fruit: Fruit with a thick peel (e.g. banana, apple, pear, guava, papaya, orange, etc.) is fine to eat raw, though it’s best to peel it yourself so you can be sure that it wasn’t peeled and then rinsed in unsafe water (as sometimes happens in India). Thin-skinned fruits like mango are, sadly, riskier, as are fruits that can’t easily be peeled, such as grapes (and raisins).
  • Oils: India has two great health hazards related to cooking oil. One is that the most common oil used for frying is rape seed oil (marketed in the Americas as ‘Canola Oil’), excessive consumption of which has been linked to deterioration of the heart muscle. The other is that, in many Indian restaurants (and especially in Dhabas and other bottom-budget eateries, the oil is used over and over, long after it should have been replaced with fresh oil, which leads to rancidity, transformation of the fats to a less digestible state, and an increase in carcinogenic free radicals. A little unrefined oil now and then is OK, but don’t overdo the fried food, and try to minimise your intake of poor-quality, old, or overcooked oil. If you’re shopping for yourself, the best domestic oils for frying are mustard (sarson) and sesame (til). Flax seed (alsi) oil is also available in the Bir market, but this should not be cooked at all (it’s better used in salad dressings and the like).
  • Organics: The use of chemical insecticides and herbicides in India is more extreme than in most industrialised countries, and with fewer regulations to protect consumers, and thus it is even more important in India than elsewhere to make efforts to buy and eat organic produce as much as possible. Since organic markets have yet to catch on (again) in most of India, in many cases this means buying directly from local, small-scale farmers, who are less likely to use chemical fertilisers and insecticides (at least in their own personal gardens, though they may use chemicals on the food they grow for sale). 

DDT warning: Inexplicably, many commercial food growers in India are still using DDT, the deadly, toxic insecticide that was banned decades ago in most industrialised countries due to exceptionally harmful effects on the health of humans and other animals (including cows). Two of the crops to watch out for in India are black pepper and mangos, both of which tend to be grown with DDT by commercial growers in India. One would be wise to keep consumption of black pepper and mango to the bare minimum throughout India unless one can confirm it was grown organically.


Immunisations

The question of immunisations has received increasing debate in recent years as awareness has increased about the use of mercury (which is now known to be highly toxic) in many common immunisations, as well as other potentially harmful factors. Some practitioners of natural medicine argue that there are natural methods that are both more helpful and less harmful than immunisations. That debate is beyond the scope of this website, so we’ll leave it to the reader to research the issue, ask your health care practitioners (natural and/or allopathic), and make the decision for yourselves.

Should you decide to pursue immunisations, it is recommended to seek injections that do not include Thiomersal/Thimerosal (a compound containing mercury). The most commonly recommended immunisations for the Indian Himalayas are the following:

  • Hepatitis A: Usually Havrix
  • Typhoid: Often given orally (start a few weeks before departure)
  • Polio: An adult polio booster (given just once in adulthood)
  • Tetanus: A current tetanus immunisation (within the last ten years)

For long-term visitors and residents: Some doctors will also recommend Hepatitis B and/or rabies vaccinations for expats and long-term travellers (who, in theory, are statistically at greater risk for these diseases due to longer time spent in India), but many consider this unnecessary in most cases except for those who are most likely to encounter rabid animals (such as veterinarians and people working in remote areas for an extended period) and those who are likely to be exchanging bodily fluids with the locals or needing blood transfusions. Again, it’s worth doing your homework so you can understand the rationale for and against and make a reasonably educated decision about what fits for you.

For those travelling elsewhere in Asia: If you are also travelling to Nepal, you may wish to consider immunisation against meningitis, which is still a measurable risk there (but not in most of India). Likewise, if you’re planning to travel further east, an immunisation against Japanese encephalitis is sometimes advised, as the disease is rare in visitors but has a high mortality rate.


No Need for Malaria Prophylaxis in the Indian Himalayas

There is effectively zero risk for malaria in Himachal Pradesh. Some doctors in Europe and the Americas do not realise this, and therefore may suggest or prescribe malaria prophylaxis for your trip to India. If you are also planning to travel in other parts of Asia where malaria risk is high (particularly rural southeast Asia), then you might consider taking malaria prophylaxis short-term during that part of your trip. But be aware that most of these anti-malarials do more harm than good. Again, this is a longer conversation but, in brief:

  • The resistance to most of these drugs is now very high in Asia (the parasite that causes malaria has adapted to become effectively immune to the drug).
  • None of these drugs actually prevents malaria; they merely partially suppress the symptoms (in the best of cases, but not always, due to the resistance mentioned above).
  • Some of the drugs prescribed for malaria prophylaxis have very serious side effects (see below).

WARNING AGAINST MEFLOQUINE/LARIAM: Whatever the case, even if you do choose to take antimalarials for part of your trip, under no circumstances should you take them for longer than the prescribed period (and be sure to ask your doctor what the limit is). Moreover, it is inadvisable to take Mefloquine/Lariam even for a day, due to risk of severe neurological and psychological side effects. Seriously, we know people who have suffered intensely for years due to Mefloquine/Lariam, and we strongly advise you to avoid it completely. (For more information, do an Internet search for ‘Lariam poisoning’ or ‘Lariam toxicity’ and you’ll find thousands of horror stories.) If your doctor wants to prescribe Mefloquine/Lariam for you, politely insist on an alternative.


Treating Intestinal Parasites: Medications & Natural Remedies for Diarrhoea

One of the main health concerns many visitors to India have is avoiding travellers’ diarrhoea. As a result, many people tend to load up on various medicines. While it’s sensible to be prepared, it is also advisable to exercise caution with regard to these medications, as when used improperly (or even sometimes when used as prescribed), these strong medicines can do more harm than good. We have consulted with numerous doctors who specialise in Himalayan medicine, and the consensus is clear: It’s wise to exercise discretion, and it is strongly recommended not to take antibiotics and antiprotozoal medications casually or preventively. It is also advisable to consider traveling with a few of the most effective natural remedies, which do the trick in most cases and without side effects (see below).

Diagnosis: The first thing to know is that there are two types of organisms that are the most common causes of travellers’ diarrhoea in India: bacteria (e.g. Escherichia Coli) and protozoa (e.g. giardia and amoeba). For each of these, a completely different class of allopathic medications is commonly prescribed for treatment. The meds used to treat bacterial infections are useless against protozoal infections, and vice versa, so proper diagnosis is necessary to avoid taking the wrong meds (and thereby subjecting one’s body to greater stress and side effects than necessary). Diagnosis is best made with a stool test (except in cases of typhoid, where additional tests are needed to confirm the diagnosis), with a sample given while the patient is still experiencing symptoms, but results aren’t always clear with the first test, so sometimes repeat tests are necessary. If one is in an area where no facility exists for stool tests, then diagnosis is done based on a thorough assessment of symptoms, but this leaves considerable room for misdiagnosis (as many symptoms are shared by both bacterial and protozoal infections, making them often difficult to differentiate on the basis of symptoms alone). In case you are in an area with no access to health professionals at all and are forced to self-diagnose, one general rule (from which there are numerous exceptions) is that extremely watery diarrhoea and vomiting are more often signs of bacterial infections, whereas mustardy stools combined with bloating and sulfury burps are more often signs of protozoal infection. Again, this is by no means a failsafe guideline, so if you have symptoms of diarrhoea for more than three days, please do consult a doctor and get a stool test if possible. (Here in Bir, stool tests can be done at Delek Clinic in the Tibetan Colony.)

Allopathic treatment for bacterial diarrhoea: For diarrhoea caused by bacterial infections, the most commonly prescribed medications are very strong broad-spectrum antibiotics of the fluoroquinolone class, such as Ciprofloxacin and Norfloxacin (and other meds with ‘flox’ in the name). Based on current research, it is advisable to avoid these medications unless your diarrhoea is so severe as to be potentially life-threatening (e.g. if you are in the middle of an extended trek in a remote area and can’t afford to risk dehydration and weakness due to the diarrhoea) and if natural remedies have not stopped the symptoms. There are four major reasons for the recommendation to avoid these medications:

  • There is now conclusive evidence of serious side effects of Cipro and other flouroquinolones including sudden tendon rupture (with as little as one use in rare cases), kidney problems, muscle pain, and more.
  • Antibiotic use depresses the immune system and disrupts the balance of healthy intestinal flora, both of which make it more likely that one may continue to experience difficulties with digestion well after the original infection has passed.
  • Most bacterial diarrhoea is self-limiting, meaning it will end naturally in a short time (generally one to five days) even without treatment.
  • Effective natural treatments are available for most cases, which are free from side effects (see below).

Allopathic treatment for protozoal diarrhoea: For diarrhoea caused by protozoal infections in India, the most commonly prescribed medication is Tinidazole (a.k.a. Tinniba, Tindamax, Fasigyn, Simplotan, Sporinex, et al). (Note that Metronidazole, a.k.a. Flagyl, is largely ineffective in India due to the development of resistant strains, but continues to be presrcibed anyway by doctors who have not kept current with the research.)  These are also strong drugs and they are potential carcinogens (meaning use of these drugs may cause cancer). Thus, they should not be taken ‘just in case’, but rather only when there is a confirmed diagnosis of protozoal infection (giardia and/or amoeba), or at least a very strong symptomatic indication (i.e. mustardy stools and bloating/cramping with foul-smelling sulfery/eggy burps but without vomiting, all of which lasts more than five days), and if natural remedies have not stopped the symptoms. A few additional notes:

  • Cysts: Protozoa can encase themselves in protective cysts that allow them to survive harsh conditions for up to a month or longer. Tinidazole is generally ineffective against these cysts, and thus it is possible (and not uncommon) that a patient will take the full treatment of Tinidazole and experience temporary relief, only to suffer a relapse of the symptoms after some weeks, when the giardia or amoeba have emerged from their cysts. The allopathic treatment for these cysts is another antiprotozoal medication called Diloxanide Furoate, which is not available in some countries (for example, it has not been approved in the US), and is typically available in India only in combination with Tinidazole. Because Tinidazole alone is ineffective against cysts, it is generally advised that those with a confirmed diagnosis of giardiasis or, especially, amoebiasis, take the two medications in combination. When taking this potent cocktail, get plenty of rest and drink a lot of (safe) water, and if possible take probiotics daily for at least a few weeks after the treatment is complete.
  • Special note on dangers of long-term amoebiasis: Infection with Entamoeba histolytica, if untreated, can result in systemic infections (in which the amoeba enters the bloodstream and moves beyond the digestive tract), which often leads to liver abscesses (not good). Thus, amoebiasis is not to be trifled with, and a confirmed diagnosis of Entamoeba histolytica is one case in which even those who are generally averse to allopathic medication are well advised to bite the bullet and take the combination of Tinadazole (for the active amoebas) and Diloxanide Furoate (for the cysts).
  • Natural remedies: Several natural treatments (see below) are effective for all but the most stubborn cases of giardiasis, which are generally free from side effects (see below). But, again, in the case of amoebiasis, it’s probably better to take the allopathic meds (Tinadazole plus Diloxanide Furoate) and then take probiotics afterward to help restore healthy intestinal flora.


Natural treatments for travellers’ diarrhoea

The following natural remedies are effective in treating most cases of travellers’ diarrhoea due to parasitic infections, including bacterial infections and mild giardiasis (but see note above in cases of amoebiasis). There are generally no side effects, and thus it is advisable to try these treatments first, before resorting to the extreme allopathic treatments above. Their non-toxicity means they can also be taken preventively for short-term situations (such as for the next day or two after a meal eaten in a place with questionable hygiene practices), but, as with anything, it’s better not to overdo them. Most of these (with the exception of charcoal and psyllium husk) can be taken together in many cases, but not right at the same time: wait at least half an hour after taking one remedy before taking a different one. Most of these can be purchased online at iherb.com, which ships reliably to India with reasonable rates (if you are shipping to Bir, ask iHerb to use USPS registered mail instead of UPS or DHL).

  • Probiotics: In addition to following the guidelines for hygiene and safe drinking and eating above, the best thing you can do to fortify yourself against travellers’ diarrhoea is to take quality probiotics daily. Probiotics keep your intestinal flora in optimal shape, which, in turn, helps your digestion and helps your body fight off intestinal parasites and other unfriendly visitors. By far and away the best brand of probiotics we have found for travellers is Daily Dophilus, which has several advantages over others: they are shipped in blister packs and don’t require refrigeration (a must for travellers), and they are lactose-free (making them suitable for vegans and the lactose-intolerant).
  • Grapefruit seed extract (GSE): A natural remedy that is useful in treating many kinds of diarrhoea as well as other forms of bacterial, yeast, and fungal infections. The most popular grapefruit seed extract product is from Nutribiotic. From personal experience, we recommend taking double the suggested dosage in cases of diarrhoea. For best results, start taking it at the very first sign of symptoms, and keep taking it every four to six hours until symptoms have been gone for at least one whole day.
  • Black walnut extract: An effective remedy for use in managing intestinal parasites, including not only bacteria and protozoa but also worms, black walnut extract has the advantage of being relatively mild and gentler on the stomach than GSE or oregano oil.
  • Oregano oil: A very strong natural remedy that must be diluted (with water or olive oil) for internal use. Just a few drops of oregano oil can be taken in a glass of water to aid in treating a variety of infection, including not only intestinal parasites but also fungal and yeast infections. Note: Fine for one to three doses, but not for prolonged use!
  • Activated charcoal: Available in both tablet and capsule form, activated charcoal addresses the symptoms of diarrhoea and bloating rather than the causes, but it can provide relief in a matter of hours, which can help one feel more comfortable while waiting for the other natural remedies to fight the parasites. It works by absorbing gases and fluids from the intestines and helping to expel them.
  • Psyllium husk: A natural remedy rich in soluble fibre. Similar to activated charcoal, psyllium husk works by absorbing the fluid in the intestines and firming up the stools. Unlike charcoal, however, it can also be used equally effectively in treating the opposite problem (constipation). As such, it’s a great regulator. Psyllium is available widely in India (where it is known as ‘Isabgol’). 

Local Resources for Health & Healing in Bir

For a directory of medical and healing resources in Bir (including allopathic doctors and clinics as well as natural medicine practices such as acupuncture, homeopathy, and herbal medicine), see the Bir Portal’s Health and Healing Directory.



*DISCLAIMER: We are not medical professionals. The material on this page is provided as an informational resource, but it is not a substitute for the advice of a qualified medical practitioner in case of serious illness.

WARNING: If you are pregnant, nursing, taking other medications, or recovering from or preparing for surgery, please consult with your doctor before taking any of the medications or natural remedies discussed in this article.