In This Chapter
- Cultural awareness
- Foodborne illness
- Water purification
- Prevention and treatment of foodborne illness
- When to seek medical help
- When dining abroad, be aware of basic customs, dining habits, and other cultural differences associated with mealtimes.
- Take extra precautions with raw meat, poultry, shellfish, eggs, fresh produce, and other foods associated with foodborne illnesses.
- Carefully wash your hands before you eat and after you use the bathroom in order to prevent illness and the spread of infection to others.
- Make sure to purify your water; drinking contaminated water can put you at risk of serious illness.
- Carry an antibiotic (prescribed by your physician) and seek medical treatment for symptoms of foodborne illness from contaminated foods or beverages.
Most operations take place on the soil of other countries, and each country, region, and even town might have its own distinct customs. Food is a large part of any culture, so sharing meals can be a great way to interact and form relationships with local people. Enjoying the local cuisine is important, but some foods or approaches to preparing meals can lead to illness for those unaccustomed to such practices. This chapter covers cultural differences and how to avoid foodborne illnesses.
Cultural awareness means recognizing, understanding, appreciating, and respecting the different perspectives and customs of other cultures. Become familiar with the local customs and cultures to avoid stereotyping, prejudice, and insulting your host, particularly when it comes to dining. Since each country has its own distinct culture and customs, there are things to consider and research before you deploy.
- Know whether punctuality is or is not emphasized.
- Use the appropriate customary greeting (handshake, bow, etc.).
- Learn if it’s customary to bring a gift, food, or beverages to your host’s home or office. In some cultures, it’s impolite to do so and implies that you’re paying for your meal, or it might even be an insult to your host’s cuisine.
- Know whether it’s customary to eat everything or leave some food on your plate. Don’t waste food, because your host might have gone to great expense to prepare an extravagant meal. On the other hand, don’t gorge yourself. In some cases what you consume might be at the expense of feeding your host’s family.
- Avoid rushing through a meal. Eating with others is often as much for social interaction as it is for nourishment.
- Learn whether a certain prayer or phrase is spoken before or after meals and be respectful during this ritual.
- Be respectful to the food and your host. Food has different meanings in other countries, and some items or practices might be considered sacred.
- Find out who is supposed to eat first. Is it your host, other guests, or the person of highest status?
Soup and appetizers
- Is slurping soup considered rude, or is it acceptable or even a complimentary sign of enjoyment?
- Is it customary for appetizers or soup to be served before your meal? Avoid filling up on these items, so you can enjoy your main course.
Meat and fish
- Some religions don’t allow certain meats to be consumed. For example, laws in Islam and Judaism prohibit eating pork. Some Jews also don’t eat shellfish or catfish. Similarly, Hindus don’t eat beef.
- In some parts of the world, dogs, cats, and horses are pets, while in others they might be food animals. Don’t be surprised or put off if your host serves lamb, goat, horse, dog, camel, or monkey.
- In many cultures, people eat or cook with all parts of an animal, including brains, organs, feet, intestines, and more.
- Observe how your host treats you or others visiting his or her office, which might include serving food or beverages. Then behave similarly and, if you’ve learned it’s appropriate, serve something when others visit your office.
- In some cultures, refusing beverages and food when offered is considered rude. In others, it might be a gesture that should be refused altogether or accepted only after a certain number of offers.
- Some meals are eaten at hours you might find unusual. Don’t expect or ask to eat at other times.
- Meals might last longer than what you consider normal, so diners can digest, talk, and relax. Don’t ask to leave too early.
- Muslims fast from sunrise to sundown during the month of Ramadan.
- Some diners use forks as primary eating utensils while others use their hands, spoons, or chopsticks. Try to become familiar with the different utensils, including how and when they should be used during mealtimes.
- Learn where to place your utensils when they’re not being used. For example, in some Asian countries, it’s disrespectful to stick your chopsticks upright in your rice. Place them on your plate or on a chopstick rest if one is available.
- Follow your host’s lead. For example, does he or she push rice from the bowl directly into his or her mouth or eat it with a utensil? And does your host use a spoon to consume soup or drink directly from the bowl?
- Sometimes hand preference is important. For example, Bosnian Muslims eat with the left hand, while Arab Muslims eat with the right hand. Saudis consider the left hand unclean because it’s typically used to maintain personal hygiene.
- Dress appropriately and not too informally.
- In some cultures, it’s important to remove your shoes as you enter your host’s home.
Paying the restaurant bill
- In some countries, it’s customary for the host to pay the restaurant bill. However, if you invite someone to eat out, expect to pay for his or her meal.
In addition to learning the food customs of other cultures, it’s a good idea to find out what foods are commonly eaten in the country you'll be in, so you don't come across any surprises. Visit foodbycountry.com for more information.
Deploying to other countries can increase your risk of foodborne illness or infections if you consume foods or water that contain certain bacteria, viruses, or parasites. The risk of infection varies depending on where the food is eaten. Food prepared in a private home is generally considered moderate to high risk, depending on the hygiene. However, your risk is higher if you purchase ready-to-eat food from street vendors.
The 250+ different foodborne diseases have different symptoms, so there’s no particular “syndrome” that describes foodborne illness.1 The “culprit” is most often a bacterium that enters your body through the gastrointestinal (GI) tract, which causes the first symptoms: nausea, vomiting, abdominal cramps, and diarrhea. Roughly 50% of travelers in high-risk destinations develop “traveler’s diarrhea.” Bacterial infections can last 3–5 days, viral infections can last 2–3 days, and those caused by parasites can last 2 weeks or longer. In addition, persistent abdominal symptoms can develop after the infection has ended.
Foods associated with foodborne illness
Certain foods are typically associated with foodborne illnesses. Raw foods, particularly of animal origin, can be a major concern. Warfighters should avoid raw meat, poultry, fish, shellfish, eggs, unpasteurized milk, and fresh fruit or vegetable juice. Raw fruits and vegetables, such as salads and alfalfa and bean sprouts, can be just as risky as raw meat and fish. That’s because washing can reduce, but not eliminate, contamination, in part because the water might be contaminated too. High-salt, high-sugar, and high-acid levels keep bacteria from growing, which is why salted meats, jams, and pickled vegetables are traditional preserved foods and usually safe to eat.
Make wise food choices
To maintain operational readiness and reduce your risk of foodborne illness, pay close attention to what you eat and drink and always wash your hands before eating. Try to follow these tips when eating abroad.
- Avoid “street food” if possible.
- However, if you choose to eat “street food,” make sure it’s cooked in front of you and steaming hot.
- Don’t choose anything that might have been cooked hours ago.
- Cooked food that’s still hot is usually safe. Don’t consume foods left at room temperature for longer than 2 hours.
- Most bakery products are safe, but avoid those with cream or meat fillings.
- Order hamburgers cooked “well done” and without lettuce or tomato. Meat, poultry, fish, and eggs also should be cooked thoroughly.
- Staple items such as pasta, rice, potatoes, or other root vegetables that have been boiled or cooked over high heat are safe.
Fruits and vegetables
- Avoid raw ingredients such as fresh vegetables. Fresh salads, even in many restaurants, can be contaminated due to the use of human waste for fertilizer.
- Fresh fruits and vegetables with skins are usually fine if cleaned thoroughly. Scrub the skin with purified water or soap and water and then peel. If not cleaned first, surface contamination might be transferred to the fruit or vegetable during the peeling process.
- Avoid fruits and vegetables that have been peeled already.
- Choose bottled or boiled water, hot beverages (such as coffee or tea) made with boiled water, and canned or bottled carbonated beverages, beer, and wine. Don’t drink from containers that have been opened already.
- Avoid ice in beverages because it might have been made from contaminated water.
- Use purified or bottled water to brush your teeth. Don’t even use small amounts of untreated water to rinse your mouth.
- Avoid milk, other dairy products, and juice that have not been pasteurized.
You can get a handy pocket guide, “Tips for Eating Local,” from the U.S. Army Public Health Command.
Contaminated drinking water or food grown or prepared with contaminated water can increase your risk of traveler’s diarrhea. Boiling is the most reliable method to make water safe to drink. Bring water to a rolling boil for one minute, and then allow it to cool. Boil drinking water for 3 minutes if you’re at altitudes higher than 6,500 feet.2
You also can purify water with chemical disinfecting agents, specifically iodine or chlorine. These chemicals might not make water taste like bottled water from home, but they will decrease your risk of developing traveler’s diarrhea. The disinfection capabilities of iodine have been recognized for many years, and iodine tablets are widely used as an emergency drinking-water disinfectant. Chlorine also is a reliable water disinfectant. Issued by the military, water purification tablets that contain chlorine kill Giardia lamblia cysts, bacteria, viruses, and other harmful microorganisms; they also remove sediment. Follow the manufacturer’s instructions on the package for whichever method you choose.
You can use filters to reduce microorganisms in water too. However, this method depends on the pore size of the filter and the amounts and sizes of the contaminants in the water. It’s important to carefully choose your filters because they might not effectively remove all viruses and bacteria. If a filter has a chemical disinfectant matrix, it’s more likely to be effective against some viruses. Just as with chemical disinfectants, carefully read and follow the manufacturer’s instructions on the package.
Prevention and treatment of foodborne illness
You might be able to prevent or treat many foodborne diseases. In addition to making wise food choices and drinking safe water, wash your hands before eating and after using the bathroom. If soap and water are unavailable, use an alcohol-based sanitizer (containing at least 60% alcohol) to clean your hands.3
Another preventive approach is to use Pepto-Bismol (brand name for the antacid bismuth subsalicylate). You can take it before and during international travel to help prevent diarrhea; doing so will reduce your risk of disease by half.3 Take 2 ounces of the liquid medication 4 times daily, or 2 tablets 4 times daily, for no longer than 3 weeks. You also can use Pepto-Bismol to treat diarrhea and reduce the duration and severity of your illness.
Possible side effects of Pepto-Bismol include temporary blackening of your tongue and stools, occasional nausea and constipation, and rarely, ringing in your ears. Check with your healthcare provider before taking Pepto-Bismol, especially if you are using other medications or supplements.
You also can try probiotics (healthy bacteria or yeast), but they don’t seem to work consistently. While antibiotics are effective, you shouldn’t take them to prevent traveler’s diarrhea unless even a short bout of diarrhea might affect your mission. Seek medical advice from your healthcare provider before going abroad.
The treatment of foodborne illnesses depends on your symptoms and the need to cure your infection in a timely manner. Illnesses that primarily cause diarrhea or vomiting can lead to dehydration. So, treating your traveler’s diarrhea also requires you to replace lost fluids and electrolytes. Early and effective treatment also can lead to a quicker recovery.
Sometimes food-borne illness can cause severe dehydration, especially if you experience frequent vomiting. Symptoms include thirst, less-frequent urination that is unusually dark, dry mouth, fatigue, dizziness, and light-headedness (as discussed in Chapter 5). If you experience severe dehydration, use oral rehydration salts (ORS) solution to restore fluid losses. ORS packets—available at stores or pharmacies in almost all developing countries—are similar to Pedialyte®. Prepare ORS by adding one packet to boiled or treated water. Follow packet instructions to ensure the salts are added to the correct amount of water.
Since bacteria cause the majority of traveler’s diarrhea, the Centers for Disease Control and Prevention recommend treatment with an antibiotic. Treatment with an antibiotic (often a single dose or one-day course) can reduce the duration and severity of traveler’s diarrhea.4 Before your deployment, your physician might provide you with an antibiotic to take with you, or you might have to seek medical care when affected to obtain this prescription treatment.
In addition to antibiotics, you can use other medications—such as loperamide (including over-the-counter Imodium®) or Lomotil (by prescription only in the U.S.)—to improve your symptoms. These are particularly effective when used with antibiotics. However, you should avoid such medications if you have a high fever or bloody stools because they could make your illness worse.
When to seek medical help
Foodborne illnesses can be dangerous, so it’s important to seek treatment. Consult a healthcare provider when your GI illness is accompanied by:
- High fever (temperature over 101.5°F, measured orally)
- Blood in your stools
- Prolonged vomiting that prevents keeping liquids down
- Signs of dehydration, including a decrease in urination, dry mouth and throat, and feeling dizzy upon standing
- Diarrhea that lasts more than 3 days
- Persistent GI symptoms lasting 2 weeks or longer after infection
For more information on avoiding foodborne illness abroad, visit the U.S. Department of Health & Human Service's Food Safety blog.
- Centers for Disease Control and Prevention. (2016). Foodborne Germs and Illnesses. Retrieved 26 April 2017 from https://www.cdc.gov/foodsafety/foodborne-germs.html
- Centers for Disease Control and Prevention. (2009). A Guide to Drinking Water Treatment and Sanitation for Backcountry & Travel Use. Retrieved 26 April 2017 from https://www.cdc.gov/healthywater/drinking/travel/backcountry_water_treatment.html
- Connor, B. A. (2015). Travelers' diarrhea. CDC Yellow Book: CDC Health Information for International Travel (2014 online ed.). cdc.gov: Centers for Disease Control and Prevention. Retrieved from https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea.
- Yates, J. (2005). Traveler's diarrhea. American Family Physician, 71(11), 2095–2100.