For every person who shows up at morning sick call, four tough it out. Riddle would like to know why. The average bout of travelers’ diarrhea lasts three to five days. Why endure this, when some of the new antibiotics, Riddle’s data show, can have you back to normal in four to twelve hours? He’s been asking around, mostly at mealtimes. The tables in the hangar-size Dorie[31] are arranged church basement–style, in long rows, so there’s always a friendly stranger across from you or at your elbow, someone new with whom to chat about loose bowel movements while you eat.
Riddle gets right into it this morning with the man to his left. The uniform identifies the man as a Marine sergeant, last name Robinson. “I’m in the Navy,” Riddle is saying, “and we’re looking at simplified treatment regimens for travelers’ diarrhea. We’re finding that a single dose of antibiotic and an anti-motility…”
Robinson looks up from his eggs. “Anti—?”
“Like Imodium,” I offer. “Stops you up.”
“Oh, absolutely not. You do not want to mess with Nature like that.” Robinson has the booming vocals and commanding bullnecked air of the actor Ving Rhames. One imagines Riddle going straight over to the lab after breakfast and tossing his data in the trash—What was I thinking?
“You have something bad in you, bad water or what have you? You got to pass it.” It’s like discussing diarrhea with the Giant Voice. “Defeat the purpose if you mess with that.”
We’ve been hearing this a lot. People think diarrhea is the body’s attempt to rid itself of invaders, or to flush out the toxins they produce. They won’t take an antimotility drug like Imodium because they think it interferes with the purge. But diarrhea is not something you are doing to pathogens; it is something they are doing to you. In varied and dastardly ways. Shigella and campylobacter, two common causes of bacterial dysentery, wield a toxin-delivering “secretion apparatus”—a hypodermic-cum-bayonet that injects toxins into cells in the intestinal lining, killing them and causing the fluid inside them to spill out. That spillage is part of the watery-stool scenario, but there’s more! With enough of those cells out of commission, the large bowel can no longer perform its duty as an absorber of water. Instead of food waste getting drier and more solid as it moves along the gastrointestinal tract, it stays liquid all the way along. The bacterium called enteroaggregative E. coli produces the same effect, in a different manner. It becomes a living cling wrap, a bacterial phalanx that coats the intestine and blocks absorption. Vibrio cholera and enterotoxigenic E. coli, or ETEC, inflict chemical weapons: Both produce a toxin that hijacks the pump that maintains cellular homeostasis. The commandeered pump begins pulling water out of cells faster than patients can replace it by drinking.[32]
Why do these creatures do this to us? Is there an evolutionary motive? Sure, says Riddle. There always is. By causing humans to produce liquid feces, feces that splatter and flow and coat a larger surface area, a pathogen speeds its spread. Cover the world! The bacterium that causes cholera is especially proficient. Cholera patients decant as much as five gallons of liquid a day. The efflux is so torrential that one of Dr. Phillips’s Navy colleagues was inspired to invent the cholera cot, an army-style cot with a hole cut out under the buttocks. (Bucket sold separately.) The cots, still made today, allow patients to “go to the bathroom without leaving the bed,” writes specialneedscots.com, taking euphemism into the realm of quantum physics.
Besides, enteric bacteria are not easily flushed out. They’ve evolved ways to hang on in the deluge. ETEC—the bacteria behind as much as half of all travelers’ diarrhea—are equipped with a hairlike grappling hook called a longus, which they use to pull themselves close to a cell wall. On receipt of a chemoelectrical signal from the cell, the bacteria sprout springy hairs called fimbriae, with suction cups at their ends. Your immune system, for its part, has more sophisticated defenses than simply hosing down the premises. It starts cranking out specially designed antibodies. One might target the suction cups and keep them from adhering. Another might gum up the longus or disable the toxin.
Sergeant Robinson has nothing more to say about diarrhea, but he would like Riddle to have a word with the people responsible for the packet of toilet paper in the combat field rations, or MREs (Meals, Ready-to-Eat). “It’s like this much.”[33] He tears off a piece of napkin the size of a drink ticket. “To wipe your ass!” Riddle volunteers that Navy guys pack baby wipes. He may regret saying this, because Robinson counters that Marines just cut off a piece of their t-shirt. Which possibly sums up the whole Marine Corps–Navy relationship.
Riddle thanks Sergeant Robinson and makes to leave. He likes to get back to his quarters before 8:00 a.m., when the national anthems—first Djiboutian, then American—begin playing over the Camp Lemonnier public address speakers. All those outdoors have to stop what they’re doing and stand respectfully until the music stops.[34] The Djiboutian national anthem is a melodic, sweeping number, like the theme song to an old TV western. The whole thing isn’t played, but it can seem that way should you be having some “postprandial urgency.” Meals—particularly the big ones occasioned by all-you-can-eat chow-hall buffets—trigger the gastrocolic reflex, a major move-along of the contents of the large intestine. Ushering out dinner to make room for breakfast. If, on top of that, you have a touch of irritable bowel syndrome (IBS), there may be times when all the patriotism in the land won’t keep you standing through the final bars.
During his years at NAMRU-3 headquarters, in Cairo, Riddle regularly got hit with diarrheal infections, a result of “sampling the fecal veneer” at local eateries. Irritable bowel syndrome is a well-documented, little-publicized aftermath of diarrheal infections—especially severe or repeated bouts. If you talk to people who’ve recently been diagnosed with IBS, about a third of them will say that their symptoms began after a bad attack of food poisoning. Defense Department databases reveal a five-fold higher risk of IBS among men and women who suffered an acute diarrheal infection while deployed in the Middle East. Even the Veterans Administration recognizes IBS—as well as a form of arthritis called “reactive”—as one of the “post-infectious sequelae” of enteric infections. If patients can show that the condition developed following an infection with shigella, campylobacter, or salmonella during deployment, they’re entitled to benefits. Riddle estimates that the Defense Department could wind up spending as much money on these long-term consequences of food poisoning as it spends on post-traumatic stress disorder.
Why not prescribe antibiotics more widely? First, there’s the issue of antibiotic-resistant strains developing, though this is less of a concern with some of the newer regimens that wipe out infections in a single day—likely not enough time for a resistant strain to evolve and thrive. More worrisome, perhaps, is recent research showing that the colons of overseas travelers who treat their diarrhea with antibiotics, particularly in Southeast Asia, tend to become colonized with two species of “bad” bacteria that they then carry home and can spread around town. Both bugs may inhabit a traveler’s gut only briefly and cause no problems while they’re there, but they are dangerous to patients with weak immune systems. Here again, with the newer single-dose regimens, it may not be an issue.
31
Full name: the Dorie Miller Galley. It is unusual for the military to use a nickname when naming a facility after one of its own. When the man’s full name is Doris, an exception is eagerly made. Doris “Dorie” Miller was a cook who showed commendable bravery during the Japanese attack on Pearl Harbor, so commendable that his name appears on twenty-three government and civic facilities, eight opting for “Dorie” and fifteen—including the US Postal Service—embracing the full Doris. The US Navy named a frigate after Doris Miller. Since most frigates omit first names, the Doris issue was easily skirted, or pantsed.
32
The dose makes the poison. In small amounts, a mimic of the cholera/ETEC toxin is an effective treatment for constipation (in particular, the constipation that afflicts a third of irritable bowel syndrome sufferers). In 2012, Ironwood Pharmaceuticals released a synthetic version that was promptly forecast by one pharmaceutical market researcher to achieve “blockbuster status,” and what could be more fitting for a constipation drug?
33
I tried, but I cannot tell you who decided how much toilet paper to include in MREs, or how. But I can tell you a lot of other things about the TP, because I found the federal specifications, ASTM D-3905. I can tell you the required tensile strength, wet and dry. I can tell you the colors it’s allowed to come in (white, dull beige, yellow, green), the minimum grammage and basis weight, the percentage of postconsumer fiber, the required speed of water absorption. And maybe that’s our answer right there. Because if your anus is as securely clamped as the anus of whoever is in charge of “toilet tissue used as a component of operations rations,” ASTM D-3905, you probably don’t need much.
34
Other bases require this at 4:30 or 5:00 p.m., when the flag is taken in. When the music begins playing, you stop what you’re doing and face the flag. I was at Natick Labs when this happened. Without explanation, my hosts stopped talking, turned, and solemnly faced a display model of a new containerized latrine standing in the sight lines of the flag. Having heard about the horrors of open-bay toileting, it seemed wholly appropriate for us to direct some respect, however unintended, to the Expeditionary Tricon Latrine System.