These are largely first-world concerns. The week I returned from Djibouti, the World Health Organization released a statistic for annual deaths from diarrhea worldwide: 2.2 million. The estimate for ETEC alone is 380,000 to 500,000 deaths per year. Children especially are at risk because they dehydrate dangerously fast. The Centers for Disease Control and Prevention puts the daily toll for deaths from diarrhea in children under five at 2,195—more than from malaria, AIDS, and measles combined. (The Gates Foundation is funding the Navy’s efforts to develop an ETEC vaccine.)
Riddle traveled a lot in his twenties and recalls being hit by a realization. So much of people’s lives—their opportunities, their health and longevity—comes down to where they were born. “It’s so random,” he says. We’re over at his office, which is downstairs from his lab, in the same container. “It shouldn’t be that way. It shouldn’t matter where your parents happened to live.” He pauses for a jet ripping through a takeoff. At certain times of day, you get this every few minutes. It’s like having a desk under the tarmac at Heathrow. The commotion fades and Riddle resumes. “I went into medicine wanting to help the greatest number of people.” And then, just when I thought he’d gone all earnest on me: “I happened to fall into diarrhea.”
AT CAMP Lemonnier there is often a quicker route to where you’re going, but to follow it you’d need to be shot. You’d need to scale a twelve-foot-high Cyclone fence and the barbed-wire Slinky along top of it, ignore the sign—Stop! Deadly Force Authorized!—and cross into the secure zone. Camp Lemonnier is the hub of counter-extremism activities in north Africa and Yemen. A fleet of drones resides in the zone, along with Navy SEALs and other Special Operations ghosts who pass in and out on their way from one classified gig to the next.
These are the people I want to speak with. I’m interested in diarrhea as a threat to national security. How would the takedown of Osama bin Laden have played out had one of the SEALs been fighting the forces of extreme urgency? How often is food poisoning the cause of a “mission fail”?
Yesterday I convinced the droll and adorable Camp Lemonnier public affairs officer, Lieutenant Seamus Nelson, to put a request in the daily email feed that goes out to everyone on base. (“. . . Mary is looking for individuals who would be willing to share a story about how a case of diarrhea has impacted them while engaged in operations. . . .”) Because really, how do you step into that conversation? The men of Special Operations are easy to spot—the beards, the build, the air of stony omnipotence—but they are not easy to talk to. They keep solidly to themselves. You don’t find them in the bar or the Combat Café. No one from Special Ops showed up at the LGBT barbeque or competed in the Fourth of July Cardboard Boat Regatta. Nor will you find them at the gym. They have their own equipment and trainers inside the zone.
“They only come out to eat,” says Riddle. We are sitting in Seamus’s office, waiting to talk to one of the four people who replied to the now infamous diarrhea email.
Seamus nods. “And to steal our women.”
The interviews have been scheduled back-to-back, one man coming in as another leaves, the Public Affairs container having taken on the quiet, hangdog air of a Catholic confessional. We just listened to the commanding officer of an inshore boat unit that protects Navy ships from USS Cole–type terrorist attacks in the port of Djibouti City. He demonstrated the maneuvers using Seamus’s stapler as the “high-value asset” kept safe by a tape dispenser and a bottle of allergy pills, zigzagging across each other’s paths. An inopportune bathroom break would leave the stapler vulnerable to attack. Even if crew stick to their posts, their vigilance is compromised; “illness preoccupation” is an overlooked military liability of diarrhea.
We heard a similar tale from a bombardier. On a long sortie out of Diego Garcia island, the only crew member capable of operating the plane’s defensive equipment abruptly left his post to use the chemical toilet—while flying over Taliban-controlled Afghanistan. On the return flight, a faulty seal combined with the pressure differential between the toilet’s tiered chambers caused the contents to spew into the crew cabin. “Be assured,” he deadpanned, “this blue-brown precipitation affected the navigator’s ability to concentrate on his duties.”
Our 3:30 is retired from Special Operations, now working as a contractor. A tattoo on the inside of one forearm depicts a pair of crossed metal objects that I can’t identify but guess to be martial arts weapons of some variety. When I ask what his job is, he answers cryptically, “I fix things.” I take this to be a euphemism for some unspeakable niche calling—eliminating witnesses, disposing of bodies, God knows. Subsequent conversation reveals that the man is, in fact, a mechanic. He fixes things. The objects in the tattoo turn out to be pistons.
The mechanic was hit with diarrhea every time his team deployed. Because of this, he was never assigned any “long-range surveillance,” meaning counter-terrorism missions deep into insurgents’ turf. These missions, he says, entail hiding out in a hole,** watching a particular spot—say, an intersection: who comes and goes, how many trucks drive through, at what time of day.
I nod, but don’t entirely understand. “To find out . . . ?”
“Do we aim a bomb here.”
“Ah.” Silly me.
I ask the Special Operations mechanic whether he knows of a vital operation that might have been compromised because someone got a vicious case of food poisoning. He dismisses the very idea. “The guys they select for this type of work? They don’t have these types of problems. They’re selected for a reason.”
After he leaves, Seamus turns to us. “Wow, do you think that’s part of the screening for Special Operations? Give you some bad food, see how you do?” He’s joking, but in fact 20 percent of the population are what Riddle calls “nongetters”: people who can eat ceviche from street vendors, drink the water, never get sick. It would certainly be an asset. Riddle wonders whether Special Operators take antibiotics or Imodium prophylactically, just in case, before critical missions. Or are they just suffering in silence? The Camp Lemonnier Special Ops doctor—they have their own, natch—talked about the men’s reluctance to seek medical help lest they lose their Special Operator status.
Riddle and I have a lot of questions. Alas, no one from Special Operations replied to the diarrhea email.
Perhaps a second email is in order, this one offering compensation. Riddle advises against it. He says people will make up a story to get the cash. He has had men sign up for the diarrhea study, go into the bathroom, and hand him a Commode Specimen Collection tub with a perfectly formed turd inside.
“Also?” Seamus again. “I’m done sending out PSAs about diarrhea. I’m set.” He got some blowback from Combined Joint Task Force–Horn of Africa headquarters regarding appropriate content for base-wide email.
Chow is my one shot.
SEAMUS NELSON is six foot three. When he extends his neck to its full reach, his head is like a periscope. It’s up now, surveying a sea of clean-shaven, supper-chewing heads in the Camp Lemonnier dining facility. He’s scanning for facial hair. Only two categories of men here are allowed to wear beards:†† Special Ops and civilian contractors who want to look like Special Ops.
“There’s your guy.” The neck now retracted. “Far corner by the door.”
Riddle and I rise from our seats. We saw this man yesterday, coming out of the tactical shop. Even without the beard, you’d know he’s one of them. There are men who attempt to broadcast toughness by what they wear or drive or have tattooed on themselves. And there are others, like this man, who do nothing to cultivate or consciously project it, and yet it is obvious. It accretes naturally of the things they’ve experienced.
Besides, I saw him go into the secure zone.
This promises to be awkward. It’s not just the topic. It’s how people like this make you feel: the sudden reveal of your smallness and the inconsequential preoccupations of your existence. What could be smaller than writing about diarrhea? And how to explain why I’ve singl
ed him out?
“Seamus, come with me. Introduce me.”
Seamus peels an orange, one long strip spiraling down to his tray. “I don’t know, Mary. We weren’t trained on this in public affairs school.”
I collect my notepad and tape recorder.
“Hang on.” Seamus, clearly stalling, wipes orange from his fingers, one at a time. “I’m going to be shaking his hand. He’ll kill me.” He lowers his voice: “You got me sticky.”
I stand up. Seamus makes a brief, warbling unhappiness sound and pushes back his chair.
We cross the cafeteria, nervous middle-schoolers at the dance. The man sees us but does not alter his expression. We stop a couple feet back from the table. Some kind of attitudinal concertina wire. Seamus plunges ahead. “Mind if we join you for a second?”
The man takes hold of the sides of his meal tray. “I’m done.”
“We . . .”
“I’m leaving.”
Seamus keeps paddling. “Do you have time for a quick question, what line of work are you in?” What line of work are you in! I adore Seamus Nelson.
The man glances at Seamus, at me, and back to Seamus. “Who are you.” Said like something thrown.
“I’m in Public Affairs, and this is an author. She’s working on a chapter for a book, and she’s specifically focused on how diarrhea impacts a mission . . .”
This is my cue. I’m going to assume the man is Special Operations, and that he knows we know. “I was wondering whether you might ever have been in a situation where . . . in a critical mission that . . .” I back up. “Well, because diarrhea is looked on as sort of a silly—”
“It’s not.”
He speaks softly, and what he says next I can’t quite make out. Something about being curled up in a hole in the fetal position. He says that where he just got back from, some unnamed “out station” in Somalia, it hits everyone. This is probably not exaggeration. In Riddle’s survey of diarrhea in Iraq and Afghanistan, 32 percent of respondents reported having been in a situation where they couldn’t get to a toilet in time. And Special Operators in the field get sick twice as frequently as everyone else.
His name, he says, is Carey. He invites us to sit down. I place my tape recorder in plain view—that is to say, in plain view of anyone on my side of the table. That is also to say, behind the condiment caddy.
I need Carey to set the scene. “What if you . . . I mean, what if someone were a sniper, and they’re in a hide for . . . well, how many hours would it be?”
“Depends on the mission. You’re watching for something to happen that might not happen.”
“Right, and most likely you’re out in some village, and you’ve had to be eating stuff that’s not prepared as hygienically as—”
“Goat,” he says. I had heard a story earlier about a goat meal in rural Afghanistan. It contained the phrases “singed hair” and “otherwise uncooked.” Unsanitary conditions, Carey confirms, are a given. “Unfortunately, we don’t fight in first-world countries.”
Carey says he does not, as Mark Riddle had heard some men did, take antibiotics or Imodium prophylactically before the mission or after the goat. He takes one precaution. It is a strict rule among Special Operators. “You go to the bathroom before going into a danger situation.” There has been no shift from the gravely quiet tone with which Carey has been speaking. Nonetheless, Seamus blurts, “Kind of like a road trip with the family, and Dad’s like, ‘I don’t care that you don’t need to go.’”
On a family road trip, no one has you in the sights of a semiautomatic rifle while you squat in the dirt. Historian of military medicine A. J. Bollet quotes a letter written by a Civil War soldier who explained that an unwritten code of honor forbade the shooting of a man “attending to the imperative calls of nature.”‡‡ In the war on terror, there’s no such etiquette.
I’m still trying to get Carey to tell the story of a specific high-stakes operation. “Have you have been in a situation where you’ve been—”
“Inabilitated?” I like this: a combination of inability and disabled. “Yes. I have been inabilitated because of food sickness.” Carey leans back, one arm along the back of the adjacent chair. “I’m not sure what you guys want from me.”
Seamus tries to help. “Can you walk us through the story. You know, like: There I was . . .”
Carey isn’t going to supply the There-I-Was. “I have many stories where I’ve soiled my pants on missions. In Iraq, I’ve soiled my pants. In Afghanistan, I’ve soiled my pants.” No one stays back or leaves to find a toilet once an operation is under way. Diarrhea cannot be a “kill stopper.”
“And then what happens?” Seamus leaning forward like a kid at story hour. “You go on to . . . do the job?”
“There’s no other option. I mean, it’s kind of a life or death thing. So.” He shrugs one shoulder. “You go. Worry about it later. As long as you walk out and the mission is accomplished. And that’s about as specific as I can get.”
I tell him about Mark Riddle’s TrEAT TD study. “You should bring along a single sixteen-hundred-milligram dose of rifaximin and a bottle of Imodium.”
Carey holds my gaze for a moment. “What is the objective here?”
I restate my mission. I show him my notebook, open to the page where Mark Riddle is describing what, for the purposes of his study, constitutes diarrhea (“has to be pourable or take the shape of the container”).
“Well, you’re in the wrong place, Mary.” Carey tells me to go down to Somalia. Yes, let’s picture it—middle-aged American with her cork-bed comfort sandals and wheelie bag, wandering the desert redoubts of the local al-Qaeda affiliate. Yoo-hoo! I’m looking for the Navy SEAL safe house?
“You could get yourself down there if you wanted to. It’s not dangerous.” He pushes two fingertips through the curl of his beard. “Well, it’s a little dangerous.”
Carey apologizes for the frosty reception earlier. “I thought you guys were NCIS.” Naval Criminal Investigative Service. “You scared me.”
CAREY IS right. People don’t get diarrhea by eating at Camp Lemonnier. They get it by “eating on the economy”: the Special Operators get it in remote villages, and everyone else gets it by going in to Djibouti City for a change of pace from spaghetti and Taco Tuesdays. Like you on your Mexican§§ holiday, they ingest contaminated tap water or food that’s been sitting out unrefrigerated. Before a downtown suicide bombing caused the base to be put on restricted liberty, a month before I arrived, Riddle was seeing two dozen food poisoning cases a week. During the past month, since everyone’s been confined to base, only one person—the guy who found a restaurant that delivers—has stepped through the door. Riddle catches up on paperwork. The lonely diarrhea researcher.
The Camp Lemonnier galley goes to lengths to keep bacteria away from the food. The entry hall is flanked by rows of knee-operated hand-washing stations, with pole-mounted Purell dispensers at the end of these. All well and good, but here’s what really matters. First, the cooks and prep crew wash their hands after they go number two. So if any of them has diarrhea, that person isn’t spreading the bacteria to food that then sits out at room temperature, allowing said bacteria to multiply to levels at which they cause illness. And second: There are no flies in the Dorie Miller Galley. Since the dawn of air-conditioning, military chow halls have been sealed. No one needs to open a window, and no one can.
It was as a result of this connection—fewer flies in the mess equals fewer gastrointestinal infections—that the filth fly was originally busted as a vector of disease. In 1898, during the Spanish-American War, a trio of army physicians, including the illustrious and eponymous Walter Reed, were called to Cuba to investigate an outbreak of typhoid fever that was killing one in five US troops. (It was Reed’s medical sleuthing that proved it was mosquitoes, not bad air or unclean bedding, that transmitted yellow fever.) Straightaway, the team noticed that the infection rate was lower among the officers whose mess tents had screens to keep bugs out. I
t also varied by the different camps’ methods of “disposing of the excretions.” Open pit latrines were associated with higher rates, possibly because, as Reed’s team wrote, “flies swarm over the infected fecal matter.”
Reed had his two suspects—flies and the bacteria-laden feces they feed on—but no smoking gun. Flies don’t bite. How were they transmitting the pathogen? One fine day Reed’s gaze fell upon a fly walking around on the soldiers’ food. Looking more closely, he noticed white powder on its little hairy legs. Where had he just seen a white powder? The pit latrines! Soldiers had been sprinkling lime in an attempt at camp sanitation. The flies’ feet were delivering bacteria from shit to stew. They’re what’s called a mechanical vector. Ten Salmonella enterica serovar Typhimurium isolates multiplying in a pot of beans in the warmth of a Cuban noon will be a million by dinnertime.
Reed’s legacy lives on in the Entomology Branch of the Walter Reed Army Institute of Research, my next destination. Military entomology runs the gamut you’d likely expect: killing disease-carrying insects, keeping them away from soldiers, and creating vaccines and treatments for the times when neither of those can be managed. In the case of filth flies, something less usual has been going on. Unlike in most military entomology war stories, the insect this time is the hero.
___________
* By the fair play rules of acronyms, this should be TEAT TD. Never mind, though. It’s hard enough for diarrhea researchers to get the respect they deserve without bringing teats on board.
† Here is my diarrhea research statistic: When you are communicating with a pair of diarrhea researchers named Riddle and Tribble, there is a 94 percent chance you are going to slip up and refer to one or both of them as Dribble.
‡ 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.