Rach's Reflections (or 'Reality Checklist') on Traveling in China

This summer, I journeyed to China for the first time ever. This was also my first major travel adventure since being diagnosed as a type 1 diabetic six months prior. The trip took 21 days, crisscrossing the continent and including some less visited places (down what might be called 'incomplete' roads). It was a great trip! Entirely doable. And I'm ready to go back!

But oh...there were a few little things that it'd have been useful to know ahead of time.

Before going I searched high and low for travel advice. I read things like not to wear shorts, tank tops, or backless sandals for modesty's sake, that trousers were better than skirts, and a heap of mind-boggling instructions on how to adjust insulin schedules across time zones. Then I started packing. Then reality set in. Then I departed. And then more reality set in.

Following is my 'reality checklist' -- my observations, comments, and new found advice on 'If this is Tuesday it must be Xichang' tours to China as a diabetic and as a madcap tourist in general. Cheers!

• Carrying Diabetic Supplies and Going Through Security
• Diabetic Supplies, Gear, and Information for Foreign Authorities to Take
• Eating
• Adjusting Insulin (Lantus) and Taking Shots on Planes
• Taking Meter Readings on Bumpy Bus Rides
• Things Having Nothing to Do with Diabetes (or 'Warnings About Restroom Facilities')
• Recommended Clothing List for a Summer Trip
• Other Good Things to Pack
• Things to Leave at Home
• Last But Not Least

Carrying Diabetic Supplies and Going Through Security

My original packing plan was to take one 22-inch suitcase (travel light as possible), a carry-on daypack, and an empty duffle bag for souvenirs. I'd double my diabetic supplies (in case of disaster); my brother (who was also going on the trip) would carry half (so as not to have all my eggs in one basket, so to speak); and of course, for the sake of safety and accessibility, all diabetic gear would be taken on the plane as carry-on...

Comment #1: You may have someone to carry half your supplies, but when you are going through airport security, you will probably want to be the one to be carrying it all. In a language as foreign to the western tongue as Mandarin, it is easier to explain you carry syringes because you are diabetic than to explain who that other person back in the line is and why they are carrying sharp objects.

Sidenote: On the subject of whether or not to inject in public, my suggestion is DO inject in public. Restrooms in China are truly truly truly unsanitary. Also, when done openly, the aura of suspicious activity is dispelled.

Comment #2: When you are toting all your diabetic supplies yourself, one daypack-sized carry-on starts to become very small!

Comment #3: Do not count on people in China being able to speak English, even in places like airports. Carry an index-sized card printed with the Mandarin characters and pinyin spelling for 'diabetes' and 'injection.'

Tip: Laminate the 'translation card' or cover it in something waterproof, like contact paper. I found some hard plastic cardholders at a Japanese stationery store that were very handy.

Comment #4: Be prepared for people in China, including airport security personnel, not to know what diabetes is or what it requires -- translation card notwithstanding. There should be someone who knows, but it may take a few minutes of conferencing between security personnel.

Comment #5: Do not carry your glucometer lancer 'loaded,' as many of us do, through airport security. Remove the lancet and keep all lancets capped.

Comment #6: Train travel in China also requires a security check. Everything that applies to airport security also applies to train station security.

Comment #7: Your back up person, the one lugging half your supplies for you -- he or she will need all the same special insulator bags as you for your insulins. And if like me, you use Frio bags, not thermal bags with ice packs, they will need mesh bags to carry the insulator bags in too.

Comment #8: Frio bags are a must. They truly are. They are activated simply by soaking them in water, and do not have to be resoaked for 2-3 days. Unless you know you will only be in major cities with refrigerators in your hotel rooms, ice packs are a no go. If you have long transits between major cities with their refrigerators, ice packs are also a no go. Don't count on finding ice itself as a back up.

Tip: If you use an injector pen, the small Frio bag for injector pens is very useful. You can leave most of your insulin in your hotel room and just carry the small injector pen bag.

Tip: I left my translation card with my insulins when I left the vials behind in my hotel rooms, to explain to bypassing housekeeping what the vials were for.

Diabetic Supplies, Gear, and Information for Foreign Authorities to Take

In terms of amount of supplies, I packed 3 bottles of Lantus (my basal insulin), 8 cartridges of Novolog (my bolus insulin), 20 syringes, 100 injector pen needles, 44 glucometer lancets, 8 vials of test strips, and 1 bottle of 50 glucotabs. I also brought along 2 injector pens, 2 glucometers, and calibration control solution for the glucometers.

Comment #9: For 21 days, 8 vials of test strips was right as a double supply. I went through about three and half vials during the trip. I do use needles for more than one shot, which of course is a personal choice, but I originally calculated for more frequent changes than normal. However, I used only 28 injector pen needles, 6 syringes, and 7 lancets. All these objects provided for some bulk in the medical bag, so personally for next time, I'd trim the numbers of supplies I'd carry a bit.

Comment #10: I actually took quadruple the amount of Novolog I usually use, and two extra bottles of Lantus. That was definitely overkill.

Sidenote: I went through exactly the same number of Novolog cartridges in 21 days as I would have at home -- 2

Comment #11: Glucotabs are definitely useful. Dragging luggage burns carbs. One bottle was a goodly amount. Glucose tablets are sold in China at the supermarket in case you should want more, but carb content isn't labeled.

Tip: Glucose gel is good to bring for low blood sugar emergencies, in addition to a glucagon kit. It can be given even to an unconscious person. Inevitably, there will be a time when your trained back up won't be with you and anyone can handle the gel with minimal prior instruction.

Sidenote: I'm told recovery from a glucagon injection is an ordeal, an intimidating thought considered in the light of the warnings against having medical treatment in China. If the gel works, a bit of trauma might be saved, and I've been told it's a simpler first line of defense.

Comment #12: Know the generic names for your insulins. Carry the pharmacy labels from the boxes for insulins and needles/syringes/lancets, and copies of your prescriptions plus a letter from your doctor about your need for them. Also carry the package information inserts for your insulins (and any other medications). You never know, it might be helpful for a doctor to understand what medications you take and what might be substituted.

Tip: Lantus is 'insulin glargine' and Novolog is 'insulin aspart.'

Tip: If you have to go to a Chinese medical facility, watch attending personnel closely to make sure they wash their hands, don't reuse needles, etc.

Tip: Do a web search, before you go, for the most appropriate medical facilities in the area you will be traveling to. In some places, there are clinics for foreigners in particular. In other places, note that western medicine may not be readily available. The U.S Embassy in China offers medical facilities info online at http://www.usembassy-china.org.cn/us-citizen/medical.html

Tip: Medical travel insurance with air evacuation is important! When you need out, you need out!

Tip: Register your pending trip with the U.S. Embassy. You can do it online at https://travelregistration.state.gov/ibrs/

Comment #13: Glucometers have an altitude specification -- that is, the highest altitude at which they've been tested and verified as able to work. My trip to China included an excursion to Lhasa, in Tibet, which has an altitude of almost 12,000 ft. The highest altitude specification I've seen for any glucometer is 10,500 ft. If you plan to go to a high altitude, it is something to keep in mind, that your meter readings may be off.

Sidenote: I use the TheraSense Freestyle Flash (which was tested to 10,500 ft.); it seemed to work fine.

Tip: Remember extra meter batteries, just in case.

Tip: Should you lose the control solution for your meter, you can get away with just changing the codes for a new vial of strips and without calibrating with control solution. I know this can be done with the TheraSense Freestyle and OneTouch Ultra meters, in any case -- not that it's recommended!

Comment #14: The injector pen proved to be a very flexible tool. I found it very easy to take shots while on the go with it. I even once managed a shot while walking through a museum on a guided tour, on a very long day of sightseeing. No doubt the pump would have been easier! (but for daunting security checkpoints).

Eating

Eating in China was pretty straightforward in terms of carb counting. The basic meal is rice and/or noodles, vegetables, and some meat. But some things to note:

Comment #15: There is NO diet soda outside of the major cities. There is a reason the Pimsleur language tapes start you off with learning how to ask for tea or beer -- those are about the only choices outside of big cities like Shanghai and Chengdu. Saving a little space in one's bags for a six-pack of Diet Coke bought in Shanghai is not without merit.

Tip: Diet sodas are labeled as "light." Asking for a "diet" soda rings no bells.

Tip: The alcohol content of the beer is pretty low. Also, beer always comes in large bottles. Ordering a beer for each person is a mistake.

Tip: The Wahaha brand of bottled water is good; others not so good. The next best brand is one with a label that highly resembles the Arrowhead label.

Tip: Examine water bottle labels carefully to avoid 'mint water.' This is like drinking liquified toothpaste. Our group mistakenly bought a case of mint water. Bad move. Very bad move.

Comment #16: The hot milk served at breakfast is often pre-sweetened, as is coffee on Chinese airlines.

Comment #17: I wouldn't go near the plain rice congee served at breakfast.

Comment #18: A small, steamed rice bun with meat filling is about 10 carbs (a good alternative to rice congee).

Comment #19: In many places, especially in the northern provinces I suspect, the rice is served at the end of the meal. Ask for it at the beginning of your meal; it makes things easier. The word for rice is pronounced fahn in Mandarin.

Sidenote: And your meal isn't over until you see the soup and watermelon!

Comment #20: Carbs are generally not labeled on packaged food items. If people say otherwise, don't believe them.

Comment #21: When carb content is labeled, like always, read carefully. Pay attention to serving size. For example, you could pick up a Coke and think you were buying low carb C2 Coke by the label. But no. It's that in China one can of Coke serves three people (and waitresses stick to that rule).

Comment #22: It's recommended that you stay away from dairy while traveling in China, but the boxed milk from supermarkets is OK.

Comment #23: Look for supermarkets on the bottom (basement) floor of the big department stores.

Comment #24: A supply of snack bars from home -- such as Luna bars -- with known carb content is extremely helpful when 40-minute monastery tours turn into two-hour ones.

Adjusting Insulin (Lantus) and Taking Shots on Planes

Adjusting basal insulin for the time zone change was easier than I expected. In researching the topic, rarely were adjustments with Lantus ever addressed and recommendations for adjustments across the international dateline, while on long flights, also went missing. I was quite confused until I talked to my nurse educator -- twice. So for Lantus, at least...

Comment #25: You always take the same total amount of Lantus in any given 24-hour period. The time(s) you take it will be adjusted incrementally (one hour at a time), and if you take a split dose, the split may also be switched around incrementally (one unit at a time).

Sidenote: So by way of example, I take a split dose of Lantus -- 12 units every day, 2 in the morning and 10 at night.

There is a 15-hour difference between my home Pacific Standard Time (PST) zone and China time (Note: China uses the same time all across the country, even though it is so large.) This translates to my morning dose being taken at 11 p.m. China time and my nighttime dose being taken at Noon China time. A virtual reversal of the way things should be.

The day after landing, my first full 24 hours in China, I started backing up "shot times" by one hour each day until I was once again taking a first shot at 8 a.m. and a second at 10 p.m. every day (because of the daily sightseeing schedule, I didn't backup all the way to my usual 9 p.m.). And each day after landing, I adjusted the split by one unit until I was again taking 2 units in the morning and 10 at night.

So Day 1, spent in transit, I took 10 units at Noon and 2 units at 11 p.m. by China time. The next day I took 9 units at 11 a.m. and 3 units at 10 p.m., and so on. Coming home, the adjustment schedule was just reversed.

If it were the case that I only took one shot a day, I would have simply altered my shot time 1 hour each day until a workable time was reached.

This is what my adjustment schedule in China looked like:

Home	China	China
Day 1		2	3	4	5	6	7	8	9
5	8	8	8	8	8-6	8-5	8-4	8-3	8-2
6	9	9	9	9-7	9	9	9	9	9
7	10	10	10-8	10	10	10	10	10	10
8	11	11-9	11	11	11	11	11	11	11
9-10	Noon-10	Noon	Noon	Noon	Noon	Noon	Noon	Noon	Noon
10	1	1	1	1	1	1	1	1	1
11	2	2	2	2	2	2	2	2	2
Midnight	3	3	3	3	3	3	3	3	3
1	4	4	4	4	4	4	4	4	4
2	5	5	5	5	5	5	5	5	5
3	6	6	6	6	6	6	6	6	6
4	7	7	7	7	7	7	7	7	7
5	8	8	8	8	8	8	8	8	8
6	9	9	9	9	9	9	9	9	9
7	10	10-3	10-4	10-5	10-6	10-7	10-8	10-9	10-10
8	11-2	11	11	11	11	11	11	11	11
9	Midnight	Midnight	Midnight	Midnight	Midnight	Midnight	Midnight	Midnight	Midnight
10	1	1	1	1	1	1	1	1	1
11	2	2	2	2	2	2	2	2	2
Noon	3	3	3	3	3	3	3	3	3
1	4	4	4	4	4	4	4	4	4
2	5	5	5	5	5	5	5	5	5
3	6	6	6	6	6	6	6	6	6
4	7	7	7	7	7	7	7	7	7

Comment #26: The pressure inside an insulin vial should be equalized before drawing insulin up into a syringe when on a plane. I verified this with my nurse educator. To do this:

1. Pull the plunger out of the syringe and stick the needle into the vial.
2. Remove the needle, replace the plunger, and draw up your dose without injecting air.
3. When you land, equalize the pressure in the vial again by the same method as above, before drawing up.

Comment #27: When you first arrive at a high-altitude location, like Lhasa, it also doesn't hurt to equalize the pressure inside your insulin vial.

Taking Meter Readings on Bumpy Bus Rides

Comment #28: Not a chance!

Things Having Nothing to Do with Diabetes (or 'Warnings About Restroom Facilities')

Conditions are not so impoverished and primitive in China, as they say they once were. We experienced no scheduled power outages, and they have recycling now. The Tibetan Hotel in Chengdu was quite glamourous. However, you may find your hotel turns off the hot water after midnight to conserve energy. And it may be a little off-putting to see sophisticated highways being built with handshovels and buckets.

And without doubt, bathroom conditions are disgusting in China. Sorry to say, this doesn't necessarily have to do with primitive conditions, or the strangeness of the squat toilet, but with mindset.

Not to be indelicate -- but for example, in the Xichang airport restroom, I saw a woman simply hold up her baby for the baby to pee on the floor. She just couldn't be bothered with the niceties. (And needless to say, it was hilarious when one of my traveling companions proceeded to remonstrate the woman with "NOT OK NOT OK!").

In Muli, our 'four-star hotel' had serious bathroom issues. What was bad was not that the whole bathroom was the shower (you can see that in Europe too), but that the water heater (in-room) had an overflow tube that was constantly dripping (once the water was turned on, which you had to ask for it to be). You had two choices, let it drip onto the floor or try to stretch the tube to hang over the toilet (for what's now called the 'insta bidet' setup).

So...

Comment #29: People do not flush toilets too often in China.

Comment #30: There is never any toilet paper anywhere. Including your hotel rooms (don't be fooled by one experience in one luxurious hotel). Carry pocket tissues; never be away from them.

Comment #31: Disposable flip flops are a great boon.

Comment #32: Waterless hand sanitizer is precious.

Comment #33: Always wear those give-away slippers in your hotel rooms. Think about the bathrooms and what people have been stepping in.

Comment #34: Ladies, do not listen to anyone, skirts are immensely practical in China. Remember those bathrooms and squat toilets.

Comment #35: When confronted with a western toilet and a squat toilet, choose the squat toilet. People do not act as if the know how to use their own squat toilets...you can just imagine what they do with a western one.

Comment #36: Take a bathroom buddy to guard the door. They may have walls between stalls, but the bathroom door will always open straight on.

Comment #37: Do not be surprised when on a long bus ride, the bus stops and your guide announces a pit stop...and you disembark into some farmer's field with nothing in sight but growing crops...and bees.

Comment #38: Everyone is hip to international fashion. Sandals are just fine, even without backstraps (as are shorts and tank tops). You may even long for them when traveling makes your feet swell. However, thinking about those bathrooms, platform sandals are good. Yes.

Comment #39: Stick with four- and five- star hotels. Whether you'll get 'the Ritz' or 'Motel $5.50' is still pretty dicey. Expect those fancy hotel people to come after you to pay for 'damaged washcloths,' even though they put you in a room with broken plumbing. In more out of the way towns, expect strange herds of mahjong players to scurry into the lounges like cockroaches.

Comment #40: Laundry services are pretty tough on clothes. Expect your clothes to come back looking like they have been beaten on a rock, but nicely pressed. (This, by the way, goes for all third-world countries.)

Comment #40: Airport tax is about 50 yuan. You pay everytime you get on a plane, and if you do the grand tour, you will get on them often. Remember money for airport tax.

Comment #42: Remember money for tips. Tipping is not illegal, in contradiction to what you might read. At least, it isn't anymore. And in some cases, you may even have to tip the bell boy before he brings up your luggage. Remember your guides and drivers.

Tip: However, note that we were advised not to tip taxi drivers, although we did.

Comment #43: 20 to 25 yuan for a bicycle rickshaw ride across town in Lhasa, from the Lhasa Hotel (the old Holiday Day Inn) to the Potala Palace and bazaar, is a decent fare tally. That works out to about 10 yuan per mile.

Comment #44: The equivalent of $500 U.S. on top of airport tax and tip money is enough pocket money for 21 days, unless you want to buy carpets and art. But then again, if that's the case, just bring your credit card.

Tip: Call your credit card company before you leave to tell them you will be going to China. If not, a freeze may be put on your card when you try to use it in China.

Tip: Money exchanges do not abound in China. Not like Europe. Usually, people in our group exchanged money at the hotels we stayed in.

Sidenote: We didn't take travelers checks, but exchanged money back home at American Express. While there I learned how hard it is in reality to replace lost travelers checks. I stood in line with a woman who had been trying for two days -- and she was only traveling within the U.S.

Comment #45: If you like to 'socialize with natives,' bring extra money -- or better yet some trinkets from home -- for gifts. Lighters make a nice gift for men. Remember your guides and drivers.

Tip: On the subject of money and 'natives,' do NOT make eye contact with beggars and do NOT give beggars money. You will be mobbed.

Sidenote: They train them early for begging, by the way. Do NOT be taken in by big eyes. I managed to keep tots away with my dragon lady, "I'm gonna box your ears IF" look of exasperation, but not all are so fortunate. I saw one poor man stumbling up a hill with three hanging onto his ankles.

Sidenote: The beggars can be very aggressive, grabbing hold of you and fighting each other. At one monastery, a bent old woman and a little boy accosted me. Granny whacked the boy out of her way. And let me tell you, the smacking sound carried.

Sidenote: Oh yes, hold onto your soda cans. My first night out in Shanghai, a woman grabbed my soda can, after I refused to give her money, and tried to pour it down her baby's throat. I grabbed it right back. All in good fun. No honestly. She then cackled madly, pointing and chanting "my coke my coke," and went her merry way.

Tip: Do not be afraid to push and push back in China. You'll be pushed over and stepped on if you don't. Don't grin and make the best of things. Look at this way, it may be a few less so-called damaged towels you have to pay for.

Comment #46: Cipro, Immodium, Peptol Bismol, and Pepcid are a must for the first aid kit. Plus Bandaids, Neosporin, and allergy tablets. A selection of different kinds of painkillers is good -- aspirin, tylenol, aleve. Remember acetazolamide (for altitude sickness) doesn't mix with aspirin.

Tip: You can get Renu contact cleansing solution in China, in department and eye-wear stores.

Comment #47: Save airplane handiwipes. A few handiwipes are a plus. But not too many. Remember hand sanitizer.

Comment #48: Guides don't sit down and eat with tour group members. They get nervous when pressured to do so.

Comment #49: Guides do NOT like you to deviate from the prescribed tour plan in China. They have emotional melt downs (that is, they do if they don't simply block out the wished-for changes). Be prepared to soothe frayed nerves if you change the tour plans.

Sidenote: All guides think all spots take 40 minutes to see, no matter what. Definitely be prepared to calm some guides.

Comment #50: Beware the 'friendship stores' (read: tourist trap after tourist trap with the same old jade bracelets) -- they will take up a lot of time on any guided tour in China.

Tip: Guides are contractually obligated to take you to these stores. Remember, though, you don't have to go inside or to buy anything.

Tip: Haggle. Do it. People see the tourist coming and prices sky rocket. It's really not so good to pay those overblown sums. Not only are you being ripped off, but that sort of thing can lead to inflation for the whole local economy. I've observed it in other countries, where spending by foreigners leads to locals being priced out of the market.

Sidenote: Those silk Tibetan welcome scarves are worth no more than 2 yuan each. Trust me. No matter what you might imagine in terms of input -- raising silk worms, spinning thread, weaving -- that's it: 2 yuan.

Tip: If you have trouble with bargaining, here's how to do it China... Let the seller name a price, then cut that figure in half and offer that. If the seller acts reluctant to drop their price, walk away. Almost inevitably, they'll call you back. If they don't come down enough, repeat the process, move to depart again.

Tip: Do not worry or feel guilty about cheating folks out of anything when you haggle. Chances are, you'll still have overpaid. In fact, expect to be depressed when you find out just how much you overpaid!

Sidenote: Yes, I paid 10 yuan for a welcome scarf.

Tip: If the seller does meet your price, it IS considered rude not to buy.

Comment #51: Remember to get your vaccinations. Go at least a month before your departure.

Recommended Clothing List for a Summer Trip

It may seem skimpy, but hauling big suitcases for 21 days gets tough, especially after you've collected a few souvenirs.

Sidenote: You can buy disposable underwear in China, and batteries too, but don't count on finding anything in larger western sizes in terms of clothes and shoes. Size 10 ladies is impossible to find, that is certain!

Other Good Things to Pack

• Dr. Bronner's Castille soap -- you can wash everything with it, from hair to clothes. All the hotels have retractable clotheslines in the tub area.
• Travel-size Febreeze (this made me very popular! apparently it was just the thing for some of my traveling companions' hotel bedding)
• Handkerchief
• Towel and washcloth
• Blunt nose scissors, packed in check-in luggage
• Emery boards
• Mosquito repellent
• Lotion with sunscreen
• Pocket umbrella (doubles as a parasol, very popular in China)
• Film in transparent cannisters or film in Ziploc bags with no cannisters (!!)

Sidenote: These days, every film cannister must and will be opened and checked individually at security, if the cannisters are the standard opaque kind.

Tip:  Ziploc bags with actual zipper pulls are very good for packing film.

Things to Leave at Home

Unless this gear is like air to you, leave home:

• The big, fancy camera
• The CD player

They get awkward and heavy, especially with that double-supply of diabetic supplies and because you can't risk them in your check-in luggage..

Last But Not Least

A camel ride in the Gobi desert to see the sunrise is splendid indeed!