Chapter 8Advising Travelers with Specific Needs

Brian D. Gushulak

OVERVIEW

Through organizations and agencies or individual activities, many thousands of people are involved in the delivery of humanitarian aid in diverse locations every year. After large-scale events such as the Haitian earthquake of January 2010, the number of those traveling to provide humanitarian aid and assistance can increase significantly. Maintaining the health of humanitarian workers is important to ensure that they are able to deliver care to those in need.

In common with other travelers, people who travel to provide humanitarian aid or disaster relief must first address their personal health and welfare before, during, and after travel. This includes knowledge and preparation for all the usual elements associated with travel to the area. In addition, aid workers can experience specific risks and situations related to the provision of humanitarian care, such as:

• Exposure to the environment that precipitated or sustains a crisis or event, such as a natural disaster or conflict
• Working long hours under adverse or extreme conditions, often in close contact with the affected population
• Damaged or absent infrastructure, including availability of food, water, lodging, transportation, and health services
• Reduced levels of security and protection
• Stress, ethical, and moral challenges related to the event and the resource capacities of the situation

Humanitarian service can damage personal health. Studies involving long-term humanitarian workers have noted that >35% report that their personal health status deteriorated during the mission. Accidents and violence are documented risks for humanitarian workers and cause more deaths than disease and natural causes. Recent estimates place the risk of violence-related deaths, medical evacuations, and hospitalizations at approximately 6 per 10,000 aid worker person-years. Conditions and outcomes vary by location, nature of the humanitarian event, and time spent in the field.

A recent study of Red Cross workers noted a 10% ratio of injury or accident and an exposure to violence of 16%. That study also showed that >40% found the experience more stressful than expected. An earlier study of deaths among Peace Corps volunteers noted that unintentional injuries were the cause of nearly 70% of deaths, followed by homicide at 17%. Illness was responsible for 14% of the Peace Corps fatalities.

However, risks to humanitarian workers are not uniformly distributed across the spectrum of humanitarian aid. For example, in 2009 a survey of violence against humanitarian workers found that a small number of insecure locations (Afghanistan, Darfur [Sudan], and Somalia) accounted for >60% of these events.

PRE-TRAVEL CONSIDERATIONS

Evaluation and Pre-Travel Medical Care

Giving careful attention to pre-travel evaluation, both medical and psychological, in addition to educating travelers can reduce the likelihood of illness and the need for repatriation. Comprehensive medical examinations can prepare travelers by helping identify previously unrecognized disease and allowing for treatment before travel. Careful evaluation of risk factors (family history, history of alcohol or substance abuse, sexually transmitted diseases, and psychiatric illness) may direct additional evaluation and identify previously unrecognized psychological problems or chronic conditions. Identifying alcohol or substance dependence, depression, or other psychiatric illness is important, as these conditions may be exacerbated by the stress of the mission and are often the reason for emergency repatriation.

Those who will be providing medical care as part of their humanitarian activities should be evaluated in terms of occupational risk and the need for preventive or postexposure interventions. Humanitarian aid workers destined to areas of active conflict or limited police presence may benefit from specialized security briefings, either provided by the employing agency or private sources. Medical facilities may be compromised by the disaster or overwhelmed in responding to it. Therefore, volunteers with underlying conditions or pregnant women should be counseled against travel and encouraged to support the response in other ways.

Regardless of the area of the world in which the aid worker will be deployed, certain basics should be addressed in the pre-travel encounter, including routine vaccinations, malaria prophylaxis (if appropriate), food and water precautions, self-treatment for travelers’ diarrhea, risks from insect bites, and injury prevention.

Counseling and Advice

Predeployment education and training are essential, as personal illness or injury burdens the community the worker has come to support. Injuries and motor vehicle accidents are a common risk for travelers anywhere in the world; thus, travelers should be sensitive to their surroundings and carefully select the type of transportation and hour of travel, if possible. In disaster and emergency situations, the traveler should also be aware of physical hazards such as debris, unstable structures, downed power lines, environmental hazards, and extremes of temperature.

Travelers to conflict areas should be aware of landmines and other potential hazards associated with unexploded ordnance. In situations associated with damage or destruction to local services and facilities, humanitarian workers should expect limited accommodation, logistics, and personal support. Humanitarian workers destined for low-resource areas or situations may benefit from pre-travel training and counseling regarding the moral complexities of providing service in these environments.

Preparation

Health Items

The traveler should be advised to prepare a travel health kit that is more extensive than the typical kit and should also be familiar with basic first aid to self-treat any injury until medical attention can be obtained. Aid workers may need to disinfect their own water and may want to carry high-energy, nonperishable food items for emergency use. Humanitarian workers should research the available resources in the destination to tailor how extensive their packed supplies should be. In addition to a basic travel health kit (see Chapter 2, Travel Health Kits), humanitarian aid workers should consider bringing the following items:

Toiletries

• Toothbrush/toothpaste
• Skin moisturizer
• Soap, shampoo
• Lip balm
• If corrective lenses are used:
  • Extra pair of prescription glasses in a protective case and a copy of the prescription
  • Eyeglasses cleaning supplies and repair kit
  • Extra contact lenses and lens cleaner
• Razor, extra blades¹
• Nail clippers¹
• Toilet paper
• Menstrual supplies
• Sewing kit
• Laundry detergent
• Small clothesline/pins

Clothing

• Comfortable, lightweight clothing
• Long pants
• Long-sleeved shirts
• Hat
• Boots
• Shower shoes
• Rain gear
• Bandana/handkerchief
• Towel (highly absorbent travel towel if possible)
• Gloves (leather gloves if physical labor will be performed; rubber gloves if handling blood or body fluids)

Activities of daily living

• Sunglasses
• Waterproof watch
• Flashlight
• Spare batteries
• Travel plug adapters for electronics
• Knife, such as a Swiss Army knife or Leatherman¹
• If traveling to an area where food and water may be contaminated:
  • Bottled water or water filters/purification system/water purification tablets
  • Nonperishable food items
• If traveling to malaria-endemic areas:
  • Personal bed net (insecticide impregnated)

Safety and security

• Money belt
• Cash
• Cellular telephone, equipped to work internationally, or satellite telephone (with charger)
• Candles, matches, and lighter in a zip-top bag
• Extra zip-top bags
• Safety goggles

¹Pack these items in checked baggage, since they may be considered sharp objects and confiscated by airport or airline security if packed in carry-on bags.

Personal Items

Because of the loss of life, serious injuries, missing and separated families, and destruction often associated with disasters, relief workers should recognize that situations they encounter may be extremely stressful. Keeping a personal item nearby, such as a family photo, favorite music, or religious material, can offer comfort in such situations. Checking in with family members and close friends from time to time is another means of support. Satellite telephones are small, can work almost anywhere in the world, and can be rented for less than $10 per day.

Important Documents

In uncertain circumstances, extra passport-style photos may be required for certain types of visas or for additional work permits. Travelers should bring photocopies of important documents, such as passports and credit cards, as well as copies of their medical or nursing license, if applicable. Medical information, such as immunization records and blood type, is also helpful to have. The traveler should carry these copies and also leave a copy with someone back home. In addition, they should carry contact information for the person who should be notified in an emergency.

Registration with Embassies

Travelers should register before departure with the US embassy in the destination country, so that the local consulate is aware of their presence, and they may be accounted for and included in evacuation plans. They should also consider supplemental health insurance to cover medical care and evacuation should they become ill or injured. See the Department of State website for additional information (https://travelregistration.state.gov/ibrs/ui).

POST-TRAVEL CONSIDERATIONS

Returning aid workers should be advised to seek medical care if they sustained injuries during their travel or become ill on return. To ensure proper evaluation, they should advise their providers of the nature of their recent travel.

Depending upon the length of time away or their activities (such as working in health care), returning aid workers may benefit from a complete medical review. Homecoming has also been identified as a risk period for difficulties in psychological adjustment, and appropriate treatment or counseling should be sought. Workers who witnessed or were involved in situations of mass casualties, deaths, or serious injuries or who have been victims of violence (assault, kidnapping, or serious accident) should be considered for referral for critical incident counseling.

Studies have indicated that >30% of aid workers report depression shortly after returning home. The adjustment process can be assisted by a skilled debriefing. Generally, humanitarian workers are able to adapt to the acute and chronic stressors of their work and demonstrate considerable resilience, but they will also benefit from proper rest and support to help them fully adjust back into the home environment.

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