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Chapter 8 Advising Travelers with Specific Needs

Humanitarian Aid Workers

Brian D. Gushulak

OVERVIEW

Through organizations and agencies or individual activities, many thousands of people are involved in the delivery of humanitarian and disaster relief aid in diverse locations every year. After large-scale events such as earthquakes or tsunamis, the number of those traveling to provide humanitarian aid and assistance can increase. Additionally, many others already engaged in international missionary or faith-based activities often become involved in humanitarian and disaster relief efforts. Maintaining the health of humanitarian aid workers is important to ensure that they are able to deliver care to those in need and avoid additional strain on local health services.

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 of and preparation for all the usual elements associated with travel to the area. Additionally, 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 limits in the 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 aid 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 person-years among aid workers. Conditions and outcomes vary by location, nature of the humanitarian event, and time spent in the field.

A study of American Red Cross workers noted a 10% ratio of injury or accident and an exposure to violence of 16%. The same 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 aid workers are not uniformly distributed across the spectrum of humanitarian aid. Ongoing surveillance of violence directed against humanitarian and disaster relief aid workers continues to demonstrate that a small number of insecure locations (Afghanistan, Pakistan, South Sudan, Syria, and the Central African Republic) account for most of these events.

PRETRAVEL CONSIDERATIONS

Evaluation and Pretravel Medical Care

Giving careful attention to pretravel evaluation, both medical and psychological, in addition to educating travelers, can reduce the likelihood of illness and the need for emergency repatriation. Comprehensive medical examinations can prepare travelers by helping identify previously unrecognized conditions 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. People planning long-term assignments should have their dental condition assessed and any problems dealt with before departure.

Missionaries and faith-based workers may have additional issues that need to be considered by health care providers. Their service may involve extended periods of time abroad, possibly their entire professional lives, so the provider must consider the implications of long-term residence in areas of health risk. Additionally, they may be accompanied by family members, including young children. Both of these factors engender additional travel health considerations that may be different than those encountered by short-term humanitarian and disaster relief workers. For more information, see the next section in this chapter, Long-Term Travelers & Expatriates.

Those who will be providing medical care or participating in clinical research as part of their humanitarian activities should be evaluated in terms of occupational risk and the need for preventive preexposure or postexposure interventions. They should also be reminded that providing aid during outbreak situations may involve contact with infected people who are asymptomatic or have nonspecific symptoms, requiring more attention to infection control protocols. Disaster relief and humanitarian aid workers destined for 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 likely to require care and pregnant women should be counseled against travel and encouraged to support the response in other ways. Travelers planning to participate in animal rescue should review information available in Chapter 6, Taking Animals and Animal Products across International Borders, and discuss rabies preexposure prophylaxis with a health care provider (see Chapter 3, Rabies).

Travelers who will be caring for people ill with potentially life-threatening infections such as Ebola virus disease or other diseases spread by contact with blood or other body fluids should be familiar with infection control measures specific for the disease. They should also ensure that their organization provides personal protective equipment (PPE), such as masks, gloves, gowns, and eye protection.

Regardless of the area of the world in which the aid worker will be deployed, certain basics should be addressed in the pretravel encounter, including routine vaccinations, malaria chemoprophylaxis (if appropriate), food and water precautions, self-treatment for travelers’ diarrhea, risks from insect bites, behavioral risk avoidance, 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 common risks 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. Although rare, emergency situations in developed nations may involve unusual exposures, such as radiation exposures observed after damage to nuclear facilities after the earthquake in Japan in 2011.

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 aid workers should expect, anticipate, and plan for limited accommodations, logistics, and personal support. Disaster relief and humanitarian aid workers destined for low-resource areas or situations may benefit from pretravel 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 and disaster relief workers should research the available resources in the destination to tailor how extensive their packed supplies should be.

Those with underlying medical conditions requiring treatment should ensure that, if possible, they travel with prescriptions and medications sufficient for the duration of their service. As not all pharmaceuticals are globally available, travelers who will be on extended deployment should review alternative preparations or compounds should their normal formulations not be available. It is a good practice to separate and store medications in 2 separate allotments in case of loss or theft. People with dental crowns or bridgework may wish to carry temporary dental adhesive for short-term management of a dislodged dental appliance. 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 and 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
  • Disposable razor, extra cartridges
  • Nail clippers
  • Toilet paper
  • Menstrual supplies
PROTECTIVE CLOTHING
  • Comfortable, lightweight clothing
  • Long pants
  • Long-sleeved shirts
  • Hat
  • Boots
  • Shower shoes
  • Rain gear
  • Bandana or 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)
  • Safety goggles
ITEMS FOR DAILY LIVING
  • Sunglasses
  • Sunscreen
  • Insect repellent
  • Waterproof watch
  • Flashlight
  • Spare batteries
  • Sewing kit
  • Laundry detergent
  • Small clothesline and clothespins
  • Travel plug or voltage 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 bag2
  • Extra zip-top bags

1 Pack these items in checked baggage, since they are considered sharp objects and will be confiscated by airport or airline security if packed in carry-on bags.
2 See www.tsa.gov for restrictions on traveling with lighters and matches.

PERSONAL ITEMS

Because of the loss of life, serious injuries, missing and separated families, and destruction often associated with disasters, humanitarian aid 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 <$10 per day.

IMPORTANT DOCUMENTS

It is often useful to have extra passport-style photos, which may be required for certain types of visas or for additional work permits or extensions. Travelers should bring photocopies of important documents, such as passports and credit cards, as well as copies of their medical, nursing, or other professional license, if applicable. Medical information, such as immunization records and blood type, is also helpful to have at hand. The traveler should carry copies and also leave copies 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 enroll in the Department of State’s Smart Traveler Enrollment Program (STEP, https://step.state.gov/step) to register with the US embassy in the destination country before departure. This will ensure that the local consulate is aware of their presence, they can receive notifications, and they may be accounted for and included in evacuation plans. Travelers providing humanitarian assistance should review and understand medical, evacuation, and life insurance provided by their employing agency. They should also consider supplemental travel, travel health, and medical evacuation insurance to cover medical care and evacuation should they become ill or injured.

POST-TRAVEL CONSIDERATIONS

Returning disaster relief and humanitarian aid workers should be advised to seek medical care if they sustained injuries during their travel or become ill after returning. 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. Those involved in situations of infectious disease outbreaks should be made aware of post-travel illness monitoring recommendations or requirements. Homecoming has also been identified as a risk period for difficulties in psychological adjustment, and 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 road traffic crash) should be considered for referral for critical incident counseling. They should also be advised that the psychological effects of traumatic experiences may present long after return.

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 aid and disaster relief 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.

BIBLIOGRAPHY

  1. Aid Worker Security Database (AWSD): figures at a glance [database on the Internet]. Humanitarian Outcomes; 2015 [cited 2016 Sep. 27]; Available from: http://reliefweb.int/sites/reliefweb.int/files/resources/ho_aidworkersecuritypreview2015_0.pdf.
  2. Brooks SK, Dunn R, Sage CA, Amlot R, Greenberg N, Rubin GJ. Risk and resilience factors affecting the psychological wellbeing of individuals deployed in humanitarian relief roles after a disaster. J Ment Health. 2015 Dec;24(6):385–413.
  3. Callahan MV, Hamer DH. On the medical edge: preparation of expatriates, refugee and disaster relief workers, and Peace Corps volunteers. Infect Dis Clin North Am. 2005 Mar;19(1):85–101.
  4. CDC. Coping with a traumatic event: information for the public. Atlanta: CDC; 2009 [cited 2016 Sep. 27]; Available from: http://www.cdc.gov/masstrauma/factsheets/public/coping.pdf.
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  8. Mitchell AM, Sakraida TJ, Kameg K. Critical incident stress debriefing: implications for best practice. Disaster Manag Response. 2003 Apr-Jun;1(2):46–51.
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