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Chapter 9 Travel for Work & Other Reasons

Humanitarian Aid Workers

Eric J. Nilles, Brian D. Gushulak, Stephanie Kayden

Humanitarian aid workers assist people forced from their homes because of conflict or natural disasters. This assistance begins within hours after a disaster and often continues for years. Humanitarian relief deployments themselves can last weeks to years. During these deployments, humanitarian aid workers must plan for self-sufficiency and for the unique challenges they will face, including insecure environments and emotional stress.

Each year tens of thousands of aid workers are deployed worldwide, and many more people (doctors, civic and religious groups) participate as amateur responders to international disasters. Professional aid workers often deploy with large specialist organizations like Doctors Without Borders that have infrastructure and resources to properly support their personnel. By contrast, amateur responders may deploy with smaller, less prepared groups with less experience in humanitarian work (Box 9-02).

Box 9-02. Voluntourism

Volunteer tourism, also called “voluntourism,” describes tourists volunteering for a charity or development organization, usually for short periods, in developing countries. Although largely well intentioned, the impact of short-term visits—often by volunteers lacking specific understanding of the local context and lacking requisite skills—is variable and may be harmful in certain settings.

Voluntourism in humanitarian emergencies may be particularly problematic given dynamic and often dangerous humanitarian environments that require professional knowledge, organizational infrastructure, and understanding of the humanitarian response coordination system. Without the necessary individual competencies and organizational support, voluntourists in these settings expose themselves to unnecessary personal risks and can create a burden on the broader humanitarian response operations.

UNIQUE CHALLENGES FOR HUMANITARIAN AID WORKERS

Aid workers experience specific risks and situations related to the provision of humanitarian relief, such as:

  • Safety and security
    • Exposure to the disaster or conflict environment that precipitated or sustained the crisis
    • Damaged or absent infrastructure, including sanitation facilities and living accommodations
    • High levels of insecurity
  • Mental health
    • Stressful environments
    • Working long hours under adverse or extreme conditions

Humanitarian service can have an adverse effect on personal health. Studies of long-term humanitarian workers indicate that >35% report a deterioration in their personal health during the mission. Accidents and violence are risks for humanitarian aid workers and cause more deaths than disease or 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 reported that 10% experienced injury or accident and 16% were exposed to violence. The same study demonstrated that >40% found the experience more stressful than expected.

SAFETY AND SECURITY

Security risks and targeting of aid workers continues to be a concern for the humanitarian community. However, risks to staff are not uniformly distributed across the humanitarian landscape. Ongoing surveillance of violence directed against humanitarian and disaster relief aid workers continues to demonstrate that a small number of insecure locations (Afghanistan, Syria, South Sudan, Somalia, Yemen, and the Democratic Republic of Congo) account for most of these events.

Injuries and motor vehicle accidents are com­mon risks for travelers throughout the world, and travelers should be sensitive to their surroundings and carefully select the type of transportation and hour of travel, if possible (see Chapter 8, Road & Traffic Safety).

In disaster and emergency situations, aid workers should be aware of physical hazards such as debris, unstable structures, downed power lines, and other environmental hazards. Workers in certain conflict and postconflict settings should be educated on improvised explosive devices, land mines, and other unexploded ordnance. Although less common, some environments may involve unusual exposures such as radiation exposure (for example, after the earthquake in Japan in 2011) or chemical agents (for example, sarin and mustard gas used on civilians in the Syrian conflict). Disaster relief and humanitarian aid workers who will be deployed to insecure areas including active conflict zones should undergo specialized security briefings by the deploying agency or private sources.

In situations associated with damage or destruction to local services and facilities, humanitarian aid workers should expect, anticipate, and plan for limited accommodations and logistical 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.

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 and can provide them with notifications, account for them, and include them 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 (see Chapter 6, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance).

MENTAL HEALTH

Studies suggest that aid workers returning from humanitarian missions, particularly missions that are characterized by high or chronic stress, have increased symptoms of anxiety, posttraumatic stress disorder, and depression. Preexisting psychological disorders including depression and anxiety predispose to worse outcomes. Generally, humanitarian aid and disaster relief workers demonstrate considerable resilience and adapt to the stressful environments, but elevated and chronic stress can lead to psychological deterioration and decompensation in certain people. Effective predeployment briefings can increase confidence a deployee’s ability to cope with highly stressful environments; however, data are lacking on the effectiveness of postdeployment psychological debriefing to decrease adverse psychological impact of deployment.

A detailed evaluation of risk factors (psychiatric illness, family history, history of alcohol or substance abuse) may direct additional evaluation and identify previously unrecognized psychological problems or chronic conditions. Identifying alcohol or substance dependence, depression, or other psychiatric illness is particularly important, as stressful humanitarian environments frequently exacerbate these conditions; they are often the reason for emergency repatriation.

PREPARATION

Careful attention to pretravel evaluation, both medical and psychological, can reduce the likelihood of illness and the need for emergency repatriation of humanitarian workers. Medical illness or injury among deployed staff, particularly serious conditions that require repatriation, are not only burdensome and potentially dangerous for the affected staff member, but these events redirect limited organizational resources from the beneficiaries.

Comprehensive medical examinations can prepare travelers by identifying previously unrecognized conditions, allowing for treatment before travel. Most of the core elements of the pretravel evaluation and counseling are discussed in detail elsewhere, including in The Pretravel Consultation (Chapter 2) and in the Health Care Workers section of this chapter. Providers should administer routine vaccinations and prescribe malaria prophylaxis (if appropriate). They should also give guidance on food and water precautions, self-treatment for travelers’ diarrhea, protection from insect bites, behavioral risk avoidance, and injury prevention. Aid workers planning long-term assignments should have dental evaluations and address any problems identified before departure.

For health care workers providing medical care as part of their humanitarian activities, evaluation of occupational risk and the need for preventive preexposure or postexposure interventions is necessary. Medical humanitarian workers res­ponding to outbreaks of communicable diseases are often at increased risk of exposure and infection by specific infectious pathogens, and meticulous attention to infection control and personal protective measures protocols may be required. Medical workers should ensure their organization provides personal protective equipment such as masks, gloves, gowns, and eye protection.

In humanitarian emergencies, direct infrastructure damage; lack of equipment, supplies, and human resources; or a surge in medical need can all contribute to a medical facility becoming compromised or overwhelmed. Volunteers with significant underlying medical conditions who are likely to require care themselves should be counseled against travel and encouraged to support the response in other ways. Similarly, pregnant women should discuss deployment with their obstetrician and should typically be encouraged to defer deployment.

Travelers planning to participate in animal rescue should review information available in Appendix E: Taking Animals & Animal Products across International Borders, and discuss rabies preexposure prophylaxis with a health care provider (see Chapter 4, Rabies).

Health Kits

Aid workers should usually prepare a travel health kit that is more extensive than a typical kit (Chapter 6, Travel Health Kits). They should liaise with the deploying organization to tailor how extensive their packed supplies should be. For example, health care workers deployed by a medical organization will usually be able to access basic pharmacologic and other medical supplies for acute care treatment from the organization. They should also be familiar with basic first aid to self-treat any injury until they can obtain medical attention.

Conversely, people with chronic medical con­ditions requiring treatment should ensure they travel with prescriptions and medications sufficient for the duration of their service. They should also consider bringing along treatment for exacerbations of diseases or conditions that they may not usually experience, such as back pain or asthma. Because not all pharmaceuticals are globally available, travelers on extended deployments 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. See Chapter 6, Travel Health Kits, for additional information on preparing, storing, and traveling with medications.

People with dental crowns or bridgework should consider taking temporary dental adhesive for short-term management of a dislodged dental appliance. In addition to a basic travel health kit, humanitarian aid workers should consider bringing the following items:

  • Menstrual supplies
  • Long pants, shirts that cover the shoulders
  • Boots (particularly in disaster or rudimentary settings)
  • Gloves (leather gloves if physical labor will be performed)
  • Safety goggles
  • Sunglasses
  • Sunscreen
  • Insect repellent
  • Headlamp with spare batteries
  • Sewing kit
  • Insecticide-impregnated bed net (if traveling to areas endemic for mosquitoborne diseases)
  • Money belt
  • Cash (new or crisp bills can often be exchanged at better rates)
  • Cellular telephone, equipped to work internationally (or preferably unlocked)

Personal Items

Loss of life, serious injuries, missing and separated families, and destruction of communities are often associated with humanitarian emergencies; aid workers should recognize that they are likely to encounter stressful situations as part of their work. Keeping a personal item nearby, such as a family photo, favorite music, or religious material, can offer comfort. Communicating with family members and close friends from time to time can be an important means of support. Access to mobile phones and Internet services are frequent challenges in humanitarian emergencies, and satellite telephones are small, function in most regions globally, and can be rented for <$10 per day. However, some government authorities may prohibit or limit the importation and use of satellite phones, particularly in conflict zones, and this should be clarified before rental.

Documents

Aid workers should take extra passport-style photos, which may be required for certain types of visas, for work permits, and security passes. Travelers should bring photocopies of 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 should be available. The traveler should carry physical copies of all of these documents, leave copies with their main contact at home, scan and email copies to their smart phones (if appropriate), and ensure the documents are securely stored and available in a cloud storage service. In addition, they should carry contact information for their designated emergency contacts.

POSTTRAVEL

Returning disaster relief and humanitarian aid workers should be advised to seek medical care if they sustain injuries during their travel or become ill after returning home. To ensure a thorough assessment, they should advise their providers of the nature and location of their recent travel. Depending on the duration and nature of the deployment, including if they were providing direct medical care, returning aid workers may benefit from a comprehensive medical review. Those involved in responding to infectious disease outbreaks should be educated on posttravel illness monitoring recommendations or requirements, if applicable.

Homecoming can be psychologically challenging, and treatment or counseling should be sought if there are concerns about an individual’s ability to transition to postdeployment life. Consider referring workers who witnessed or were involved in mass casualties, deaths, or serious injuries or who have been victims of violence (assault, kidnapping, or serious road traffic crash) for critical incident counseling. They should be educated that the onset of adverse psychological effects after exposure to traumatic experiences may be delayed, sometimes by several months or longer.

BIBLIOGRAPHY

  1. Aid Worker Security Report 2017: Behind the attacks—a look at the perpetrators of violence against aid workers. Humanitarian Outcomes; 2017 [cited 2018 Mar 19]. Available from: https://aidworkersecurity.org/sites/default/files/AWSR2017.pdf.
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  6. Lopes Cardozo B, Gotway Crawford C, Eriksson C, Zhu J, Sabin M, Ager A, et al. Psychological distress, depression, anxiety, and burnout among international humanitarian aid workers: a longitudinal study. PLoS ONE. 2012;7(9):e44948 [cited 2018 Mar 19]. Available from: https://doi.org/10.1371/journal.pone.0044948.
  7. Peytremann I, Baduraux M, O’Donovan S, Loutan L. Medical evacuations and fatalities of United Nations High Commissioner for Refugees field employees. J Travel Med. 2001 May–Jun;8(3):117–21.
  8. Substance abuse and Mental Health Services Administration. Disaster preparedness, response, and recovery [cited 2018 Mar 19]. Available from: www.samhsa.gov/disaster-preparedness.
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