Health Issues Affecting Those Who Travel to Help

Persons who travel to provide humanitarian aid or disaster relief require preparation for all the usual elements associated with travel to a particular region of the world, but they must also take additional steps to address their personal health and welfare, both during and after travel. Aid workers are often exposed to great suffering on the part of the local population and must work long hours under extreme conditions with minimal support. The normal infrastructure for provision of basic needs of food, water, lodging, transportation, disease control, and provision of medical and security services may be either absent or impaired.

The number of persons of concern to the United Nations High Commissioner for Refugees (UNHCR) rose from 2.5 million in 1975 to 25 million in 1995. During the 1-year period from 1994 to 1995, the UNHCR found that the major causes of evacuation of its workers were infectious diseases (17%), obstetric-gynecologic conditions (15%), accidents (15%), ophthalmologic/ear, nose and throat conditions/dentistry (11%), and gastrointestinal diseases (10%). The major causes of fatalities were infectious diseases (41%), cancer (24%), accidents (16%) and cardiovascular diseases (11%) (1). In contrast, a Peace Corps study from the 1980s showed the most commonly reported health problems to be diarrhea (48 cases per 100 per year), injuries (20 cases per 100 per year), and skin conditions (19 cases per 100 per year) (2). Examination of deaths occurring in workers from nongovernmental organizations (NGOs), the Red-Cross related agencies, or the United Nations Programs and UN Peacekeeping activities during the period 1985-1998 found that the absolute number of deaths increased, but that rates or risks could not be calculated due to lack of denominator data. Nearly half of the deaths were in workers from the UN programs; most were due to intentional violence. One third of the deaths occurred in the first 90 days of service and 17% within the first 30 days; the timing was unrelated to previous field experience. Age was not associated with circumstances of death. Men accounted for 90%. Workers who were parents were less likely to die from unintentional violence than from other causes. Motor vehicle accidents accounted for 17% of deaths, and disease and natural causes for only 8% (3).

Before Travel

Careful attention to pre-travel evaluation, both medical and psychological, and education can help reduce the likelihood of illness and repatriation. Comprehensive medical examinations can prepare travelers by helping to identify previously unrecognized disease and allow for treatment (e.g., dental work) before travel. Careful evaluation of risk factors (e.g., 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 are likely to be unmasked by the associated stress and can often be a reason for emergency repatriation (2,4).

The period of time immediately after deployment has been described as a particularly vulnerable period for both trauma and preventable diseases. This is true among novices and experienced field workers alike, as risk is present even before it is recognized or preventive behaviors and avoidance measures adopted as normative; there is no allowance for a learning curve. Predeployment education and training thus become essential, as personal illness or injury places a burden on the population the worker has come to support. The amount of health and safety training may increase with the size of the sponsoring organizations, but the ultimate responsibility still rests with each individual (5,6).

Thus, 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: routine vaccinations, food and water precautions, prevention and self-treatment for travelers’ diarrhea, risks from insect bites, and injuries (see Chapter 2). Additional measures may be indicated depending on the region of the world affected (see Chapters 3-5). The traveler should be advised to prepare a travel kit that is more extensive than the typical kit (see Chapter 2) and should also be familiar with basic first aid in order to self-treat any injury until medical attention can be obtained. Hand washing becomes extremely important. Travelers may be advised to wear close-toed shoes and protective clothing. Injuries (see Chapter 6) are a common risk for travelers anywhere in the world; thus, travelers should be extremely aware of their surroundings and carefully select the type of transportation and hour of travel (e.g., avoiding travel after dark). In disaster situations, the traveler should also be aware of physical hazards such as debris, downed power lines, environmental hazards, and extremes of temperature (http://wwwn.cdc.gov/travel/contentReliefWorkers.aspx). Travelers to combatant areas should be aware of landmines and other potential hazards associated with unexploded ordnance.

Expanded Travel Kit

Travelers should also register with the US Department of State 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 evacuation should they become ill or injured. See the U.S. Department of State website for additional information: http://travel.state.gov/. Medical facilities may be compromised by the disaster or overwhelmed in responding to the disaster. Therefore, volunteers with underlying conditions or pregnant women should be counseled against travel and encouraged to support the response in other ways.

Because of the tremendous loss of life, serious injuries, missing and separated families, and destruction of whole areas often associated with disasters, relief workers should recognize that the situation they encounter may be extremely stressful. Keeping an item of comfort nearby, such as a family photo, favorite music, or religious material, can often offer comfort in such situations. Checking in with family members and close friends from time to time is another means of support (7).

After Travel

Returning aid workers should be advised to seek medical care if they sustained injuries during their travel or become ill upon return. To ensure proper evaluation, they should advise of their recent travel. Depending upon the length of time away, those returning may benefit from a complete physical examination. Fever in a traveler returning from a malarious area should be evaluated immediately for up to year after return. Homecoming has also been identified as a risk period for difficulties in psychological adjustment, and appropriate treatment or counseling should be sought. Approximately 36% of aid workers report depression shortly after returning home. The adjustment process can be assisted by a skilled debriefing, which can assist the worker in finding personal rewards in the constructive pursuit of rebuilding communities. 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. (2,8)

References

1. 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;8:117-21.
2. Gamble K, Lovell D, Lankester T, Keystone J. Aid workers, expatriates and travel. Principles and Practice of Travel Medicine, Hoboken, NJ: John Wiley and Sons, 2001. p. 448-66.
3. Sheik M, Gutierrez M, Bolton P, Spiegel P, Thieren M, Burnham G. Deaths among humanitarian workers. BMJ. 2000;321:166-8.
4. Callahan M, Hamer D. On the medical edge: preparation of expatriates, refugee and disaster relief workers, and Peace Corps volunteers. Infect Dis Clin N Am. 2005;19:85-101.
5. Pearn J. Pre-deployment education and training for refugee emergencies: health and safety aspects. Journal of Refugee Studies. 1997; 10:495-502.
6. CDC. Health recommendations for relief workers responding to disasters. Available at: http://wwwn.cdc.gov/travel/contentReliefWorkers.aspx. (Accessed 30 November 2006.)
7. CDC. Coping with a traumatic event. Available at: http://www.bt.cdc.gov/masscasualties/copingpub.asp. (Accessed 30 November 2006.)
8. McFarlane C. Risks associated with the psychological adjustment of humanitarian aid workers. Australasian Journal of Disaster and Trauma Studies 2004. ISSN: 1174-4707. Available at: http://www.massey.ac.nz/%7Etrauma/issues/2004-1/mcfarlane.htm. (Accessed 05 December 2006.)

CHRISTIE REED