Preparing to work in a crisis: Health and safety for field volunteers

1. Preparing to work in a crisis:Health and safety for field volunteers Dr Peter A Leggat MD, PhD, DrPH, FAFPHM, FACTM, FFTM Associate Professor, School of Public Health and Tropical Medicine James Cook University, Townsville, Ausrtalia, & Visiting Professor, School of Public Health University of the Witwatersrand, Johannesburg, South Africa

2. About the author • Dr Peter Leggat has co-ordinated the Australian postgraduate course in travel medicine since 1993 and also co-ordinates the postgraduate program in disaster and refugee health. He has also been on the faculty of the South African travel medicine course, conducted since 2000, and the Worldwise New Zealand Travel Health update programs since 1998. Dr Leggat has assisted in the development of travel medicine programs in several countries and also the Certificate of Knowledge examination for the International Society of Travel Medicine.

3. Objectives of the session • Understand and appreciate the pre-employment steps, which assist in preparing field volunteers • Discuss some of the major hazards of working as a field volunteer in a refugee camp or disaster situation • Reflect on the responsibilities of refugee agencies for the health, safety and security of field volunteers • Appreciate practical security issues-an important area, which may need a consultant

4. Going To Work In A Crisis?Usually Don’t Just Go!Need information, make an application, evaluation of capabilities, and preparation

5. Going To Work In A Crisis?Usually Don’t Just Go! • Idea-type of employment, where • More information including application procedures and make an application • Evaluation including pre-employment medical examination • Preparation (applicant may have suitable training) • Pre-deployment health advice • May be placed on a standby list

6. It is important to be aware of what the area of operation will be like

7. Information on possible environment • Disaster situation • Perhaps little or no infrastructure except what you take with you

8. Information on possible environment

9. Information on possible environment • Conventional war • Regular soldiers. • Supposedly governed by convention; may protect. • Political/Issue/Religious motivated groups • In extreme circumstances will play by the no rules philosophy • Bandits/Criminals • Will play by the no rules philosophy

10. Information on potential agencies • Foreign mission • Military and UN • Other government agency • NGO’s, church groups • Private company • Other, including private consultant

11. Information on organisational back-up • Does the NGO have any level of UN or host nation commitment? • If not, there is likely to be no military support or protection. • Some NGOs may hire private security

12. Understanding of how to work as field volunteer • Hardship posting • Need to be able to make hard decisions • Need to be tactful • Many motives to go to work as volunteer • Need to integrate into the camp environment • Need to be multifunctional • Need to be prepared!

13. Personal information needed • Work to be done • Facilities • Accommodation • Lifestyle at the destination • Lines of communication • Medical care • Security and evacuation plans • Application procedures • Insurance and compensation

14. Personal information needed • Be aware of local customs and traditions • Violation of these whether or not intentional may have disastrous security consequences

15. Assessment • Review of application • Interview • Psychological assessment • Medical and dental examination • Laboratory screening • Further assessment through training

16. Medical & dental examination • Assess individual’s medical suitability for work (examining physician needs information on job) • Ensure that allowable medical and dental conditions are under optimal control • Detect any medical, dental or surgical problems that need to be dealt with before departure • Travel health advice may be separate

17. Laboratory testing • H.I.V. • Hepatitis B, C • Urine testing • Other screening tests, e.g. mantoux for TB, STIs etc • Drug and alcohol screening

18. H.I.V. screening • Need for working in or entry to some countries • Baseline for health and life insurance cover • Personal and military, NGO or company reference

19. Training • Organization-related • Philosophy and doctrine • Task-related • First aid • Skill training • Train-the-trainer • Languages • Understanding the major diseases which affect refugees • Understanding the main hazards which may effect anyone, including field volunteers

20. Malnutrition Measles Malaria Pneumonia Diarrhea Meningitis Cholera HIV/AIDS Tuberculosis EID’s, e.g. SARS, Ebola Training-major diseases of disaster settings and refugee camps

21. Main hazards for field volunteers

22. Main hazards for field volunteers • Common infections • Trauma/accidents • Stress and conflict • Substance abuse • Sexually transmitted infections (STIs), including H.I.V. • Security

23. Common infections • National Council of Churches: 75% of health problems were infectious (J Travel Med 1994;1:111-112) • Common infections: diarrhoeal disease, arthropod-borne diseases (malaria), vaccine preventable diseases (measles), respiratory tract infection, tuberculosis, HIV/STIs

24. Protective measures • Chemoprophylaxis (Therapeutic Guidelines) • Environmental and Hygiene (course) • Personal protective measures (WHO) • Immunizations (NHMRC; WHO)

25. Main hazards for field volunteers • Common infections • Trauma/Accidents • Stress and conflict • Substance abuse • STI’s/H.I.V. • Security Source: www.unhcr.ch

26. Trauma and accidents • Good figures for mortality and morbidity from accidents hard to find, however accidents are a leading cause of death (J Travel Med 1994;1:16-29) • Threat of the disaster itself • Threat of the disaster past, e.g. landmines • Motor vehicle accidents and pedestrian accidents (speed/road condition etc..) • Other accidents, including aircraft, burns and scalds

27. Protective measures • Travel on reliable, scheduled transportation if not provided by agency • Protection against HIV/Hepatitis B • Training on recognition of unexploded ordinances, e.g. landmines • Need for “all humanitarian and emergency aid workers to hold current, certified, hands-on first aid certificate” (J Refugee St 1997;10:495-502)

28. Protective measures • Defensive driver training, especially training with 4WD • Watch out for pedestrians and animals • Watch speed/roads • Avoid driving at night Source:www.msf.org

29. Main hazards for field volunteers • Common infections • Trauma/Accidents • Stress and conflict • Substance abuse • STI’s/H.I.V. • Security

30. Stress and conflict • Fatigue, loneliness, stress and conflict • Readjustment problems associated with emergency evacuation; Peace Corps Volunteers-50% depression/disorientation, 40% psychological stress (J Travel Med 1997;4:128-131) • Post-traumatic stress syndrome (PTSS) (3% post-deployment NGO and military workers) (J Refugee St 1997;10:495-502)

31. Protective measures • Don’t forget the family; lines of communication are important • Full briefing concerning risk of PTSS • Importance of recognition and seeking help in the field • Teaching of early self-recognition and seeking treatment • Critical incident debriefing and ongoing professional support

32. Main hazards for field volunteers • Common infections • Trauma/Accidents • Stress and conflict • Substance abuse • STI’s/H.I.V. • Security

33. Substance abuse • Legal, e.g. alcohol, smoking • Illicit, e.g. cannabis, heroin

34. Protective measures • Establish policy on legal drugs, e.g. limited supply or dry camp • Establish policy on illicit drugs, e.g. zero tolerance and drug screening • Training, esp. awareness of health, safety and legal risks, e.g. country may have severe punishment or even death penalty

35. Main hazards for field volunteers • Common infections • Trauma/Accidents • Stress and conflict • Substance abuse • STI’s/H.I.V. • Security Source:www.mc.duke.edu

36. S.T.I.’S and H.I.V. • Potential for high rates of sexually transmitted infections amongst expatriates aboard (condoms and other protective measures inconsistently used) • Sexual, occupational, accidental transmission • Peace Corps Volunteers (West Africa): STI’s-57/1000/year notified during period 1988-1993 (HIV-1 positive results - 3/2491 tests) (J Travel Med 1995;2:174-177)

37. Protective measures • No sex, “safe” sex • Establish policy and pack condoms • Medical equipment packs • Treat S.T.I.s promptly • Pre- and post-screening procedures

38. Main hazards for field volunteers • Common infections • Trauma/Accidents • Stress and conflict • Substance abuse • STI’s/H.I.V. • Security

39. Security issues • Threat of the disaster just passed • Aggression • Armed attack • Theft • Kidnapping and hostage crises • Personal assault, “muggings” and rape • Response: need to establish organisational policy (armed/not armed) and be consistent

40. Protective measures • Protective service • Use of military or private security (armed/unarmed) • Security briefing • Camp protection • Use of secure perimeter especially at night • Exclude alcohol and drugs • Have an evacuation plan • Individual protection • Travelling in pairs as a minimum • Communications • Not travelling at night • Use common sense • Give up your wallet not your life!

41. Health insurance plans and compensation • Insurance is an important safety net • Many major NGO’s have subscribed to a plan • Military and NGO’s may have own plan • Some have no plan • UNDP will provide cash payment ($250) in lieu of medical insurance coverage (for activities of limited duration-1-3 years) • Medical insurance is your own responsibility http://www.undp.org/jobs/toa.html (accessed 3 September 2005)

42. Health insurance plans and compensation • Check out the fine print • Will it cover all medical, surgical and dental costs? • Will it cover against pre-existing illnesses? • Will it cover the whole time you are there? • What happens about long term disability/compensation? • Check out the aeromedical evacuation capacity

43. Medical evacuations • J Travel Med 2001;8:117-121 has some interesting data on medical evacuations of UNHCR workers • Over 2 year period (1994-95), there were 162 evacuations of 140 persons and 37 deaths of UNHCR field employees (total UNHCR staff approx 5000 in 1995) • Expatriates accounted for approx. 2/3 of evacuations and one quarter of the deaths

44. Medical evacuations • Major conditions resulting in evacuations were infections (17%), O&G (15%), accidents (15%), ophthalmological/ENT/dental (11%), Gastrointestinal (10%) • Major causes of fatalities were infectious diseases (41%), cancer (24%), accidents (16%), and cardiovascular disease (11%). • Firearms caused 4 fatalities and 2 evacuations

45. What is the role of disaster relief & refugee agencies and administrators? • Preparation of workers • Obtain health and security intelligence • Provide medical care, pastoral care/welfare/support, personal protection, security and possibly insurance • Provide briefing and de-briefing • Great deal of personal responsibility as well!

46. Further Reading • Leggat PA. Ensuring the health and safety of humanitarian aid workers. Travel Medicine and Infectious Disease. 2005; 3: 119-122. • Jackson BA, Baker JC, Ridgely MS, Bartis JT, Linn HI. Protecting Emergency Responders. Vol 3. Safety management in disaster and terrorism response. Cincinnati: NIOSH/CDC/RAND Corp., 2004 • UNHCR. Security awareness: An Aide-memoire. New York: United Nations Security Co-ordination Office, 1995.