Humanitarian Aid Workers

Introduction

Humanitarian aid workers assist people in need due to conflicts, natural disasters, outbreaks, a breakdown of health care or infrastructure, and more. Assistance may begin within hours after a disaster and often may continue for years. Humanitarian relief deployments can last for weeks to years; the work can be rewarding and adventurous but requires preparation. During deployments, humanitarian aid workers must plan to be self-sufficient and to face unique challenges, including insecure environments and emotional stress.

Each year, hundreds of thousands of professional aid workers are deployed worldwide to support people affected by disaster and conflict. Many of these efforts are coordinated by the United Nations Office for the Coordination of Humanitarian Affairs, which estimated that approximately 363 million people needed humanitarian assistance in 2023, representing continual rapid growth over the prior decade.

Professional aid workers often deploy with large specialist organizations (e.g., Doctors Without Borders) that have infrastructure and resources to properly support their personnel. Many more people (e.g., doctors, civic, and religious groups) participate as amateur responders to international disasters. In contrast with professional aid workers, amateur responders might deploy with smaller, less prepared groups with little experience in providing humanitarian aid (Box 8.3.1).

Box 8.3.1

Unique challenges

Aid workers experience situations and specific risks (e.g., safety, security, mental health) related to providing humanitarian relief. Safety and security challenges include exposure to the conflict or disaster environment that precipitated or sustained the crisis; damaged or absent infrastructure (e.g., living accommodations, sanitation facilities); high levels of insecurity; and fractured safety and health systems. Mental health risks include living in stressful environments; exposure to secondary trauma and a sense of helplessness; working long hours under adverse or extreme conditions; and challenges to re-entering home life and post-deployment activities.

Humanitarian service can also have an adverse effect on personal health. Studies of long-term humanitarian aid workers indicate that >35% report a deterioration in their personal health during the mission. Injuries from accidents and violence are risks for humanitarian aid workers and cause more deaths than disease or natural causes. Conditions and outcomes vary by location, nature of the humanitarian event, and time spent in the field. A study of International Committee of the Red Cross workers reported that 7.5% experienced accident or injury and 12% experienced security incidents during their most recent mission. The same study demonstrated that >40% found the experience more stressful than expected.

Safety and security

Security risks and targeting of aid workers with kidnapping and violence continues to be on the rise (see Safety and Security Overseas chapter). Risks to staff are not uniformly distributed across the humanitarian landscape, however. Ongoing surveillance of violence directed against humanitarian aid and disaster relief workers continues to demonstrate that most of these events occur in a few insecure locations, including Democratic Republic of the Congo, Gaza, Mali, Myanmar, South Sudan, Syria, and Ukraine.

Injuries due to motor vehicle crashes are common risks for travelers, including humanitarian aid workers, throughout the world (see Injury and Death During Travel chapter). Motor vehicle crashes are the most common cause of non-natural deaths of U.S. citizens living abroad. Aid workers should carefully assess the type of transportation taken, routes and alternative routes, and appropriate drivers. In many insecure environments, it is advised that travel take place during daylight hours, if possible.

In disaster and emergency situations, aid workers should be aware of physical hazards (e.g., debris, downed power lines, unstable structures, and other environmental hazards). While the deploying agency is responsible for making aid workers aware of the actual and potential hazards they may encounter, aid workers themselves have an individual responsibility to stay up to date because circumstances can change rapidly. Workers in certain conflict and post-conflict settings should be educated by their deploying agency on improvised explosive devices, landmines, other unexploded ordnance, and relevant signage. Although less common, some environments might involve unusual exposures, such as radiation (e.g., after the 2011 earthquake and tsunami in Japan) or chemical agents (e.g., mustard gas and sarin used on civilians in the Syrian conflict). Humanitarian aid and disaster relief workers who will be deployed to insecure areas, including active conflict zones, should undergo specialized security briefings by the deploying agency and/or private sources. Reputable and free resources exist for basic security training (e.g., the United Nations BSAFE course). With chemical, biological, radiological, nuclear, and explosive (CBRNE) threats on the rise, specialized training and supplies should be provided when entering these environments.

In situations associated with damage or destruction to local services and facilities, humanitarian aid workers should anticipate and plan for limited accommodations, logistical, health, and personal support. Humanitarian aid and disaster relief workers destined for low-resource areas and conflict environments can benefit from pre-travel training and counseling regarding the moral complexities of providing service in these environments.

Encourage humanitarian aid workers from the United States to enroll in the Department of State's Smart Traveler Enrollment Program (STEP) to register with the U.S. embassy in their destination country. Enrollment before departure 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 also should consider supplemental travel insurance, travel health insurance, and medical evacuation insurance to cover medical care and evacuation should they become ill or injured (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). Travelers should carefully review evacuation policies for any exclusions, such as from higher risk countries, conflict zones, or potential exposure to certain infectious diseases (e.g., Ebola, COVID-19).

Mental health

Studies suggest that aid workers returning from humanitarian missions, particularly missions characterized by high or chronic stress, have increased symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD; see Mental Health in Travelers chapter). In humanitarian environments, the volume and tempo of work, accumulating fatigue, and exposure to mass suffering can change perceived value of life and increase recklessness, risk-taking, and suicidal behaviors.

Generally, humanitarian aid and disaster relief workers demonstrate considerable resilience and adapt to stressful environments, but different psychological needs arise during different phases of the emergency and response, and long-term exposure to stress can lead to deterioration in mental health and decompensation in some people. People with preexisting mental health issues, including anxiety, PTSD, substance use disorder, or depression, may be predisposed to worse outcomes.

A detailed evaluation of risk factors (e.g., preexisting mental illness, family history of mental illness, history of alcohol or substance use disorder) is recommended as it may identify previously unrecognized chronic mental health conditions. Identifying alcohol or substance dependence or underlying mental health issues is particularly important because stressful humanitarian environments frequently exacerbate these conditions, which are often the reason for emergency repatriation (see Substance Use and Substance Use Disorders in Travelers chapter).

Pre-deployment briefings can increase an aid worker's ability to cope with highly stressful environments; data are lacking, however, on the effectiveness of these briefings or post-deployment briefings to decrease the mental health impacts of deployment. Humanitarian workers should prioritize engagement with organizations that have defined rest and recuperation policies, mental health support throughout the response cycle, and psychological first aid training.

Preparation

Careful attention to pre-travel evaluation, of both physical and mental health, can reduce the likelihood of illness and the need for emergency repatriation of humanitarian aid workers. Comprehensive medical and—for those planning long-term assignments—dental evaluations can prepare aid workers by identifying previously unrecognized conditions, enabling treatment before travel. Medical illness and 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 also redirect limited organizational resources from their intended purpose.

Most of the core elements of the pre-travel evaluation and counseling are discussed in detail in The Pre-Travel Consultation and the International Travel to Deliver Health Care in Resource-Limited Settings chapters. Administer indicated vaccinations and prescribe malaria prophylaxis or medications to prevent altitude sickness, as appropriate (see Vaccination and Immunoprophylaxis—General Principles chapter; Malaria chapter; and High-Altitude Travel and Altitude Illness chapter). COVID-19 risk and related guidance can vary based on the individual and the destination, but CDC recommends that all travelers be up to date with their vaccines (additional COVID-19 guidance is discussed in the COVID-19 chapter). Give guidance on food and water precautions; self-treatment for travelers' diarrhea; protection from insect bites; environmental protection from the elements including sun exposure; behavioral risk avoidance; and injury prevention. Several of these topics are covered in detail in the Environmental Hazards and Risks and Travel-Associated Infections and Diseases chapters.

For healthcare professionals providing medical care as part of their humanitarian activities, evaluate occupational risk and the potential need for HIV post-exposure prophylaxis. Medical humanitarian aid workers responding to outbreaks of communicable diseases are often at increased risk for exposure and infection by specific infectious pathogens, which requires meticulous attention to infection control and personal protective measure protocols. Medical workers (see International Travel to Deliver Health Care in Resource-Limited Settings chapter) should ensure that their organization provides adequate safety protocols and personal protective equipment (e.g., gloves, gowns, masks, 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. Counsel aid workers with significant underlying medical conditions, who are likely to require care themselves, against travel. Encourage them to support the response in other ways. Similarly, a woman who is pregnant should discuss their plans with their obstetrician and should typically be advised to defer deployment (see Pregnant Travelers chapter).

For travelers planning to participate in animal rescue activities, share information available in the Traveling with Pets and Service Animals chapter, and discuss rabies pre-exposure prophylaxis (see Rabies chapter).

Travel health kits

In general, because aid workers will need a more comprehensive travel health kit than the typical traveler, they should consult with their deploying organization to determine how extensively to tailor their packed supplies (see Travel Health Kits chapter). For example, healthcare professionals deployed by a medical organization will usually be able to access basic pharmacologic and other medical supplies for acute care treatment from the organization and should 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 that they travel with prescriptions and medications sufficient for the duration of their service (see Travelers with Chronic Illnesses chapter). They also should consider bringing treatment for exacerbations of diseases or conditions they might not usually experience (e.g., asthma, back pain). Because not all pharmaceuticals are globally available, travelers on extended deployments should review safe alternatives to their regular medication. Aid workers should store medications in 2 separate allotments in case of loss or theft. The Travel Health Kits chapter, provides additional information on preparing, storing, and traveling with medications. Individuals should avoid bringing controlled substances (see Traveling with Prohibited or Restricted Medications chapter).

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 items listed in Box 8.3.2.

Box 8.3.2

Personal items

Aid workers should recognize that they are likely to encounter stressful situations as part of their work. Keeping a personal item nearby (e.g., a family photo, favorite music, religious or spiritual material) may 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. Global mobile coverage continues to improve, however, and free applications (e.g., WhatsApp) have expanded accessibility. For more remote regions, satellite telephones are an option, although some government authorities might prohibit or limit their importation and use, particularly in conflict zones. Before travel, aid workers should clarify any restrictions to telephone, internet, or satellite technology in the destination country.

Documents

Aid workers should carry extra passport-style photos, which might be required for certain types of security passes, visas, and work permits. Travelers should bring photocopies of documents (e.g., credit cards, passports) and copies of their medical, nursing, or other professional licenses, if applicable.

Aid workers also should have medical information (e.g., blood type, immunization records) available. Travelers should carry physical copies of all these documents, leave copies with their main contact at home, scan and email copies to their smartphones (if appropriate), and ensure that the documents are securely stored and available in a cloud storage service. In addition, aid workers should carry information for their emergency contacts written on paper and not rely exclusively on an electronic device.

Post-travel

Returning humanitarian aid and disaster relief workers should seek medical care if they sustained injuries or serious illness during their travel or if they become ill after returning home (see Post-Travel Evaluation of the Ill Traveler chapter). To ensure a thorough assessment, returning aid workers should advise their healthcare professionals of the nature and location of their recent travel, in addition to any medical care received during that time. Depending on the duration and nature of the deployment, including if they were providing direct medical care, returning aid workers might benefit from a comprehensive medical review. Guidance, tools, and resources can be found at Post-Deployment Phase. Travel medicine professionals should educate workers involved in responding to infectious disease outbreaks on post-travel illness monitoring recommendations or requirements, if applicable. Homecoming can be psychologically challenging, and aid workers should seek treatment or counseling if they have concerns about transitioning to post-deployment life. Consider referring workers who witnessed or were involved in mass casualties, deaths, or serious injuries or who have been victims of violence (e.g., assault, kidnapping, serious road traffic crash) for critical incident counseling. Travel medicine specialists should counsel returning aid workers that the onset of adverse psychological effects after exposure to traumatic experiences can be delayed, sometimes by several months or longer.

Acknowledgements

The following authors contributed to the previous version of this chapter: Stephanie Kayden and Eric J. Nilles.