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
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.
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
Going To Work In A Crisis?
Usually Don’t Just Go!
Need information, make an application,
evaluation of capabilities, and preparation
Going To Work In A Crisis?
Usually Don’t Just Go!
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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
It is important to be
aware of what the area of
operation will be like
Information on possible environment
 Disaster
situation
– Perhaps little or no infrastructure
except what you take with you
Information on possible environment
Information on possible environment

Conventional war
– Regular soldiers.
– Supposedly governed by convention; may
protect.
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Political/Issue/Religious motivated groups
– In extreme circumstances will play by the no
rules philosophy
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Bandits/Criminals
– Will play by the no rules philosophy
Information on potential agencies
 Foreign
mission
 Military and UN
 Other government agency
 NGO’s, church groups
 Private company
 Other, including private consultant
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
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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!
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Personal information needed
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Work to be done
Facilities
Accommodation
Lifestyle at the destination
Lines of communication
Medical care
Security and evacuation plans
Application procedures
Insurance and compensation
Personal information needed
Be aware of local customs and traditions
 Violation of these whether or not
intentional may have disastrous security
consequences
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Assessment
Review of application
 Interview
 Psychological assessment
 Medical and dental examination
 Laboratory screening
 Further assessment through training
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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
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Laboratory testing
H.I.V.
 Hepatitis B, C
 Urine testing
 Other screening tests, e.g. mantoux for
TB, STIs etc
 Drug and alcohol screening
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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
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Training
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Organization-related
– Philosophy and doctrine
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Task-related
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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
Training-major diseases of disaster
settings and refugee camps
Malnutrition
 Measles
 Malaria
 Pneumonia
 Diarrhea
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Meningitis
 Cholera
 HIV/AIDS
 Tuberculosis
 EID’s, e.g. SARS,
Ebola
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Main hazards for field volunteers
Main hazards for field volunteers
Common infections
 Trauma/accidents
 Stress and conflict
 Substance abuse
 Sexually transmitted infections (STIs),
including H.I.V.
 Security
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Common infections
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National Council of Churches: 75% of
health problems were infectious (J Travel
Med 1994;1:111-112)
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Common infections: diarrhoeal disease,
arthropod-borne diseases (malaria),
vaccine preventable diseases (measles),
respiratory tract infection, tuberculosis,
HIV/STIs
Protective measures
Chemoprophylaxis (Therapeutic
Guidelines)
 Environmental and Hygiene (course)
 Personal protective measures (WHO)
 Immunizations (NHMRC; WHO)
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Main hazards for field volunteers
Common infections
 Trauma/Accidents
 Stress and conflict
 Substance abuse
 STI’s/H.I.V.
 Security
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Source: www.unhcr.ch
Trauma and accidents
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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
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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)
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Protective measures
Defensive driver
training, especially
training with 4WD
 Watch out for
pedestrians and
animals
 Watch speed/roads
 Avoid driving at night
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Source:www.msf.org
Main hazards for field volunteers
Common infections
 Trauma/Accidents
 Stress and conflict
 Substance abuse
 STI’s/H.I.V.
 Security
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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)
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Post-traumatic stress syndrome (PTSS) (3%
post-deployment NGO and military workers)
(J Refugee St 1997;10:495-502)
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
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Main hazards for field volunteers
Common infections
 Trauma/Accidents
 Stress and conflict
 Substance abuse
 STI’s/H.I.V.
 Security
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Substance abuse
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Legal, e.g. alcohol, smoking
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Illicit, e.g. cannabis, heroin
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
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Main hazards for field volunteers
Common infections
 Trauma/Accidents
 Stress and conflict
 Substance abuse
 STI’s/H.I.V.
 Security
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Source:www.mc.duke.edu
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’s57/1000/year notified during period 1988-1993
(HIV-1 positive results - 3/2491 tests) (J Travel
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Med 1995;2:174-177)
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
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Main hazards for field volunteers
Common infections
 Trauma/Accidents
 Stress and conflict
 Substance abuse
 STI’s/H.I.V.
 Security
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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
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Protective measures
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Protective service
– Use of military or private security (armed/unarmed)
– Security briefing
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Camp protection
– Use of secure perimeter especially at night
– Exclude alcohol and drugs
– Have an evacuation plan
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Individual protection
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Travelling in pairs as a minimum
Communications
Not travelling at night
Use common sense
Give up your wallet not your life!
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
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– 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)
Health insurance plans and compensation
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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
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
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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
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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!
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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 Coordination Office, 1995.
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PREPARING TO WORK IN A CRISIS