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The travel health needs of humanitarian workers

Liz Rosies
RGN MSc(TravelMed)
Bank Nurse
Travel Clinic - InterHealth
London
Author of www.travelhealth.co.uk
E:liz@travelhealth.co.uk

Frequent reports of war and internal conflicts, compounded by economic crisis and natural disaster, have led to an increased number of workers moving to the developing world.(2) Often populations in areas of poverty and conflict have little hope of survival without humanitarian assistance from both government and nongovernmental organisations (NGOs).

Situation assessment
The travel health input from general practice will vary according to the support these workers receive from their sending organisation. Health needs are diverse, with vaccination and malaria advice required for often complex situations. Added to this is the psychological support required for working in highly stressful areas of the world.
Due to the limited amount of time for consultations within general practice, there is a need for a high level of motivation and training to deal with such patients. The use of alternative resources beyond our database is essential. Likewise, in obtaining a complete picture of the traveller's needs, nurses should aim to work alongside medical personnel from sending organisations. Full use should be made of any health briefings that have been prepared.
Any person planning to work overseas should ideally have a full medical before leaving, including a trip to the dentist to prevent unnecessary treatment while away. Many organisations also require their workers to undergo psychological testing before acceptance, an element of preparation that bypasses those individuals who venture out alone.
When planning a vaccination schedule, careful assessment should be made of the situation the worker is going into, as well as the risks associated with the length of time they are spending overseas. Both vaccine- and nonvaccine-preventable disease will need careful discussion. For those integrating with refugee populations this will include vaccination against measles, for which immunity is essential. Measles is a common cause of death in a refugee situation - more than 2,000 children died of the disease in Sudan in 1985.(3)
Many of the malaria zones of the world are situated in areas of poverty and unrest. Workers in malarious areas should be given advice on suitable malaria prophylaxis related to their personal situation and length of time away. Advice regarding bite prevention should be given along with the recommended use of insect repellents and impregnated bed nets.(4) In remote malarious areas the provision of a malaria standby treatment kit is also advised. It should be stressed that the kit is for use in emergency situations and should always be followed up with a medical consultation. As the medication could be taken for the first time in a medical emergency, full information about the drugs and the potential side-effects should be provided.(5)

Physical dangers
Physical hazards are part of any humanitarian assignment and include terrorism and intentional harm. Research has shown that death following intentional crime accounts for the highest mortality rate among humanitarian workers.(6) While this is an issue that is essentially covered in organisational briefings, advice relating to personal safety should also be discussed in the pretravel consultation.
While accidents might not be the leading cause of death among this group, they still pose a threat in countries where poor economies are associated with decaying structures and inadequate roads. Accidents also cause disability and pose an increased threat of HIV and hepatitis B and C due to the possibility of contaminated blood transfusions. Organisational policies to help prevent accidents are in place, and workers should be encouraged to follow such guidelines.(7)
First-aid techniques and the use of a well-equipped first-aid kit and sterile medical pack are recommended for most travellers. All workers should be aware of their blood group and carry copies of essential medical details, including their health insurance policy. Workers will also need advice related to climate adjustment as well as the need for clean food and water, as most will be going to places where such commodities are considered luxury.

Psychological dangers
Culture shock and stress are commonplace risk factors among humanitarian workers and should be addressed in the pretravel consultation. Issues such as loneliness, inadequate skills for the job assigned, and personality problems can be contributing factors to early repatriation. While those on short-term projects are sometimes overwhelmed at the immensity of the task, they often lack experience, have language difficulty and are vulnerable, which puts them at a high risk of psychological problems. For the longer-term worker, stress and exhaustion are often noticeable on return.(8)

Returning travellers
Many workers find themselves with problems when they return home. Those who have been living in remote situations with local populations often return with diarrhoea, fever and weight loss. Those who have been working on short-term projects overseas tend to return exhausted and feeling unwell. While symptoms could represent a number of differing diagnoses, it is essential that a full checkup is given. The need for adequate debriefing and counselling should be made available for those who have been in difficult situations while overseas.

Conclusion
While humanitarian work placement offers a special challenge in time and commitment, for those nurses willing to undertake the assignment it can be one of the most rewarding and challenging aspects of travel medicine practice.

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References

  1. Burkle FM. Lessons learnt and future expectations of complex ­emergencies. BMJ 1999;319:422-6.
  2. Report of the Secretary General on the work of the Organisation, United Nations Supplement 1 (A/56/1). Available from URL: http://www.un.org/ documents/ga/docs/56/a561e.pdf
  3. Howarth J. Refugees, disaster relief and migration. In: Lockie C, Walker E, Calvert L, et al. Travel medicine and migrant health. London: Churchill Livingstone; 2000.
  4. Tucker R. The challenging traveller. Primary Health Care 2000;10(4):43-9.
  5. Lankester T. The traveller's good health guide. London: Sheldon Press; 1999.
  6. Sheik M, Gutierrez MI, Bolton P, Spiegel P, Theiren M, Burnham G. Deaths among humanitarian workers. BMJ 2000;321:166-8.
  7. People in aid, preventing accidents. Available from URL: http://www. peopleinaid.org.uk/download/­accidents.doc
  8. Jones M. Psychological aspects of travel and the long-term expatriate. In: Lockie C, Walker E, Calvert L, et al. Travel medicine and migrant health. London: Churchill Livingstone; 2000.

Resources
Interhealth Medical charity specialising in the care of overseas workers
157 Waterloo Rd
London SE1 8US
T:020 7902 9000
F:020 7928 0927
E:info@interhealth.org.uk
W:www.interhealth.org.uk
Lankester T. The Traveller's Good Health Guide. London: Sheldon Press; 1999. (Price £6.99)
Lloyd Roberts D. Staying Alive - Safety and ­security guidelines for humanitarian volunteers in conflict areas. Geneva: International Committee of the Red Cross; 1999. (Price £8.50)
Elphinstone International Health Centre
A clinic for ­voluntary ­agencies
Elphinstone Wing Carberry
Musselburgh
Scotland EH21 8PW
British Travel Health Organisation
W:www.btha.org
Voluntary Agency Medical Advisors
W:www.vama.org.uk

Forthcoming events
31 October 2002
RCN Travel Health Forum, British Travel Health Association and Royal Society of Tropical Medicine and Hygiene Joint Conference
Venue: Royal College of Physicians
London