A. Staying healthy
This section highlights some simple precautions to minimise the chances that you will fall ill. Some suggestions may seem obvious. Unfortunately, many civilian experts on mission do not take necessary precautions, often because they are deployed at short notice or adopt an overly tough attitude and assume they are immune to microbes and mosquitoes.
Keeping these guidelines in mind throughout your deployment can help save your life.
1. General health advice
If you consider and abide by the following rules before eating, you could eliminate the main reasons why crisis managers fall ill. The following recommendations apply to food vendors on the street as well as to expensive hotel restaurants:
- Cooked food that has been kept at room temperature or under the sun for several hours constitutes one of the greatest risks of foodborne illness. Make sure your food has been thoroughly and recently cooked and is still hot when served.
- Egg yolks should be firm and not runny.
- Avoid any uncooked food apart from fruit and vegetables that can be peeled or shelled. Avoid fruit with damaged skin. Remember the dictum ‘cook it, peel it or leave it’.
- Ice cubes and ice cream from unreliable sources are frequently contaminated and may cause illness. Avoid them.
- Certain species of fish and shellfish may contain poisonous biotoxins even if they are well cooked. If you are not sure, avoid them.
Contaminated water is the second main reason for people to fall ill during their stay in foreign countries. Follow some simple rules to prevent disease caused by unclean water:
- When the safety of drinking water is doubtful, boil water for a full minute and ideally for three minutes if over 2,000 metres, or use reliable disinfectant tablets/liquid.
- Avoid ice cubes in your beverages.
- Beverages such as hot tea or coffee, wine, beer and carbonated soft drinks or fruit juices that are either bottled or packaged are usually safe to drink. Check that the lid of the bottle is properly sealed before purchasing.
- Unpasteurised milk should be boiled before consumption.
- It is recommended that bottled water be purchased and used whenever possible – even for brushing teeth.
The following notes on hygiene should go without saying, but there is no harm in reminding yourself of some of the most important basics. In certain situations it may not be possible to maintain the standard of hygiene you are used to at home. However, the following points are important for the prevention of infection and contribute to your general health and well-being.
Care of the body:
- Try to wash your body with a warm bath or shower whenever possible. It is essential for personal health and hygiene, as is the wearing of clean underwear.
- Be sure to visit a physician regularly. Schedule an appointment with your home physician when you are back on leave.
- If living in a container or group housing, use flip-flops to take a shower (one pair to walk to the container shower, another pair in the shower).
- Wash your clothes regularly, especially underwear.
- Be aware that some hygiene products, such as tampons, may not be available in the country in which you are deployed.
Care of hands and nails:
- Hands and nails should be washed and cleaned thoroughly after visiting the toilet and every time before handling any food.
- Cut nails regularly.
- No person who has sores, cuts or broken skin on their hands should handle food. Disease-causing micro-organisms can be transferred in this manner.
Procedures for the washing of hands:
- Use soap.
- Use water as hot as the skin can tolerate (if available).
- Moisten hands, wrists and forearms, apply soap to the palm of one hand and rub over the hands, wrists, forearm and between fingers.
- Rinse hands thoroughly under clean (and, if possible, hot) running water.
- Dry hands and arms with a disposable paper towel, start with the hands and end at the elbows.
Alcohol gel, hand sanitiser or antibacterial dry wash are effective at killing germs and worth using frequently. If hands are visibly dirty, then using soap and water is preferable.
Large numbers of germs are transferred when shaking hands and through touch. Respiratory infections as well as diarrhoea are caused by touching the face and mouth with dirty hands. Regular use of alcohol gel will reduce your risk of these common and annoying conditions.
- Keep your teeth clean, healthy and brushed at least twice a day.
- Try to schedule regular dentist appointments when you are on leave back home.
- Wear clean, comfortable, closed shoes with closed heels, sufficient room for the toes and good arch support.
- Wear clean socks or stockings.
- Wear clean, well-fitting, adequate protective clothing and change it every day (if possible).
- Store clean clothing separately from dirty clothing.
- Hair should be worn away from the face and not hang over the collar of protective clothing.
3. Common illnesses: diarrhoea, fever and malaria
Diarrhoea is a common problem when travelling. To avoid getting diarrhoea, ensure that hand washing and hygiene are given attention and the source of water consumed is safe. Many diarrhoea attacks are caused by viruses; these are self-limiting and clear up in a few days. It is important to avoid becoming dehydrated. As soon as diarrhoea sets in, drink more fluids, such as bottled, boiled or treated water or weak tea. Dairy products should be avoided as they can aggravate diarrhoea.
The body loses water, salts (especially sodium and potassium), water-soluble vitamins and other important trace minerals through diarrhoea. In order to replenish some of these losses, it is recommended that you consume at least three litres within the first three hours and continuously drink fluids thereafter, especially oral rehydration solution in the correct dilution.
Evidence and experience show that antibiotics such as ciprofloxacin and azithromycin can reduce the frequency and severity of diarrhoea in about 7 out of 10 cases and can be taken as part of the medical kit. They can be especially helpful when work, travel or important engagements may otherwise be disrupted.
You should seek medical help if there is any blood in your stools or accompanying fever and vomiting. Diarrhoea that lasts for more than three days requires medical attention.
A high body temperature (i.e. 38.5 °C or more) should always be taken seriously, especially if you are in a malaria-prone area or have come from one in the past. You should see a doctor if a fever persists or is worsening. It helps to be aware of some important causes of fever. These include: meningitis (severe headache, stiff neck, often a rash that does not fade
when you touch it); acute bilharzia or katayama fever (often accompanied by wheezing and itching 20 or more days after swimming in an area where bilharzia is common, such as Lake Victoria or Lake Malawi); kidney infection or pyelonephritis (aching in the loins, often with nausea, shivering, and frequent urination that creates a burning sensation); typhoid (progressive fever and feeling increasingly ill – with no response to malaria treatment – usually accompanied by diarrhoea, sometimes by coughing and sometimes by a faint rash); blood poisoning (alternate shivering and sweating, often in the presence of an infected bite or other skin infection like a boil, or warm infected feet or legs). Heat stroke also causes high temperature.
If you are in a malarial zone, this is an essential list of precautions:
- Take your malaria prevention tablets.
- Use a DEET-based insect repellent.
- Sleep under an insecticide-treated mosquito net.
- Keep skin covered as much as possible beginning before dusk or dawn. Keep in mind that some mosquitoes also bite during the day.
- Take a standby treatment kit.
Even if you take all these precautions, you may still get malaria. Whenever you travel, take your malaria standby treatment kit with you. Consult your doctor on the type of treatment kit and prevention tablets, since different drugs are needed in different parts of the world. If you develop a fever, sweats and chills, a bad headache or other symptoms that could be attributed to malaria, get tested as soon as possible by a reliable doctor or laboratory. If this is not possible, if you do not trust the result or if the correct treatment is not available, self-treat within 8-12 hours of the time your symptoms first started. In all cases you should put yourself under the care of a trusted doctor or other health worker as soon as possible.
Malaria kills more people than wars do.
4. Treating infections, parasites and bites
Infections, parasites and bites can turn nasty, so proper treatment is important. This section will offer you advice about what to do in case of an infection or bite and what medication to take. However, you should refrain from self-treatment unless it is impossible to reach a doctor and get medical advice.
This is a mosquito-borne illness that can cause severe illness very rapidly. The Aedes mosquito, which spreads this severe flu-like illness, tends to bite during the day. Typical symptoms are high fever, severe headache, muscle and back pain, and feeling seriously ill. If you experience these symptoms, see a doctor, get a blood test (including a blood slide to rule out malaria), then rest, drink plenty of fluids and be patient. There is no cure, but expert health care can be life-saving if (rare) complications set in.
Dengue is spreading worldwide with amazing speed and is becoming as great or greater a risk than malaria in many areas such as South East Asia and South America.
Viral haemorrhagic fevers
Lassa fever, ebola and marburg are the best known of these rare afflictions. There are regularly cases of lassa in rural areas of West Africa. Most viral haemorrhagic fevers are spread by close contact with infectious cases, while some are spread by mosquitoes or ticks. If you are deployed in areas where known outbreaks are occurring, get specialist advice. Symptoms start with fever, headaches, muscle pain and conjunctival suffusion (redness of the eye/conjunctiva). Lassa may be treated by a slow intravenous infusion of ribavirin; however up until now, no effective cures have been found for ebola and marburg. Prevention consists of avoiding contact with infectious cases.
Pneumonia and respiratory infection
These are especially common at times of stress, tiredness and overcrowding. Symptoms are coughing, shortness of breath, fever and sometimes pain when breathing deep. If you experience these symptoms, seek good medical advice as soon as possible. Timely treatment with effective antibiotics usually shortens these illnesses. If you are deployed in a country where any currently severe episodes of flu or flu-like illness are known to be occurring in the area or in a world-wide outbreak, follow official guidelines carefully.
Skin and wound infections
In hot climates, even small cuts, grazes, bites and other wounds can quickly get infected. Use an antiseptic cream or powder. Cellulitis – hot, red skin spreading outwards from an infection or upwards from the feet and toes – can come on extremely rapidly. Start a high-dose antibiotic at once under medical supervision.
Bites from dogs and other animals
Clean bites scrupulously with soap and water. Get them looked at by a doctor or other trusted health workers. Bites often become infected and in principle you should start a course of antibiotics even if no infection is obvious. Make sure you have been immunised against tetanus. (That means a primary course of three injections in the past and a booster every 10 years.) If this is not the case, you will need a tetanus shot without delay.
Unless you are in a region known to be free of rabies, you absolutely must report to a good health centre at once if you are bitten. If you have been fully immunised prior to deployment, you will need two further vaccines. If you have not, you will need five post-exposure vaccines and probably also Human Rabies Immunoglobulin, which can be hard to get a hold of. Everyone deploying to a country where rabies is endemic should be immunised prior to mission.
Sexually transmitted infections (STIs)
These are very common among mission personnel and humanitarian workers for reasons that are usually obvious. The key rules are never to have unprotected sex (i.e. use condoms) and to avoid sex when alcohol has significantly blurred your decision-making. Also report any signs such as abnormal discharge, sores or genital warts. If in doubt whether you may have become infected, get checked out at the end of your mission as some STIs may cause no symptoms, but can cause infertility and other problems. Include an HIV test.
At the end of your mission
It is now considered good practice to have a post- mission medical checkup unless your deployment has been short or to low-risk destinations. If you have any unusual or persistent symptoms, including unexplained tiredness or weight loss, have these checked out by a doctor.
5. Dealing with climatic extremes
Altitude sickness, hypothermia and heat stroke can be dangerous. This section will instruct you on how to cope with extreme climate and altitudes.
Beware of altitude sickness, which can set in at any height above 2,000-3,000 metres. When climbing or travelling to heights above this, try to take one or two days to get acclimatised. Above 3,000 metres, try to sleep no more than 300 metres higher than the night before. Maintain your fluid levels. If you become short of breath while at rest, develop a persistent cough, experience a pounding headache or feel drowsy, return to a lower altitude as quickly as possible.
Hypothermia can quickly set in with any combination of cold weather, high elevation, strong wind and being wet. To prevent this, wear several layers of loose-fitting clothing, with a waterproof outer layer, and cover head, neck and hands. Set up a ‘buddy system’ so that individuals can look after one another. Signs of danger include feeling intense cold, shivering, drowsiness or confusion. If this happens to you or your companion, warm up without delay by having warm sweet drinks, sharing warmth in a sleeping bag or having a bath with water up to 40 °C. Check for signs of frostbite (an aching or numbness, often in the hands or feet, with the skin feeling rock-hard and looking very pale or purplish). Do not drink alcohol.
Working in high temperatures brings with it the risk of heat stroke or sun stroke. This is when your body’s cooling mechanism (including your ability to perspire) breaks down. In these situations, your body temperature escalates to 39 °C or above, you feel hot and dry, your pulse rate goes up and you may feel sick and confused. Get into a cool place at once, drink cold non-alcoholic beverages if you are able to, get sponged down, fanned or have cold water poured on your body to evaporate the heat. Get medical help, as this can be an emergency.
Useful websites include:
6. Mental health and stress management
Working in crisis management environments can expose you to stressful situations and conditions. You might be shocked to realise that a situation your colleague judges to be extremely stressful is one that you can handle like a walk in the park. It is only natural that different people react differently to stress triggers and that coping strategies vary from one person to another.
Experiencing stress in a crisis management environment can be helpful. It can focus your attention, increase your concentration and mobilise the necessary energy you need to achieve your everyday goals.
However, failure to cope effectively with stress may cause a decrease in productivity, prove detrimental to your functioning and affect the work of your entire team. Early prevention can stop the stress reaction from escalating into a real problem in the short- and long-term future.
This section will focus on three types of stress, namely cumulative stress, acute traumatic stress and vicarious trauma. It will provide you with tips on how to deal with both and take advantage of the resources at hand to speed up your healing process. Furthermore, you will find a section on post-deployment stress in Chapter 7.
Stress that builds up over time and that is not well managed can gradually lead you to perform less effectively. Some form of stress in missions is inevitable, but failure to address cumulative stress may lead to burnout.
What creates cumulative stress?
Every individual has different reasons for feeling stressed. Some can cope with stress better than others by consciously controlling their state of mind. This is a list of possible causes of cumulative stress:
- problems with basic needs, e.g. housing discomforts, lack of privacy, food (lack of variety, poor quality, etc.) and clean water shortages;
- travel delays;
- lack of safety and security, or health hazards;
- immobility, inactivity, lack of exercise;
- problems at home, or missing family and friends;
- witnessing violence or tragedy;
- inability to make a difference, lack of progress or apathy among responders or survivors;
- noisy or chaotic environment;
- malfunctioning equipment;
- no rest or relaxation periods;
- unclear or constantly shifting tasks, unrealistic expectations (imposed by yourself or others);
- media attention and coverage of security incidents close to your location;
- non-recognition of work or hostility towards your efforts;
- pressure to achieve;
- unsupportive or difficult colleagues or superiors;
- anxiety about the mission, your accomplishments, responsibilities or skills;
- lack of resources or limited control of the situation;
- cultural and linguistic differences.
How to recognise it
It is important to recognise indicators of cumulative stress. It may be a good idea for individual team members to share clues with their colleagues that will indicate when they are not handling their stress satisfactorily.
- narrowing of attention, impaired judgment, loss of perspective;
- disorientation, forgetfulness;
- impatience, verbal aggression or being overly critical;
- inappropriate, purposeless or even destructive behaviour;
- sleep disorders;
- susceptibility to viruses or psychosomatic complaints;
- hyper-emotions, e.g. grief, elation, wide mood swings;
- physical tension, headaches;
- increased substance abuse;
- eating disorders, e.g. lack of appetite, eating too much;
- ack of energy, interest or enthusiasm;
- withdrawal, depression or loss of sense of humour;
- nability to perform;
- questioning basic beliefs and values, or cynicism.
How to cope
Experience has shown that knowledge, especially through training prior to deployment, about cumulative stress, how to build up resilience, awareness of early-onset indicators and prompt action to establish coping mechanisms has had a positive effect on reducing cumulative stress and avoiding burnout. It is normal to experience cumulative stress during a disaster operation and most reactions to stress are considered normal behaviour. Cumulative stress may be identified and managed.
How to minimise cumulative stress
Some of the actions below may help reduce stress:
- know your limitations, manage your expectations, accept the situation;
- get rest, relaxation, sleep, and exercise;
- eat regularly, drink enough water;
- change tasks and roles;
- identify and act on the source of stress;
- take time off regularly;
- create personal space;
- control substance abuse;
- talk, laugh or cry with your colleagues;
- practice prayer, meditation, progressive relaxation – depending on your preferences;
- pamper yourself – read, sing, dance, write, listen to or play music, work on a hobby, take a sauna, cook a meal;
- Participate in non-work related social activities.
Acute traumatic stress
This powerful, acute type of stress is brought on by sudden exposure to a traumatic event or a series of such experiences. It is classically described as a set of normal reactions to an abnormal event. For example, these events might include:
- witnessing casualties and destruction;
- serious injury to self or injury/death to relative, co-worker, friend;
- events that are life threatening;
- events that cause extreme physical or emotional harm.
There is no right or wrong way to react to these kinds of experiences and it is important to remember that strong emotional and psychological reactions can often occur in the immediate aftermath of a traumatic experience.
What are common reactions?
Emotional and psychological reactions may include the following:
- shock or disbelief
- fear or anxiety
- sadness, hopelessness and grief
- guilt and shame
- lack of perception or numbness
- difficulty making decisions.
Physical traumatic stress symptoms may include the following:
- trembling or shaking
- rapid breathing or hyperventilation
- decreased attention
- stomach problems
- sleeping problems
- substance abuse
- nausea, sweating or chills
- irrational activities.
Steps towards recovery
Going through a potentially traumatic experience can often fundamentally challenge our sense of safety and meaning. We can often feel helpless and out of control. It is important that we take proactive steps to address these sensations as soon as we can:
- If possible, try to re-establish a routine.
- When not working, try to distract yourself (books, films, etc.) as opposed to dwelling on the experience.
- Importantly, try to connect with others and seek helpful support from your family, friends, other survivors of the same (or a similar) event, your colleagues and management.
- Participate in memorials and organised events concerning the traumatic event.
- Challenge your sense of helplessness by reclaiming some control. Taking positive action can do this, in particular by helping others and seeking creative solutions.
Dealing with strong emotions
Allow yourself time and make yourself aware that you may well experience strong emotional reactions:
- Don’t rush the healing process.
- Try not to be judgmental about the feelings you have.
- Connect with people! Talk to someone you trust or who is trained or experienced in traumatic reactions.
- Practice relaxation techniques.
- Pamper yourself and try to ensure the essential sleep you need for recovery.
When to seek help for traumatic stress
Try to seek support from your natural networks (e.g. friends, family, colleagues) as much as possible during the aftermath of trauma. If this support is not immediately available or you do not have access to these networks, then try to find a specialist. As stated above, quite extreme emotional reactions to traumatic experiences are perfectly normal.
However, should you find that your functioning is profoundly affected and your reactions are taking a long time to subside or are even worsening over time, then you should seek professional assistance. This is especially true if:
- more than about six weeks have passed since the incident;
- you are not feeling that things are getting better;
- you are finding it difficult to communicate socially;
- you are having frightening flashbacks or nightmares;
- you are having difficulties at work or at home;
- you are having thoughts of suicide or self-harm.
If these criteria are present, you should make contact with a professional through your insurance provider or other medical networks. You may be in danger of developing post-traumatic stress disorder (PTSD), a severe and disabling condition that can be alleviated with professional help.
It is possible that your seconding organisation provides access to services to support you in dealing with stress or trauma. Be sure to inform yourself about all available services and how to access them prior to your deployment.
If you feel like you can no longer remain in the mission because of the trauma that you have experienced, do not hesitate to take the necessary steps to end your contract. There is no shame in leaving a stressful and traumatic situation.
Vicarious trauma (otherwise known as secondary trauma) can affect anyone who is exposed on an ongoing basis to the suffering of others. Anyone, therefore, who works in crisis environments can be vulnerable.
You are particularly at risk if:
- you care deeply about your work, but tend to set unrealistic expectations;
- you have not processed previous traumatic experiences;
- you lack social support or find it difficult to talk about your feelings.
Vicarious trauma is a cumulative process that makes gradual changes over time to a person’s emotional, physical and spiritual well-being. Common reactions include:
- loss of a sense of meaning, purpose and hope;
- difficulty maintaining healthy work/life boundaries;
- relationship problems;
- cognitive confusion and disorientation;
- unpredictable emotional shifts.
Coping with vicarious trauma
Because vicarious trauma is such a gradual process, there is no quick fix for recovering from it. Some helpful strategies for dealing with vicarious trauma include the following:
- Take good care of yourself. Ensure that you are getting adequate sleep, nutrition and moderate physical exercise.
- Take regular breaks. Create space to get away from your job, both physically and mentally (e.g. reading books, engaging in hobbies, spending time with friends, taking short trips).
- Examine your limits. Do you need to make changes to the amount of time you spend in crisis environments (temporarily or permanently)? Do you need to balance crisis work with other kinds of activity? It can be helpful to talk this over with a friend or counsellor.
- Explore your motives. Think about what inspires you and where you find a sense of higher purpose. Look for ways to connect with yourself more deeply (e.g. meditation, journal writing).
7. Substance abuse
The high levels of stress that can form part of the daily work of civilian experts on mission can some times become a breeding ground for substance abuse. By substance abuse, we are not only talking about cases of drug overdoses or drunkenness, but rather about a long and complex problem of intoxication and addiction.
While addiction can cause serious health problems for civilian experts on mission, intoxication can pose safety risks as well as low levels of productivity in the workplace and increased absenteeism. While each type
of drug affects a person’s mind and body in different ways, there are general signs and symptoms to watch out for:
- smelling of alcohol
- intoxication (slurred speech, unsteady on feet, confusion)
- injection marks on arms (drugs used intravenously)
- tremor and sweating of hands (alcohol or sedative withdrawal)
- multiple bruises, especially if some are more recent than others
- loss of weight and gaunt appearance
- accidents at work, at home or on the road.
Habits and moods
- multiple mood swings within a single day (alternation between drug-induced euphoria and delayed depression)
- increased irritability, nervousness, and argumentativeness
- poor relations with fellow workers and management
- avoidance of supervisor
- tendency to blame others.
Absence from work
- frequent absenteeism, especially after the weekend or pay days
- frequent times off sick
- bad timekeeping
- unexplained absences.
- reduced quality and quantity of work
- increasing number of mistakes and errors of judgment
- loss of interest in work
- failure to meet deadlines.
How to deal with substance abuse
If you recognise the aforementioned symptoms in your colleagues, then they could be struggling with alcohol or substance abuse. The best solutions you can offer them (or seek out in case you are going through these problems yourself) are guidance, support and treatment. Some options include:
- talking to staff members about the situation and collectively agreeing on a realistic plan of action;
- if you find that the situation has escalated to a more serious level and is starting to affect work performance, discuss it with a supervisor or contact whoever is in charge of offering confidential counselling;
- make sure you or the person concerned seeks medical advice and this issue is being dealt with in a confidential manner.
Addiction to trauma
If people have suffered early trauma in their lives or are repeatedly exposed to acute stress in adulthood, it is possible to become addicted to the experience (the term ‘adrenalin junkie’ may be familiar). Otherwise known as ‘repetition compulsion’, it refers to the need to persistently revisit disturbing experiences.
Clinical research suggests that this may represent an attempt to gain mastery over a previous trauma. It is also thought that the excitement of the risk acts as a distraction from feelings of loss and confusion that might otherwise prove overwhelming.
If you are in the grip of repetition compulsion, you may experience any of the following. You may:
- feel bored and numbed by ordinary life back home;
- only feel engaged and alive in violent and unpredictable surroundings;
- compulsively watch violent or disturbing films or listen to aggressive music;
- engage in sexual promiscuity or other risky behaviour;
- repetitively become involved in abusive relationships.
Responding to trauma addiction
In many ways, repetition compulsion needs to be treated like any other addiction. That may mean a period of abstinence in order to ‘detox’. It can be very helpful to take breaks from adrenalin-fuelled crisis environments to reflect on your experiences and talk through your reactions.
Addiction of any kind is a very isolating experience, which can usually only be fully resolved in relationships with others. If you are aware of difficult or traumatic experiences that you sense you have not come to terms with, it is important that you find someone to discuss this with.
Some people prefer to talk to one other person (such as a trusted friend, colleague or counsellor) but others find group support more helpful. However you do it, clinical experience indicates that dealing with past experiences can help people move on in their working lives with a renewed sense of purpose and engagement.
8. First aid
Knowing and applying simple first aid principles can save lives even when you only have basic equipment at your disposal. It is important to realise that first aid is a practical skill. In order to be effective it requires regular practical training. We strongly recommend that you attend a professional first aid course and possess a valid first aid certificate. As an alternative, you may take an online course, such as a first aid e-learning course offered by the British Red Cross. This is accessible free of charge at www.firstaidforfree.com.