Education and debate

Selection, training, and support of relief workers: an occupational health issue

Maureen McCall, primary care physician, ^a Peter Salama, emergency medical coordinator. ^b

^a Red Deer Regional Hospital, Red Deer, Alberta T4N 6R2, Canada, ^b Concern Worldwide, Camden Street, Dublin 2, Republic of Ireland

Correspondence to: Dr Salama peter.salama{at}concern.ie

Courage rather than cowardice, compassionate human concern of one for the other; and resilience in the face of overwhelming stress.¹

Many of today's violent conflicts can be characterised as "complex humanitarian emergencies." Complex humanitarian emergencies are defined by Leaning as "Crises in life support and security that threaten large civilian populations with suffering and death and impose severe constraints on those who would seek to offer help."² Lauttze interprets these emergencies as "complicated disaster situations that have political, military and humanitarian dimensions and are often associated with natural disasters, especially drought."³ Kosovo, Rwanda, Sudan, and Afghanistan are recent examples.

The rapid growth, in capacity and number, of humanitarian relief organisations in response to complex humanitarian emergencies has created concern about the professionalism of their relief workers. The risk to the psychological wellbeing of relief workers caused by exposure to traumatic events is a particular worry and has been studied little.⁴ Research on the psychological sequelae to trauma has focused on primary victims,^5-7 domestic rescue workers, ^{8 9} military personnel,¹⁰ and psychologists.¹¹

Complex humanitarian emergencies may generate more stress among relief workers than "natural" disasters for several reasons. Firstly, an element of physical insecurity, with the risk of violent personal assault or injury, is increasingly present.¹² Secondly, work in these situations necessarily involves moral and ethical dilemmasfor example, negotiating with warlords; witnessing human rights abuses, but being constrained from responding by operational considerations; and concern that humanitarian aid may perpetuate conflicts.^13-16 Finally, caring for people with serious injuries caused by violence, witnessing unnatural deaths, and handling dead bodies or body parts are highly traumatic experiences in themselves.¹⁷

Codes of practice have been drawn up to improve technical standards and accountability.^18-20 Furthermore, many universities and relief organisations (including Harvard University, Johns Hopkins University, London School of Hygiene and Tropical Medicine, University of Hawaii, Université de Louvain in Belgium, the International Committee of the Red Cross, and Médecins Sans Frontières) are responding by developing training courses in humanitarian relief. However, individual relief organisations still carry the ultimate responsibility for preparing new recruits for field work. The broad range of current organisational practice in this regardand particularly practice related to psychological issuesis of concern to all those with an interest in developing a cadre of resilient, professional, humanitarian relief workers.

	Survey

We undertook a survey of leading relief organisations to capture and describe a cross section of practice for selecting, training, support, and follow up of relief workers. The survey focused on medical staff and on psychological aspects of relief work. A questionnaire, developed from a search of published reports and from interviews with returned relief workers, formed the basis for semistructured telephone interviews. The 16 questionnaire items were open ended and centred on five themes (box). Interviews were conducted with headquarters staff from 12 of the leading international humanitarian relief organisations. They were completed over a two month period in 1997. Respondents were chosen from the human resources departments or from staff health services. Confidentiality was crucial to obtaining an honest appraisal of organisational practice and is maintained here.

The 12 organisations (non-governmental, governmental, and intergovernmental), based in the United States, United Kingdom, and other countries in Europe, deployed medical and other relief personnel to complex humanitarian emergencies in as many as 25 countries and territories in 1996. They have provided a minimum of 14 years to over 70 years of service. All rely heavily on volunteers, most have national offices throughout the world, and all but one governmental organisation have several sources of funding.

	Findings

Selection and training
The formal process for selection and training of relief personnel varied widely between organisations. Selection procedures ranged from a single telephone interview to a multiple stage process of individual and group interviews lasting a full day as well as phone contact or personal visits to the site of the project. In acute emergencies, team members are more often found through less formal channels.

Workers' characteristics and qualities
Flexibility, adaptability, technical expertise, and extensive work experience in a relief setting were seen as key positive qualities predictive of success in new recruits (table 1). One interesting reply included reference to self destructive behaviour as a positive quality: "Some situations require people who can destroy themselves and thrive on chaos ... at times we have employed workaholics and alcoholics."

Psychological support
Most organisations admitted that support mechanisms were underdeveloped. Staff were expected to seek help in coping with stress from direct superiors in the field with the option of contacting headquarters if necessary. One organisation used peer support groups for this role. Another organisation asked field workers to nominate respected peers, who were then trained as counsellors, and another made formal mental health support available to relief workers, but only for projects in extremely insecure areas.

Awareness of post-traumatic stress disorder
Although there is a large body of formal research on post-traumatic stress disorder²⁰ in primary victims and emergency rescue workers,^4-10 we know of no studies of this disorder in relief workers. In contrast to military and rescue workers, aid workers are usually deployed individually and do not benefit from the support of a cohesive group of colleagues who may have longstanding relationships; their preparation and training may be vastly inferior; and their mandate much less clear.²⁷ Unlike the domestic rescue worker, he or she may also have to deal with continuing "low intensity" trauma over a period of years, rather than discrete traumatic incidents.

Developing an experienced workforce
Although many organisations stated that a high proportion of their workers returned for further assignments, no data were kept on this. Return rates were estimated to be in the range of 30-75%. Most organisations had little formal contact with past workers after the debriefing process. Two respondents stated that it was more important for their organisations to staff the head office with experienced personnel and that field workers were easily replaced.

	Discussion

Although the immense suffering of the victims of complex humanitarian emergencies will always be of primary concern for relief organisations, discounting the effects of traumatic events on the relief workers reflects disregard not only for their wellbeing but, more importantly, for the impact of distressed aid workers on the population they seek to serve.

One of the consequences of the apparent ad hoc nature of current practices may be an unnecessarily high prevalence of psychological morbidity (ranging from "burn out" to classic post-traumatic stress disorder) that is as yet inadequately documented and awaits further research. Recommendations stemming from our research and survey are detailed in the box.

Conclusion
Relief work in complex humanitarian emergencies exposes individuals and organisations to new dilemmas and challenges. One such challenge is the increasing recognition of stress related illness as a problem that can no longer be neglected.

	Acknowledgments

We thank Dr Jennifer L Leaning for her assistance.

Funding: None.

Conflict of interest: None.

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