Ebola in West Africa is no longer in the headlines, but on the morning of 25 April 2015, many workers who were still in or not long returned from Sierra Leone, Liberia or Guinea, were woken by phone calls asking them to pack a bag and head to Nepal. A natural disaster, causing large numbers of casualties and fatalities, had struck. As the earthquake ripped families, homes and communities apart, people cried out for food, water, shelter and medical assistance. Teams landed from all corners of the earth and set to work building a response, but before long the humanitarian effort was questioned.
A headline in The Guardian read, ‘Nepal earthquake: tensions rise over slow pace of aid’.1 It is easy to criticise, but the logistics and planning that go into a major international crisis response are immense. The death toll in Nepal climbed to over 6,000 and many more people were displaced. ‘At least 200,000 houses have been destroyed and another 190,000 badly damaged. An estimated 2.8 million people are living in the open in need of assistance and protection.’2
The welfare of humanitarian and aid workers will never capture the public imagination in the way that their beneficiaries do. But consider their stress profiles. How often are they at home? Do they even have a secure base? How do they build and sustain intimate relationships? How much suffering, brutality and scarcity have they witnessed? How does their own safety measure up to the needs of, for example, the people of the Central African Republic where life expectancy is 51 years?
InterHealth Worldwide is an agency that specialises in supporting just such workers. It was founded in 1986 by two former missionaries, Marjory Foyle, a psychiatrist, and Veronica Moss, a medical doctor. They experienced first hand the physical and psychological impact of working in what is rather euphemistically called ‘the field’. InterHealth started from humble beginnings in a small back room at the Mildmay Hospital, a former cholera facility, in Bethnal Green.
In 1988 Ted Lankester joined as Director. The team has now grown into a registered charity supporting around 300 organisations and 10,000 individuals. InterHealth offers holistic care covering travel, medicine, nursing care, occupational health and psychological services. Its aim is to prepare, sustain and support individuals serving around the world from offices in London and Nairobi.
There is more demand than ever before. Individuals are more at risk of being wounded, killed or kidnapped. The UK-based UN Humanitarian Outcomes research, 2013, shows there has been a 66 per cent increase of risk from the previous year. They suggest that the reasons for this include the increasing number of workers being deployed and the increasingly unstable environments in which they serve. The research further reveals that travelling by road is the most dangerous activity. In 2013, 155 aid workers were killed, 171 seriously wounded and 134 were kidnapped.3
World Humanitarian Day is held on 19 August each year. In 2003 this was the date that the UN headquarters in Baghdad was bombed, killing 22 people. Anthony Lake (Executive Director of the UN Children’s Fund – UNICEF) highlights the risk: ‘Humanitarian workers were killed in South Sudan by armed fighters while supporting the mission to reach malnourished children… In Gaza aid workers have lost their lives in shelling attacks while providing critical care to the sick, the wounded, and the dying, and comforting families of the dead.’4
A range of responses
InterHealth’s clients include the Department for International Development (also known as UK Aid), Save the Children, Médecins Sans Frontières (MSF), Mission Aviation Fellowship (MAF), World Vision, Plan International and the British Red Cross. I have recently reviewed and developed InterHealth’s responding in a crisis (RIC) plan. The model has three tiers, incorporating low-level, mid-level and high-level responses. A low-level response includes incidents that impact individuals, such as suicidal ideation, psychosis and sexual assault. These crises can generally be managed by one member of the Psychological Health Services (PHS) team. InterHealth has developed a suite of appointments to meet the needs of our unique client base. Low-level interventions include trauma assessment consultations (TACs) and the longer personal impact review (PIR) appointments. Mid-level responses are designed to address incidents that impact several individuals, such as road traffic accidents, suicide bombings, hostage-taking or kidnapping. These would generally need to be managed by the wider PHS team. In some circumstances we offer TACs and PIRs alongside trauma briefings or debriefings for groups.
High-level incidents that InterHealth has responded to include the case of the Arctic 30 – when Greenpeace environmental protesters were held in a Russian prison in 2014, the impact of Typhoon Haiyan in the Philippines, and the public health crisis surrounding the Ebola epidemic. In addition, we train agencies in family liaison in crisis and psychological first-aid programmes.
The fact that the Nepal earthquake came right on the heels of the Ebola crisis defines the world we live in; lurching from one disaster to another. It’s significant that we have managed as many RIC cases so far in 2015 as in the whole of last year. At an individual level, humanitarian and aid workers present with post-traumatic stress disorder (PTSD), traumatic stress response (TSR) and burnout.
Agencies involved in the Ebola response demanded urgent support from InterHealth when the World Health Organisation declared Ebola an international epidemic on 7 August 2014. InterHealth rapidly designed a bespoke psychological support programme for aid workers being deployed. The package enabled candidates to think seriously about their self-care and resilience levels.
‘I realised that the psychological support before and after my deployment was really helpful in keeping me going: I recognised this had been missing previously. I will definitely use these services again’ (doctor, Liberia, January 2015).
Working with Ebola
The PHS practitioners are skilled at predicting outcomes in the field, preparing individuals to be as resilient as they can be in highly demanding roles and supporting and enabling a quick recovery on their return… As individuals returned home from Ebola-affected areas we began to hear stories of just how tough these assignments were: ‘In 35 years of emergency response experience, working with Ebola in the early stage was the hardest thing I have ever done’ (senior leader from INGO).
Most assignments that involved direct contact with patients were kept to a maximum of four weeks due to the intensity of the work. The average amount of time wearing the personal protective equipment (PPE) was one hour and it took 20 minutes to remove the kit after each shift. Many clinicians were frustrated in what they could achieve in such a limited amount of time. The ‘no touch rule’ and obsessive thoughts of catching Ebola became challenging:
‘I was fine until I started working there. The slightest ache or pain made me think I had a death sentence’ (lab technician, Sierra Leone, November 2014).
‘As a doctor I was doing very basic care rather than using my skills to the full’ (doctor, Sierra Leone, December 2014).
The work was intensive, distressing and exhausting. All these factors made the individual more vulnerable to mental health concerns. During the psychological reviews (end of assignment) we noted high levels of anxiety and burnout. Due to the high demand for personnel needed in such a crisis, less experienced staff were sent out. This created a risk for the patient and colleagues. Some staff were sent for longer periods of time, and these individuals showed greater signs of suffering from vicarious trauma, as well as individuals whose assignments were extended. Staff often overworked, which can be a sign of vicarious trauma; not knowing when to stop or listen to one’s body for signs of exhaustion.
‘One patient ran out of the confined area as she was delirious; we had to contain her quickly. Everyone was at risk’ (lab technician, Sierra Leone, January 2015).
Many aid workers found Christmas 2014 a particularly difficult time; the desire to reconnect with their family and friends, especially not having been able to experience touch from anyone, became challenging, due to the 21-day rule. Some individuals chose not to see their family and spent Christmas alone, especially if family members had young children. The fear factor surrounding Ebola led some individuals to believe that they could catch Ebola from anyone who returned from the Ebola-affected area and therefore, at times, this caused aid workers to be isolated and left out of work or family situations. Aware of this, once a member of staff had gone through the medical screening process, we made a significant point of shaking the hand of an aid worker returning from an Ebola-affected area.
‘The no-touch policy was really hard and it was made worse by those who avoided me when I returned home’ (HR manager, Sierra Leone, November 2014).
While listening to these moving stories from aid workers on their return, one image stayed with me: the tree of hands. Children who were leaving the clinic after having been given the all clear (many having lost family members to Ebola), painted their hands and left their print on the survivors’ tree.
Some of the material worked through in the counselling sessions involved guilt (placing someone in the wrong area or not being able to do enough), powerlessness (the enormity of the disease), and/or difficulties re-integrating into ‘normal life’. Some aid workers struggle to find purpose or meaning when returning from the field, or experience difficulty joining in socially (conversations feel ‘meaningless’) or even giving themselves permission to have ‘fun’ again. I often hear, ‘how can I enjoy myself, when all these terrible things are going on?’
However, generally humanitarian aid workers are highly resilient individuals and, with the right specialist support, recover well. Reflecting on her experience accompanying aid workers to West Africa to respond to the Ebola crisis, Ruth Dormandy, PHS team leader at InterHealth, commented in May 2015:
‘While it has been one of the most challenging ongoing pieces of work we have encountered, it has also been a privilege to accompany humanitarian staff on their journey to West Africa and back. They are a dedicated group who often feel isolated as a result of the work they do, so InterHealth’s contact and specialist understanding really make a difference to their resilience. We are full of gratitude for what they do on behalf of all of us and are ready to be of assistance by focusing on an individual’s psychological wellbeing before, during and after their assignments.’
Learning from crisis
On 24 March 2015, InterHealth held an Ebola Forum in Southwark Cathedral, focusing on learning points. Among the organisations that attended were: Public Health England, The Salvation Army, VSO, CHASE OT, Medair, Save the Children, The British Red Cross and Doctors of the World. It was exciting to see these organisations work collaboratively, many stating that through the Ebola crisis new working relationships had been formed. We facilitated groupwork and the following themes emerged from this (collated by Dr Simon Clift, InterHealth Worldwide, Director of Health Services, March 2015):
- The inherent challenge of mounting such a large-scale emergency response. It was identified that there will be some chaos in the beginning phase. Organisations must have their policies and procedures up to date.
- Specialist training. Specialist training was essential pre-deployment as well as in the country.
- Psychological health services. There was a general recognition that this was an extremely important component of the healthcare provision for staff and volunteers.
- National staff care and support. Equal support needs to be offered to national and international staff.
- Provision of healthcare and psychosocial support in the country during deployment. Psychosocial support for staff and volunteers in the field was a key component of safeguarding the health and welfare of those deployed. It was suggested that key managers could be trained in psychological first aid (PFA) so that those experiencing stress-related symptoms could be identified at an earlier stage and appropriate support given in a timely fashion.
- Post-deployment. More than one group felt that the post-deployment processes and support were underdeveloped when compared to the rigorous pre-deployment process.
- Interagency collaboration. There were calls for greater interagency co-operation eg standardising HR policies and benefits packages, agreeing a system of accreditation of prior learning (diplomatic passport) and a sharing of good practice.
- InterHealth’s Ebola-related services. There was a general consensus that InterHealth’s partnership with organisations had been very much appreciated. In particular having a named contact person at InterHealth has been valuable.
InterHealth Worldwide is committed to the health and wellbeing of those making the world a better, fairer and healthier place. I can only admire the stories I hear every day from international workers willing to take on these challenging roles to make the world a safer place. Their passion and drive are inspiring. As an NHS nurse stated during her psychological review appointment on her return from Sierra Leone earlier this year: ‘I am so excited to tell you how wonderful it was to serve and make a difference. I would go back in a heartbeat.’
Fiona Dunkley is a senior accredited BACP psychotherapist, supervisor and trainer. Fiona worked in the NHS within forensic sexual assault and was the lead counsellor at Transport for London. She is an associate working with the Police and The London Fire Brigade, and also works for InterHealth Worldwide and in private practice in Walton-on-Thames. www.fionadunkley.com
The author would like to thank Lynn Keane, psychotherapist at InterHealth, for her help in editing this article.
This article first appeared in the summer 2015 issue of Counselling at Work, the quarterly journal of BACP Workplace.
1. Davey M, Weaver M. Nepal earthquake 2015. [Online.] 29 April 2015. www.theguardian.com (accessed 5 June 2015).
2. Burke J, Rauniyar I. [Online.] 1 May 2015. www.theguardian.com.
3. World Humanitarian Day: UN honours sacrifices, celebrates spirit of aid workers. [Online.] 19 August 2014. www.UN.org (accessed 17 June 2015).
4. Executive Director Anthony Lake. Protect those who work to protect children and families. NY: UNICEF; 19 August 2014. www.UNICEF.org.