“Doctor, this will be a very long war if for every division I have facing the enemy, I must count on a second division in hospital with malaria and a third division convalescing from this debilitating disease.” General Douglas MacArthur to Colonel Paul F. Russell, US Army malaria consultant, May 1943.
Just like soldiers going to war, people on humanitarian missions anywhere in the world can fail to accomplish their mission due to illness or injury. Whether missionaries seeking to advance the gospel of Christ, secular humanitarians trying to dig a well and build a school in a rural African village, or a combination of both, medical problems can inactivate the best intentioned and most capable teams. This article is intended to help people medically prepare themselves to go overseas on humanitarian missions. You can also watch the accompanying video.
Your baseline health
While in college I attended a lecture about living overseas doing humanitarian and missions work. The talk was fascinating but what changed my attitude was when the speaker said “to be most effective you must be in good physical condition. It does little good being an expert in your field or having the highest hopes when you physically are unable to perform.” That very day I took up running and in the 30 years since have never stopped. The basic three components of good physical health are adequate sleep (7-9 hours per night), good nutrition, and plenty of exercise. Meals should be high in fruits and vegetables, moderate in dairy, grains, and nuts, and low in meats and sweets. Exercise has three components: flexibility training six days per week, aerobic exercise at least three days per week, and resistance exercise at least two days per week, totaling at least 150 minutes of exercise per week. 10,000 steps per day is a common benchmark for walkers. Someone who is unfit at home will not become magically fit overseas; they are more likely to become even more unfit.
Living conditions will not be as comfortable on mission as they are at home. Water in developing countries is often contaminated, and ice is contaminated and scarce. Air conditioning is unheard of in much of the world, and the neediest countries are frequently the hottest. Showers, laundry, and good toilet facilities are usually harder to find in the developing world, Transportation may be lacking or dangerous, and garbage is often ubiquitous. Expect to walk farther and work harder on humanitarian trips than you do at home. Conditions that would be a minor annoyance back home can be harder to overcome. Overall, be in the best possible health before you go on mission.
Your pre-trip medical evaluation
Having practiced medicine for over two decades, I have evaluated many people preparing to travel overseas for business or pleasure. Such a visit is vital for medical preparation because it accomplishes a lot:
- Getting travelers up to date on their standard (US) required vaccinations.
- Giving travelers the vaccinations that are required for their destination, considering the conditions they are likely to face. For example, a person shopping in Tokyo for a week is not likely to need the vaccine against Japanese Encephalitis virus (JEV), but someone on a humanitarian mission for six weeks in rural Vietnam definitely needs it.
- Giving travelers the prophylactic medications, such as antimalarials and antidiarrheals, that are required.
- Refilling key prescriptions that travelers need to manage their baseline health problems, such as blood pressure or diabetes medications.
- Counseling the traveler on risks common to their destination, including identifying what they plan to do and figuring out how to minimize the health risks they face if they do it. This can range from teaching people about mosquito protection (bed nets, DEET and permethrin) to giving them information on local medical facilities in case they have trouble.
- Discussing what to bring on the trip.
- Discussing what to do on return from the trip, and when to come in again.
Visit your doctor at least four weeks before you leave for this evaluation. The Center for Disease Control and Prevention (CDC) provides useful information at their Traveler’s Health website. It is a good idea to visit the dentist before going since dental problems can be big and care may not be available. Patients with glasses may wish to get an updated prescription if they haven’t had one in the past year.
Insurance and Other Concerns
Most people going on humanitarian journeys will have medical insurance of some type, but you need to check the terms carefully. What benefits are available overseas? Is medical evacuation included? Do they require preapproval for visits, and is that possible at your destination? Will you need supplementary medical insurance? Trip interruption and cancelation insurance are also important. Such insurance can cost less than $10 per day.
The US State Department offers the Smart Traveler Enrollment Program (STEP). This free program allows US citizens and nationals to register their trip with the local embassy or consulate. The embassy will provide enrollees information about safety conditions in their destination countries, contact them in case of emergency, and provide a conduit for family and friends to get in touch if trouble strikes. Travelers who don’t mind the US government knowing about their trip may benefit.
The US Customs and Border Protection offers the Global Entry Program, in which pre-approved, low risk travelers get expedited clearance into the United States. The application process includes an online application, an interview, and a fee.
Your health packing list
Travelers on humanitarian trips must take the things that they need to stay healthy at home. These include:
- Enough prescription medications to last for the entire trip and two weeks afterward. These must be in their original containers and with original markings or they may be confiscated.
- One pair of glasses and one spare, or one pair of contact lenses and one spare pair of glasses.
- Other personal stuff such as extra batteries for a hearing aid, knee or ankle braces.
- Hand sanitizer, sunscreen and insect repellent.
- Ear plugs, since developing nations can be noisy, especially in vehicles.
- A pillow or neck pillow to improve sleep on planes and other vehicles and if you will be in primitive lodging.
- Eye covers (sleep masks) to improve sleep.
- Hygienic wipes to clean up when showers, or even water, are not available.
- Over the counter medicines – motion sickness, pain medications such as Tylenol and Motrin, decongestants, antacids, etc.
- If going on a medical missions trip, be sure to take personal protective equipment (PPE). This includes gloves and goggles in case you will be exposed to body fluids. For more serious risks of infection, such as responding to the current ebola outbreak, gowns and masks, or even face shields, are required. Gloves must be disposable, and everything else should at least be laundered daily after contact with patients. Adequate PPE may not be available at your destination.
- A basic first aid kit, including Bandaids for small wounds.
- Health documents such as copies of prescriptions, health insurance documents, and a contact card in case you are debilitated and colleagues need to reach the US Embassy or Consulate and someone back home.
Individual travelers will have other needs. Some may need a cane for walking, while others may need a back support to minimize their pain. Diabetics may need needles and syringes to self-treat their diabetes, and asthmatics may need inhalers. Again, people should take whatever they need to function at home, and a few other things tailored to the risks at their destination.
People going to places with poor toilet facilities often don’t drink enough clean water because they can’t find it, it is unappetizing (often warm), or they don’t want to use the toilet. This fact makes it even more important to be well hydrated (clear urine) before the trip. During the flight (or long drive), take off your shoes and stretch your feet and ankles. Stand and walk whenever you can, and sleep whenever you can, keeping a jacket or blanket nearby because planes can get cold. Keep medications, a change of clothes and raingear handy in case your luggage is lost.
Staying healthy on site
Drinking bottled water is important in all but the most developed countries, as is frequent hand washing, and using sunscreen and insect repellent. Missionary teams will likely be working with long term field workers and native staff and should take their cues from them. Non-faith based humanitarian teams should also have local support. I have seen troops in Iraq develop diarrheal disease from ice or even water on plates or soda cans so travelers must be careful. Motor vehicle accidents are the number one cause of death among travelers in the developing world and it is OK to ask local drivers to slow down.
Dietary suggestions are harder to give. The official recommendation is to eat only cooked foods and avoid salads or fresh vegetables. These recommendations are sound and can be followed by casual travelers but are harder in a missions context. Teams will often be invited into the homes of those they are working with and as such will be offered local food. As unappetizing as the food may look, it is probably the best that the host family has, and as such it would be a grave offense to reject it. There are no easy answers here, but eating small portions (never a bad plan) and staying with the food most thoroughly cooked is helpful. If you develop symptoms and make a return visit to your doctor after your trip, be sure to tell him about things like this.
The body operates on circadian rhythms which impact everything from hours of sleep to hormone levels. These rhythms are inherent and are influenced by light, drugs and other factors. Symptoms of jet lag include fatigue, slow mental processes, and poor sleep. Since most people don’t get enough sleep and have a baseline sleep deficit, they can minimize symptoms by getting as much sleep as possible before and during the trip. Once you are in the new time zone, stick as closely as possible to the new schedule, limiting yourself to no more than one nap of up to two hours duration per day.
When travelers first arrive in a new place they are often enamored by its newness. This “honeymoon” stage lasts up to a few weeks, by which time most casual travelers have returned home. Soon however, travelers who stay longer, as missionaries and humanitarian workers often do, start to dislike much of what they recently found so quaint, and they want to go home. Effectiveness plunges. Eventually they become acclimatized to the new culture just as they do to the new climate. Their function will improve and they will return to a new baseline. Culture shock happens when returning home as well.
Part of providing successful humanitarian aid is keeping team members safe. We have discussed medical issues and important threats such as motor vehicle accidents, but there are other things to keep in mind.
- Make copies of all travel documents, including passport, visa, plane tickets, and insurance. Keep a copy on the trip and leave a copy at home.
- Get good medical insurance, including evacuation insurance.
- Keep your passport and identification with you at all times.
- Avoid drawing attention to yourself, either with obnoxious behavior, ostentatious displays of wealth or immodest clothing. Avoid alcohol and drugs. You are there to serve others, not to display yourself.
- Do not walk or travel alone. Go in teams of at least two.
- Be sensitive to others and to the local culture.
- Do not identify yourself with issues likely to be controversial. Don’t wear obviously American or military clothing, or anything that may cause offense locally.
- Do not violate the trust or the security of the long term staff you are working with.
It is your job to make sure that every member of your team is as ready as they can be. Consider an example from World War II:
“Good doctors are useless without good discipline. More than half the battle against disease is fought not by doctors, but by regimental officers. It is they who see that the daily dose of mepacrine is taken, that shorts are never worn, that shirts are put on and sleeves turned down before sunset… I therefore had surprise checks of whole units, every man being examined. If the overall result was less than 95% positive, I sacked the commanding officer. I only had to sack three; by then the rest had got my meaning.” General Slim, Burma Campaign, WW II (under General Slim, the malaria rate in troops decreased from 12/1000 per day to 1/1000 per day.
While team leaders in missionary and humanitarian endeavors do not have the same control over their teams as generals during war, the principles still apply. Leaders must do everything possible to help those working with them to succeed in whatever mission they face. The ultimate responsibility remains with the individual, but the leader has a vital role to play. Make sure that everyone knows what your team’s mission is, and that your team members have the right equipment and supplies to accomplish that mission.
Leaders should ensure that a first aid kit is available for the team. This should include larger quantities of medication and supplies than individuals are likely to bring.
- Over the counter (OTC) pain medications such as aspirin, acetaminophen and ibuprofen – at least 100 tablets of each
- OTC diarrhea medications such as Imodium.
- OTC motion sickness medications such as meclizine.
- Three and four inch elastic (ACE) wraps to wrap injured knees, ankles, wrists, and elbows. Be sure that someone knows how to use them.
- A large box of Band-Aids.
- Extra water bottles with water filter and purification tablets (if in a remote location).
- Large bottles of sunscreen and insect repellant.
It may seem that there is too much to do. It may seem like much of this preparation is not necessary. Both statements are false. First, humanitarian and missions work is vital, there are so many people with so much need that people who can should go. Second, every part of the preparation noted above must be done. To do otherwise is to compromise the effectiveness of each individual, and each team, in doing this important work.
For more information, please look at the section “Personal and Team Preparation for Humanitarian Response” under the Virtual Emergency Operations Center at MDHarrisMD.com.