My hat goes off to humanitarian aid workers serving in the world’s neediest places as they face the very threats that call for their help: war, terrorism, poverty, disease, famine, natural disasters, and the list goes on.

My heart goes out to them, too, as they face not only those dangers, but mental and emotional stresses, as well.

Outer Turmoil

In their latest “Aid Worker Security Report,” Humanitarian Outcomes announced that 2013 marked an all-time high for the number of civilian aid workers who were victims of violence. The 460, an increase of 66% over the previous year, were the targets of 251 separate attacks, including shootings, kidnappings, bodily assaults, and explosives.

Those working in their own countries accounted for the vast majority, 87%, of the victims, but the 13% who were expats represented a greater rate of attack, as they made up less than 8% of workers in the field.

A study by the Johns Hopkins Bloomberg School of Public Health, looking at 18 humanitarian organizations for the period between 2002 and 2005, found that deaths, medical evacuations, and hospitalizations due to violence occurred at the rate of 6 per 10,000 aid worker person-years.* Of all deaths reported by the organizations, 55% were caused by intentional violence. Coincidental illness accounted for 27% of the deaths, and accidents made up 15%.

In another study, researchers from Geneva University Hospitals surveyed expats returning from their missions with the International Committee of the Red Cross (ICRC). They found that 36% reported having worse health than when they began, 16% said that they had been exposed to violence, and 10% reported injury or accidents.

A look at these numbers highlights the real need for physical care for aid workers. But the risks of humanitarian work also takes its toll on mental and emotional health. Another finding of the Geneva survey was that 40% of the ICRC workers reported that their service had been more stressful than they had expected. Certainly, attention to mental and emotional well being is also an ongoing need.

*Simply put, a “person-year” is a unit of measure representing the number of people involved in a study multiplied by each individual’s time spent in that study.

(Abby Stoddard, Adele Harmer, and Kathleen Ryou, “Unsafe Passage: Road Attacks and Their Impact on Humanitarian Operations,” Aid Worker Security Report 2014, Humanitarian Outcomes, August 2014; E.A. Rowley, et al., “Violence-Related Mortality and Morbidity of Humanitarian Workers,” American Journal of Disaster Medicine, Jan-Feb 2008; A.H. Dahlgren, et al., “Health Risks and Risk-Taking Behaviors among International Committee of the Red Cross (ICRC) Expatriates Returning from Humanitarian Missions,” Journal of Travel Medicine, Nov-Dec 2009)

Inner Turmoil

The causes of stress on humanitarian aid workers are many and varied. There are acute stressors, such as those from the events shown above, as well as chronic stressors, relating to day-to-day pressures and environmental and workplace factors.

When UNHCR, the UN Refugee Agency, surveyed aid workers in Pakistan and Bangladesh in 2012, they asked them which of the following items were “a common cause of stress.”

• Exposure to suffering of persons of concern
• Exposure to incidents when you were seriously injured or your life was threatened
• Political situation in the county where you are presently working
• Relationship with supervisors
• Relationship with work colleagues
• Family concerns
• Health concerns
• Safety concerns
• Financial concerns
• Feeling undervalued
• Feeling unable to contribute to decision making
• Status of employment contract
• Workload
• Working hours
• Ability to achieve work goals and objectives

While no one would argue that exposure to suffering, violence, and threats are not legitimate stressors, the aid workers’ responses showed that more-mundane factors played a greater role in harming their mental health. The top-five stressors they reported were

1. Workload
2. Status of employment contract
3. Feeling undervalued
4. Family concerns
5. Feeling unable to contribute to decision making

Respondents were also asked about symptoms that commonly show up with depression and post-traumatic stress disorder (PTSD). At least half reported “feelings of sadness, unhappiness, or ’emptiness'” (57%), “irritability or frustration, even over small matters” (54%), and “fatigue, tiredness and loss of energy” (50%).

In a study published in 2012 (referred to by UNHCR), researchers from the U.S. Centers for Disease Control and Prevention (CDC), among other organizations, asked participants from 19 international NGOs about their mental health before and after their period of service. Before deployment, 3.8% of respondents reported symptoms of anxiety; immediately after they returned from deployment that figure had risen to 11.8%; and a follow-up 3-6 months after deployment showed 7.8% with symptoms. Before deployment, 10.4% reported symptoms of depression, 19.5% post-deployment, and 20.1% at the follow up. And finally, in the area of psychological distress, the rates were 6.5%, 14.7%, and 17.6%, respectively.

Another study from 2012 looked at national aid workers serving in northern Uganda with 21 humanitarian-aid agencies. The researchers, from Columbia University, Fuller Theological Seminary, and the CDC, found that 68% of respondents reported symptom levels associated with a high risk for depression, 53% for anxiety disorders, and 26% for PTSD.

What Can Be Done?

What steps can be taken to help humanitarian aid workers facing threats to their physical and mental well-being?

Giving a comprehensive list of protocols for tackling the threats of violence is well beyond my abilities, but I can point in the direction of a few resources.

For instance, on the subject of combating violent situations, Humanitarian Outcomes’ annual “Aid Worker Security Report” tackles specific threats, such as kidnappings (2013) and road attacks (2014). Staying Alive: Safety and Security Guidelines for Humanitarian Volunteers in Conflict Areas, written by a decorated member of the British Army and former operational security advisor for the ICRC, gives a comprehensive look at avoiding threats. And “To Stay and Deliver: Good Practice for Humanitarians in Complex Security Environments,” published by the United Nations Office for the Coordination of Humanitarian Affairs/Policy Development and Studies Branch, was written for “aid practitioners and their organisations seeking practical solutions to gain, maintain, and increase secure access to assist populations in a range of complex security environments.”

While the physical and mental consequences of traumatic events has long been recognized, as the UNHCR report points out, only recently have the debilitating effects of chronic stressors for aid workers begun to come into focus. “Humanitarian agencies,” it states, “are increasingly concerned about the potential impact of staff stress on effectiveness and efficiency of service delivery.”

In developing their study and evaluating their organization’s reduction of and response to worker stress, UNHCR used stress-management guidelines formulated by the Antares Foundation. Antares, a Netherlands-based non-profit providing staff care to humanitarian and development organizations, was also involved in the two 2012 studies previously cited here. Its eight guidelines for agencies are

1. Having a written and active policy to prevent or mitigate the effects of stress.
2. Systematically screening and/or assessing the capacity of staff to respond to and cope with the anticipated stresses of a position or contract.
3. Ensuring that all staff have appropriate pre-assignment preparation and training in managing stress.
4. Ensuring that staff response to stress is monitored on an ongoing basis.
5. Providing training and support on an ongoing basis to help its staff deal with their daily stresses.
6. Providing staff with specific and culturally appropriate support in the wake of critical or traumatic incidents and other unusual and unexpected sources of severe stress.
7. Providing practical, emotional and culturally-appropriate support for staff at the end of an assignment or contract.
8. Having clear written policies with respect to the ongoing support offered to staff who have been adversely impacted by exposure to stress and trauma during their assignment.

After assessing UNHCR’s shortcomings in these areas, the writer of the UN agency’s report presented four recommendations for improvement. Each of these is presented in greater detail in the publication:

• Ensure appropriate response and follow up for survivors of critical incidents
• Increase availability and utilization of formal mental health and psychosocial support
• Encourage informal social support amongst staff
• Enhance accountability of staff welfare related services through regular rigorous evaluation, clear staff welfare policies, and role distinction between sections

As a result of their own findings, the researchers behind the first CDC study above also present a list of recommendations for aid organizations, designed to “diminish the risk for experiencing mental illness or burnout during deployment”:

• Screen candidates for a history of mental illness and family risk factors pre-deployment and provide expatriate employees psychological support during deployment and after the assignment is completed. Although possibly controversial given the considerable stigma associated with mental illness, screening allows organizations to alert candidates to the risks associated with deployment and to consider means for managing and supporting such workers during and after their employment.
• Staff should be informed that a history of mental illness and family risk factors may create increased risk for psychological distress during deployment.
• Provide the best possible living accommodations, workspace, and reliable transportation.
• Ensure, when possible, a reasonable workload, adequate management, and recognition for achievements.
• Encourage involvement in social support and peer networks.
• Institute liberal telephone and Internet use policies, paid by the organization [to] help increase social support networks of deployed staff.

If only all of these could be implemented. Maybe they can. But even if that happens, care for humanitarian aid workers needs to go beyond what their organizations might be willing or able to provide. Care needs to extend beyond the workers’ time with the organization, and it needs to aim for the health of the workers for the workers’ sake, not just for the sake of the service they are providing.

This will take more groups and individuals who can provide the “formal mental health and psychosocial support” (see UNHCR’s list). To this I would add spiritual support, as well. It will also take groups and individuals who can become part of the “social support networks” (see the CDC list).

Both of these will require those groups and individuals, and the workers themselves, to be proactive in implementing the necessary relationships.

May we continue to document and understand the problem, may we continue to draw attention to the risks faced by humanitarian aid workers, and may we continue to seek solutions. These workers are a valuable resource for a needy world. They are also deserving of help when they become the ones with needs.

May we provide them with safe people and safe places in the midst of the dangers.

(Courtney E. Welton-Mitchell, “UNHCR’s Mental Health and Psychological Support for Staff,” United Nations High Commissioner for Refugees, July 2013; Barbara Lopes Cardozo, et al., “Psychological Distress, Depression, Anxiety, and Burnout among International Humanitarian Aid Workers: A Longitudinal Study,” PLoS One, September 2012; Alastair Ager, “Stress, Mental Health, and Burnout in National Humanitarian Aid Workers in Gulu, Northern Uganda,” Journal of Traumatic Stress, December 6, 2012; Managing Stress in Humanitarian Workers: Guidelines for Good Practice, Third Edition, Antares Foundation, March 2012)

[photo: “Darfurian Refugees in Eastern Chad,” by European Commission DG ECHO, used under a Creative Commons license]