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| COMMENTARY |
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| Year : 2020 | Volume
: 18
| Issue : 2 | Page : 176-181 |
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Common Global Challenges and Common Stressors of Humanitarian Field Workers Related to the COVID-19 Outbreak
Boris Budosan
Consultant Psychiatrist, Public Mental Health Specialist, Croatia
| Date of Submission | 01-May-2020 |
| Date of Decision | 26-Jun-2020 |
| Date of Acceptance | 14-Sep-2020 |
| Date of Web Publication | 30-Nov-2020 |
Correspondence Address:
Boris Budosan
Vocarsko Naselje 22, 10000
Croatia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/INTV.INTV_11_20
There are a number of challenges in response to the Coronavirus (COVID-19) disease outbreak encountered by many countries in the world. This commentary divides them into those encountered by (health) care delivery systems and those encountered by affected communities and states. There are also a number of stressors experienced by humanitarian field workers during the COVID-19 outbreak. They are divided into those caused by personal/family issues, isolation and difficulties to travel/ evacuate and those caused by different and sometimes contradictory information on COVID-19 response as well as limited ability to follow the guidelines on self-protection from the virus in the field. The commentary includes information from relevant national and global sources on COVID-19 and information collected by the author during the provision of stress management for humanitarian field staff. The author expresses his personal opinion on a number of challenges.
Keywords: COVID-19 outbreak, global challenges, humanitarian field workers, stress, stress management
How to cite this article:
Budosan B. Common Global Challenges and Common Stressors of Humanitarian Field Workers Related to the COVID-19 Outbreak. Intervention 2020;18:176-81 |
| Introduction | |  |
According to John Hopkins Coronavirus Resource Centre (2020), on 2nd July 2020 the global confirmed number of Coronavirus cases was 10.729,336. In spite of all the previous efforts by the World Health Organization (WHO) and other international and national players to strengthen public health systems around the world (World Health Organization, 2007, 2010) and improve disaster risk management, such as in the Western Pacific after 2013 Typhoon Haiyan (World Health Organization − Western Pacific Region, 2015), the recent COVID-19 outbreak caught many countries unprepared for a pandemic of such magnitude. It seems that many of the previous efforts related to disaster and epidemic preparedness and strengthening public health systems worldwide were not really effective. We have many technical guidelines and documents related to the COVID-19 outbreak now (World Health Organization, 2020a), but the pandemic has not been prevented and the virus has affected the entire world and the lives of people in many countries. Therefore, more practical disaster/epidemic preparedness efforts are recommended in the future. This outbreak could perhaps have been better contained and prevented from spreading to the whole world. For example, the outbreak of Ebola in West Africa in 2014 was mostly contained within Africa, with some sporadic cases on other continents. Of course, COVID-19 is more contagious than the Ebola virus, so it is much more difficult to contain it. Still, more swift and decisive action on both a national and international level is recommended to better contain any similar outbreaks of communicable diseases in the future. Currently, many countries around the world are facing common challenges in response to the COVID-19 outbreak and they are responding in a more or less similar manner following the recommendations of the WHO and/or their national public health authorities. The COVID-19 outbreak has hit the population worldwide hard, including emergency responses in vulnerable communities − from refugee camps and disaster displacement sites to border crossings and conflict zones. It has generated stress and even mental health problems throughout the general population and caused additional stress to health and humanitarian workers. Different organisations have issued guidelines on addressing mental health and psychosocial aspects of the COVID-19 outbreak, including a series of messages supporting first responders and humanitarian workers engaged in the COVID-19 response (Inter-Agency Standing Committee, 2020; World Health Organization, 2020b; Psychosocial Centre of International Red Cross and Red Crescent Societies, 2020; Sphere, 2020). It is interesting that some scientists have even tried to predict the end of the outbreak by the country (Luo, 2020). Vaccine development has become a global effort (Mullard, 2020) with a recommendation to distribute vaccines globally in the future. One drug called remdesivir has shown good results in shortening the time to recovery in adults hospitalised with COVID-19 (Beigel et al., 2020). Other medication, such as the use of chloroquine and hydroxychloroquine, is dubious and can even be harmful, especially in patients with cardiac problems. In Africa, the herbal remedy called COVID-Organics has become very popular for the prevention and the treatment of Covid-19 disease. However, only evidence-based treatment for COVID-19 is recommended. The final outcome of the outbreak will ultimately depend on the effectiveness of the public health response of care delivery systems, communities and countries worldwide.
| Common Global Challenges Related to the COVID-19 Outbreak | | |
Box 1: Common global challenges related to the COVID-19 outbreak
Health and care delivery systems- Shortage of PPE, health and care staff, respirators and space for COVID-19 patients
- Not enough diagnostic testing for COVID-19 and early detection of disease
- Understaffed and unprepared (public) health and care systems
Communities- Challenge of social distancing, isolation and safety nets
- Challenge of access to proper hygiene measures (clean water, soap and disinfectants)
- Shortage of face masks for general population
- Challenge of tracing contacts and quarantine
- Mental health, social stigma considerations and domestic violence
States- Delay in critical preparedness, readiness and response action
- Economic impact of COVID-19 outbreak
- Conflicting messages on COVID-19 outbreak
- Challenges for humanitarian operations, camps and other fragile settings
Health and Care Delivery Systems
Common challenges encountered by health and care delivery systems around the world include a shortage of personal protective equipment (PPE) to protect health and care workers, insufficient number of health staff and respirators, understaffed and unprepared (public) health systems and lack of space in health facilities to accommodate the rising number of COVID-19 patients (see Box 1). Countries have put in place different measures in order to overcome these challenges. There has been an increase in production of PPE and respirators (European Commission, 2020) and also an increase in their donations (CNBC, 2020). The United Kingdom’s (UK) National Health System (NHS) decided to invite retired health workers to assist with the outbreak in UK (Personnel Today, 2020). Chinese, Russian and Cuban health staff went to assist Bergamo, the most affected town in Italy (National Public Radio, 2020a). Germany treated patients from Italy suffering from COVID-19 in German hospitals. In spite of all the difficulties in containing the outbreak at the beginning, there were also a considerable number of good initiatives that showed solidarity within and among different countries. Countries and people should continue to work together in fighting COVID-19 outbreak in the future.
Many countries opened additional temporary field hospitals or arranged spaces in different facilities such as churches, mosques and exhibition places to accommodate COVID-19 patients to release pressure on health facilities. This was definitely justified especially at the beginning of the outbreak because nobody was sure how many people would be affected by the virus and in need of isolation and/or treatment. Diagnostic testing for COVID-19 became crucial for the early detection of disease and tracing contacts in order to isolate them and prevent the spread of the disease. However, there is still a lack of widespread, systematic testing in most countries, which is also the main source in discrepancies of death rates internationally (BBC, 2020). Most of the countries in the world do not have enough COVID-19 testing kits and are trying to increase their production or import them. Legislation, action and more funding to improve (public) healthcare system are urgently needed. Similar to many previous emergencies, the outbreak of COVID-19 is providing a good opportunity to apply the principles of “building back better” and “from crisis to opportunity” to (public) health systems around the world. A vaccine against COVID-19 still does not exist, and it looks it might be widely available only next year. There are clinical trials to find a vaccine in various countries at the moment, and there are also many trials on different treatments for the coronavirus disease.
Communities
Ensuring social distancing, isolation measures (quarantine) and broader ‘safety nets’ for communities are common challenges around the world. They are challenges for every community, but especially for crowded towns/cities and slums in low- and middle-income countries in Africa and Asia, where social distancing is virtually impossible and where many daily labourers have to go out and earn their daily wages in order to survive (National Public Radio, 2020b). For example, the government in Bangladesh had to re-open textile factories because widespread unemployment became critical for the political situation in the country. Many communities in developing countries do not have safety nets other than assistance from their families. In many communities in both developing and developed countries, volunteers have been delivering food to older people, to those in poverty and to those without homes. Shortages of facemasks for the general population are still a challenge in many communities though their production and donations have increased lately. Longer term isolation has a negative impact on mental health on many people causing additional stress, anxiety, depression, suicidal behaviour and domestic violence. Additionally, stigma is attached to people suffering from the coronavirus disease (World Health Organization, 2020a). Even health workers who fall ill by helping others are stigmatised and avoided by other community members. Similar to the epidemic of Ebola in West Africa in 2014–2016, people who have died from the coronavirus disease have also been stigmatised and in some countries they cannot even be properly buried, such as in Iraq. The best way to overcome these challenges is in the education of communities on COVID-19 and in providing mental health assistance to those who suffer from stress-related and other mental health issues. The increase in domestic violence due to isolation should be addressed through prompt interventions by local authorities.
States
A delay in strategic preparedness plans and response action for COVID-19 is a major challenge for many states. In many contexts, people were simply not prepared for this pandemic. The aim of strategic preparedness and response action is to slow transmission, delay the spread of the virus and minimise the impact of the outbreak on health systems, social services and economic activity. Several countries where the outbreak occurred first, including China, South Korea and Singapore, have demonstrated that COVID-19 transmission from one person to another could be slowed down by social distancing, testing, tracing of contacts and isolation of suspected and confirmed COVID-19 cases. However, these measures were not put in place immediately in some countries in Europe and in the US. For example, the WHO’s advice to test, trace, isolate and quarantine suspected cases was not followed in the UK at the beginning (Horton, 2020). Only later when it was obvious that the COVID-19 outbreak should be taken seriously and that it does not recognise borders, many countries around the world introduced appropriate measures to combat the virus. Social gatherings were forbidden, restricted and/or even penalised. Places such as coffee shops, theatres, museums and religious sites were closed and social distancing of at least two metres was required when going for shopping of necessary food items. “Stay at home” campaigns started to be implemented using printed, audio and visual media. Many countries closed public transportation and some countries even introduced curfews to keep their population off the streets. Many countries closed their borders to prevent the outbreak. For example, New Zealand implemented early, tough and very successful border restrictions. In many countries, hotlines were established for updates on the COVID-19 outbreak and also to offer psychological assistance. Some countries such as Sweden and UK that initially relied more on a herd immunity strategy to combat the spread of the virus also decided to strengthen social distancing and a “stay/work at home” strategy to control the outbreak. Still, social distancing and isolation remain major challenges for crowded humanitarian settings such as refugee camps that depend on the delivery of humanitarian assistance, which has been hampered due to the COVID-19 outbreak.
The COVID-19 outbreak has had a major economic impact in every country too. Jobless claims are on the rise both in Europe and in the US and in developing countries daily labourers and immigrant workers cannot earn their daily wages to feed their families. To overcome these economic challenges, many countries have offered financial packages and loans for small businesses and humanitarian assistance to vulnerable individuals, for example, social meals programmes and housing for people who are homeless. Countries under economic sanctions such as Iran face additional economic difficulties to procure the much-needed PPE, respirators and testing kits (Murphy et al., 2020).
Conflicting messages on COVID-19 by politicians and experts present yet another challenge. While politicians in some countries try to underplay the seriousness of the outbreak and to restart their economies as soon as possible, health experts warn about the consequences if proper measures to contain the outbreak are not taken (leading to a second wave of the virus, for example). The professional opinion of experts should precede statements by politicians if the health of a population is a priority. The economic downturn should be addressed by a gradual opening of the economy and careful monitoring of health indicators related to the COVID-19 outbreak. It is a delicate balance, and we are all still learning about the best way of keeping the outbreak under control and minimising its impact on the economy.
| Common Stressors of Humanitarian Field Workers | | |
Box 2: Common stressors of humanitarian field workers during the COVID-19 outbreak
Personal/family issues- Separation from family/partners
- Feeling powerless in protecting loved ones and fear of losing loved ones because of the virus
- Fear of losing job
- Fear of contracting COVID-19 due to shortages of PPE, proper testing and adequate treatment
- within the health system of the host country
Isolation/difficulties in travelling and evacuation- Feelings of helplessness, boredom, loneliness and depression
- Work from home with limited or no access to beneficiaries (restricted movement)
- Challenges to use R&R and evacuate if/when needed
- Social stigma attached within community towards frontline humanitarian workers
Access to reliable information on COVID-19 outbreak/self-protection issues- Conflicting messages on the COVID-19 outbreak from different sources
- Challenge of social distancing, hygiene measures and lack of responsible staff care
- Challenges of working in countries with poor health systems
During the outbreak of COVID-19, it is very important that humanitarian field workers have access to responsible staff care (Antares Foundation, 2012), which is unfortunately still not regularly provided by many humanitarian organisations. One example of a good responsible staff care initiative was launched by the Office for Human Resources of the Lutheran World Federation (LWF) in March 2020. Three stress management consultants trained in community-based psychosocial support by Church of Sweden were recruited to provide direct support to LWF humanitarian field staff as per individual staff member’s requests. This initiative is still going on and has been welcomed by the majority of LWF humanitarian field staff in different countries where LWF has its programmes. Humanitarian field staff can make an appointment by email for an online, one-hour, confidential session with the stress management specialist (usually via Skype). A number of group and individual stress management sessions covering different stressors (see Box 2) have been delivered so far with a limit of three individual sessions per one humanitarian worker.
Personal/Family Issues
Separation from family members for a long duration can be a big stressor for humanitarian field workers, especially if they have smaller children and older or sick family members at home. During an individual stress management session one humanitarian worker from Uganda mentioned, “I have a new born son but I cannot see him because of lockdown in Kenya where I work now”. Similarly, separation is a stress for partners who are in a relationship and cannot see each other in person. The best way to overcome challenges of separation at the moment is communication via the internet (Skype) or mobile applications such as WhatsApp and Viber. Time differences can be a significant challenge for this kind of communication if the difference between time zones is too big. The hardship of separation between partners was summed up by one humanitarian field worker from Myanmar: “It is very difficult for me to discuss a long-term relationship with my partner online because of a time difference of 10 hours between us”.
Feeling powerless in protecting loved ones and fear of losing loved ones due to the virus is present in cases when people are not physically separated, but may be even more so when there is a physical separation. It is not easy to overcome these fears, but logical thinking, knowledge of facts related to the COVID-19 outbreak, protection measures and a regular update on the health status of significant others can reduce such fears. Fear of losing one’s job is especially present for local humanitarian field workers but also to some extent for international ones. It can prevent them from looking for any kind of outside assistance to alleviate their stress. Country representatives and team leaders can play a significant role in reducing this fear by explaining that seeking outside help will not affect their jobs and that it can even boost their resilience and help them to perform their jobs better. During one group stress management session, the country representative of LWF for Myanmar rightfully said, “I think as a whole we are managing quite well. But of course there are different challenges for different people that we need to pay attention to. Good if we can help supervisors support their team members”.
Isolation/Difficulties in Travelling and Evacuation
Working and/or staying at home most of the time is causing some humanitarian field workers feelings of helplessness, loneliness, boredom and even depression. One humanitarian worker from South Sudan said, “I am trying to isolate myself as much as possible because I am afraid to catch the virus. Sometimes I feel that I will die here alone”. In many countries, there are restrictions on movement in place and they also affect humanitarian workers and their work in the field. It takes some time to adjust to new working and living circumstances, and it is important to stay connected via telephone, email, social media and/or video conference. It is also important to pay attention to personal needs and feelings, engage in healthy activities, exercise regularly, keep regular sleep routines, eat healthy food and keep things in perspective (World Health Organization, 2020b). One humanitarian worker from Myanmar appeared to handle this issue very well: “Apart from my work, I do daily walk, practise yoga and socialise with two other humanitarian workers. I also watch interesting movies and listen to good music”.
One very important stressor for humanitarian field workers is that because of cancellation of many flights and lockdown in different countries they cannot use their rest and recuperation (R&R) on time and/or evacuate if needed. One humanitarian worker from Uganda described the problem in the following way: “I have been in the field as the only international for five months now. We have increased demand for assistance by South Sudanese refugees during the COVID-19 crisis and I have started to feel tired and irritable. I think I really need my R&R now”. It helps if while waiting for transportation that workers seek to be patient and try to get regular updates on the COVID-19 situation and transportation issues, (such as information on possible flights and the latest COVID-19 measures being planned, both in host and destination country).
Social stigma towards humanitarian workers and foreigners is present in some countries. This does not only hamper humanitarian response but it also affects the lives of humanitarians because communities and even family members may avoid them because of fear they can transmit the virus. It is therefore important to share facts and accurate information about the coronavirus disease and challenge myths and stereotypes within the community (IFRC, UNICEF & WHO, 2020).
Access to Reliable Information on COVID-19 Outbreak/Self-Protection Issues
Humanitarian workers in the field do not often have enough time to get updates on the COVID-19 outbreak, especially in regard to new developments worldwide. There is also an excessive amount of information on COVID-19 now (“infodemic”), some accurate and some not.
It is important to enable humanitarian workers to access reliable sources of information on COVID-19 (World Health Organization, 2020a; The Lancet, 2020; Mental Health Innovation Network, 2020). In one of the LWF group stress management sessions, a lot of up-to-date information on COVID-19 was provided by the stress management specialist to the team of humanitarian field workers from South Sudan. In some countries, humanitarian workers may also face challenges with social distancing in their compounds and overcrowded refugee settlements. Proper hygiene practices may also be compromised, for example, not having enough water and soap to regularly wash hands and/or disinfectants to clean their environment. All this can put an additional strain on their work and reduce their protection from the virus. At the moment, many humanitarian organisations have decided to leave only essential staff in the field and evacuate the others. Some of the evacuated humanitarian staff continue their work online from their countries of origin.
One humanitarian worker who works for the Myanmar programme from the UK said, “Actually, now I have more time to keep track of different meetings and events, but I miss the casual interaction with people and humanitarian workers in the field”. In some countries, personal health issues for humanitarian workers may present a challenge because of relatively poorly equipped local health systems. This is especially a challenge for those humanitarian workers who work far from big cities. One humanitarian worker based in Chad described it in this way, “I can get basic health services in the field but for more specialised health services I have to travel to the capital and this takes two days”.
| Conclusion | | |
The COVID-19 pandemic is likely to put humanitarian field workers across the world in an unprecedented situation, having to work under additional pressures. Active monitoring of field staff by human resources and line managers is recommended to ensure that the minority who become unwell are identified and assisted to access responsible staff care. Organisations need to ensure that staff have adequate access to stress management services. Additional awareness raising and evidence-based lobbying with donors accompanied by adequate internal budgeting for responsible staff care is important to support and improve wellbeing and resilience of humanitarian workers during the COVID-19 outbreak and beyond.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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