Improving the Safety and Security of Those Engaged in Global Health Traveling Abroad

Risks to Personal Safety in the Context of Violence

Violence against foreigners (e.g., petty robbery, sexual violence, and carjacking) has always been a concern. Some health care professionals believe that their profession shields them from attacks, but they may be upset to know that attacks specifically targeting health care providers are increasing, particularly in conflict zones, but also in post-conflict and non-conflict zones.^11–15 Acts of violence targeting health care providers violate international humanitarian laws¹⁶ and have caused innumerable losses, prompting an outcry among those who believe in medical neutrality.^17–19 Between 2012 and 2014, of all armed violence incidents against the health care system, the majority of the targets were health care facilities, followed by medical transports.²⁰

Increasingly, the primary motivation of many violent attacks is political. One study estimated a 55% increase in politically motivated attacks between 2004 and 2008.²¹ The authors of the study concluded that "even though many organizations make considerable efforts to dissociate themselves from political actors and project an image of neutrality … organizations are being attacked not just because they are perceived to be cooperating with Western political actors, but because they are perceived as wholly a part of the Western agenda."²¹

In Mali and Burkina Faso in late 2015 and early 2016, al Qaeda terrorists killed nearly 50 people from various parts of the world in a series of coordinated attacks targeting hotels frequented by businesspeople and foreigners, and injured many more. These attacks brought to light the potential dangers to national and international health and development workers regardless of the purpose of their visit or work. These kinds of attacks are worrisome even to the most experienced and savvy global health professionals.^22,23 No longer can those engaged in global health work expect to stay safe even in locations outside of direct service sites such as hotels, malls, and conference centers. Some major international organizations have updated safety security protocols and now require training for their staff.²³

Personal safety is an integral component of guidelines created by the Working Group on Ethics Guidelines for Global Health Training to introduce trainees and others involved in global health to ethical issues that may arise during short-term training experiences abroad.²⁴ The Association of Medical Education in Europe also addresses the issue of personal safety among its undergraduate medical students, acknowledging the crucial importance of risk management for those students who study internationally.²⁵ These guidelines, however, do not include safety and security measures in the context of conflict, political, or terrorism-related violence. The U.S. Peace Corps requires all Peace Corps Volunteers to participate in up to 12 weeks of intensive preservice training in their country of service, which covers risks associated with serving abroad, coping with unwanted attention, promoting country-specific strategies and best practices to manage risks, and identifying emergency plans.²⁶

Insufficient Resources and Barriers to Improvement

Some smaller programs with partial or no security risk management systems have access to resources through membership organizations, such as InterAction's minimum operating security standards and training course for security management.²⁷ However, many students, staff, and faculty engaged in global health do not have the backing of international health and development organizations, or even universities, with established safety and security planning, protocols, and dedicated staff.

Common barriers that smaller organizations face in improving preparedness for safety and security may include:

• General lack of awareness of safety and security threats depending on the region, political stability, practice setting, type of work expected, and residential setting

• No independently developed institutional safety and security protocols

• Lack of capacity to develop and manage safety and security programs

• Lack of funding to create a training and support infrastructure

• Lack of information on the effectiveness of existing security training

• Lack of funding for security training by outside or independent companies that specialize in security training

• Lack of knowledge of existing standardized protocols used by other organizations and programs, such as InterAction's minimum operating security standards²⁸

• No access to credible and timely security risk and threat assessment

• Lack of guidance about whether individuals with certain profiles or characteristics (health, or otherwise) should be advised not to go to certain locations.

Lack of Pre-Departure Training

Few published articles exist that document safety and security training as part of pre-departure preparations for students, residents, or faculty involved in global health work abroad.^29–31 Even fewer studies document whether programs have any impact on mitigation of adverse events. One study concluded that "medical students are often poorly prepared for the … safety dilemmas they encounter during these electives" based on a survey of 23 medical students returning from international study.³² Another study, focusing on accidents among medical students studying abroad, mentioned that there is often a lack of advice on personal safety issues.³³ A Canadian study of medical school faculty also noted gaps in pre-departure planning and concluded that reviews of health and safety should be mandatory for all international electives.³⁴ A few studies have documented student satisfaction with health and safety training, but they lack details about what safety training their programs covered.^35,36

Gender Differences

Some studies have noted gender differences in security risks and training. For example, a study using the Security in Numbers Database looked at the risk profile of 1,361 staff members affected in 615 security incidents and found that women were targeted more frequently for petty crime and sexual assault.³⁷ Men, however, were more likely to be involved in violent encounters—and more likely to be killed or injured.³⁸ Another study of security perceptions among NGO workers around the world found that a greater proportion of men than women received security training.³⁹

Emergency Management Planning

When planning for emergency management, it is helpful to consider the following 4 phases^40,41:

1. Mitigation: refers to activities that may help prevent or reduce the chances of an emergency from happening, or to reduce the harmful effects of unavoidable emergencies

2. Preparedness: consists of strengthening individual and institutional capacities to effectively anticipate, respond to, and recover from hazardous events or conditions

3. Response: details what actions to take during an emergency to save lives, reduce health impacts, ensure public safety and basic needs, and prevent further harm or damage

4. Recovery: refers to activities carried out after the emergency to return to a safer environment or to normal operations

Organizations should consider each of the 4 phases as they create their overall safety and security plans, including strategies and policies as well as individual and institutional responsibilities—from what the ultimate individual beneficiary (student, resident, faculty member) should know, to what protocol should be developed by organizations and programs, to setting national or specialty- and discipline-specific standards for security and safety and sharing resources among various stakeholders.

Specific Actions to Take at All Levels

To overcome some of the common barriers faced by organizations, we propose a checklist of specific actions for institutions and individuals at all levels (Table). The list of actions is divided into 6 core elements: (1) institutional commitment, (2) trainee and faculty participation, (3) safety and security assessment and analysis, (4) risk and hazard prevention, (5) safety training, and (6) program evaluation. These actions can serve as a conversation starter for those engaged in global health programming and can jumpstart the process of developing a comprehensive safety and security plan.

Individual Responsibility

Travelers themselves must be prepared before departure, understand the risks, plan for emergencies, and understand their roles and responsibilities in emergencies. It is the duty of supervisors and program directors to ensure that students, residents, and faculty are empowered to ask questions—and that host institutions (e.g., schools, agencies, programs, facilities) are prepared to answer them.

Questions that prospective travelers should consider asking their host and sponsoring institution:

• What are you doing to enhance my safety and security?

• What are the threats I may face where I am going?

• What safety and security questions should I ask?

• How do I find out if now is the right time to go?

• What should I look out for (regarding safety and security protocols) when selecting a small organization to travel with?

• What should I look for in regard to food and lodging?

• What are the communication procedures should problems arise?

• Are there added services and costs for enhanced safety measures?

• Should I engage in safety and security training with an outside group?

• Should I purchase travelers insurance?

• Does my health insurance cover conditions encountered abroad?

• Should I purchase security evacuation insurance? Are there protocols for medical evacuation?

• What security responsibilities will be required of me?

• What incidents have you had in the past and how did you handle them?

• What safety and security protocols are in place in case of an unexpected event?

The U.S. Department of State issues travel warnings and alerts online to assist travelers with travel plans to any country in the world (see https://travel.state.gov/content/passports/en/alertswarnings.html). For example, travel warnings are issued when there are unstable government conditions, civil war, ongoing intense crime or violence, or terrorist attacks, while travel alerts are for short-term events such as election seasons when strikes and demonstrations are likely to happen and health alerts such as disease outbreaks. It also hosts a free service called "Smart Traveler Enrollment Program" (STEP) that allows U.S. citizens and nationals traveling abroad to enroll their trip with the nearest U.S. Embassy or Consulate (see https://step.state.gov/step/). The service provides travelers important information about safety conditions in the destination country and helps the U.S. Embassy, family, and friends contact the traveler in an emergency.

The U.S. Centers for Disease Control and Prevention provides a host of travel resources on its website, including information about vaccinations (see http://wwwnc.cdc.gov/travel/page/resources-for-travelers).