Emergency medicine service (EMS) personnel have opportunities to deploy in a variety of settings from urban international disaster response to sustained humanitarian missions for developing areas of the world. Types of deployments are listed in Table 69-1. Terms to describe these missions vary but generally offer some combination of direct clinical care to refugees, displaced persons or host country citizens, medical education information exchange, including consulting and training, establishing public health programs, health care team development, building or rebuilding health care infrastructure, and medical support to other deploying professionals. Missions may be short in duration, require multiple rotations over time, or require months to years of direct sustained medical support. Medical operations are usually conducted as a component of multidisciplinary teams or organizations, and other services offered may include food and water distribution or civil engineering programs. Each stage of response may need medical support, and personnel responsibilities may be well defined or fluid depending on needs. Clinical or administrative medical roles may be necessary depending on the circumstances. There are multiple ways for EMS personnel to participate in international deployments.

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  Describe types of need prompting international deployment.

  
  
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  Describe different ways to participate in international deployments.

  
  
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  Describe planning for readiness to deploy to international venues.

  
  
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  Discuss how to determine what supplies may be available locally, when planning insertion into locations that are difficult to access.

  
  
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  Describe health risks and other potential hazards inherent to international deployment to a disaster area.

  
  
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  Discuss cultural, legal, and other nonmedical operational concerns that must be addressed in the predeployment planning and during deployment operations.

  
  
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  Describe unique medical conditions related to disasters in international venues.

Involvement in international missions may be on an individual basis. Alternatively, personnel may participate through private/not-for-profit groups, EMS agency team, hospital team, government or nongovernment organizations (NGOs), or through interagency operations. Becoming involved in these missions is a matter of personal and professional preference. Some issues to consider when joining a medical mission: Are the sponsoring organization’s views and beliefs supportable? Are capabilities and resources provided to meet mission goals? Is the safety profile for the mission acceptable? Protecting personnel against violence and dangerous conditions is a key consideration.

Ground operations for humanitarian missions may be complex and involve multiple agencies. Key operational players in regions vary and may include international governmental agencies, both military and civilian, international organizations (IOs), NGOs, and host nation (HN) agencies. See Table 69-2 for examples. Each of these operational agencies may have a niche area of focus or response and are funded by a range of sources ranging from private donation to competitive governmental grants. An example of an NGO that fills a specific niche is Operation Smile that provides surgical correction and educational services for children and adults with congenital facial abnormalities such as cleft palates. Coordination of these agencies is sometimes problematic and may lead to overlap in services, diversion of care from other needed areas, or conflict between agencies. These operational players may have political views or agendas that may be congruent or in conflict with other organizations on the ground.

The Office for the Coordination of Humanitarian Affairs (OCHA), an office that operates under the United Nations (UN), facilitates humanitarian agency response when multiple agencies are working in the same area. OCHA serves to provide a cross-organizational coordination of humanitarian activities in partnership with national and international actors. It utilizes “cluster” meetings, which are organizations with similar focus, logistics support, and financing management to maximize effective utilization of resources in regions where the OCHA is involved in operations. Some agencies may choose not to cooperate with other agencies, such as the military, in order to preserve a perception of neutrality. An example of this would be Médecins Sans Frontières (MSF or “Doctors Without Borders”). Military and civilian agencies have different doctrines guiding their missions, organization structures, and strengths and weaknesses, which can lead to challenges with interagency missions. Each agency has different organizational structures, chain of commands, and financial sources. Some may only participate in long-term missions and others focus on short-term interventions in disaster settings.

A disaster is any event that results in a precipitous or gradual decline in the overall health status of a community with which it is unable to cope adequately.¹ Often disasters are described as an event that adversely affects a region where the needs exceed available resources. Disasters often overwhelm local health care capabilities and illustrate need for acute global health response. As demonstrated by numerous catastrophes over the last decade (ex: 2015 earthquake in Napal, 2014 mudslide in Afghanistan, 2011 tsunami in Japan, 2010 mudslides in the Philippines, 2010 earthquake in Haiti, 2004 tsunami affecting Thailand) natural disasters are occurring with alarming frequency worldwide. Twenty-four-hour news cycles and social media may sway public opinion to affect missions. Long-term “disasters,” like famine, lasting years or decades receive less media coverage and may arise from man-made or natural events such as wars, political instability, drought, or persecution. These conditions may lead to population displacement within the host country or to surrounding countries where communities often are not receptive to the presence of immigrants.

Outcomes from short- or long-term disasters depend on the magnitude of the event and the susceptibility of the affected population. There are a number of host country aspects impacting humanitarian medical operations including extent of poverty, limited resources, including personnel and equipment, differential access by the population to health care when these services are available, urbanization and overcrowding, malnutrition, limited access to potable water, and disease outbreaks.¹ Disasters may be a short distinct event with fairly quick recovery, recurrent or periodic, or can be long term in nature without a defined recovery period. Duration of recovery from disasters depends on a number of factors including predisaster civil infrastructure and state of host country’s health system, amount and duration of damage sustained to region, and number of mass casualty incidents (MCI).

This chapter will outline concerns in predeployment, deployment, and postdeployment phases of international operations. Planning in each phase is critical to minimize challenges and frustrations that can occur during these operations. Flexibility is certainly needed in potential settings of limited resources, variable training of international coworkers, encountering diverse cultural habits, respecting foreign laws and rules, language barriers, and differences in standards of care.

MEDICAL READINESS AND TRAVEL HEALTH

Medical personnel who travel as part of humanitarian missions to provide medical aid may be tasked to leave suddenly without much preparation, with limited information and few medical supplies. This is typically the case for medical support of acute disasters and less commonly an issue for long-standing humanitarian operations. The major focus for these missions is often on helping others and less on personal health and safety. However, becoming a casualty during the mission makes the unprepared person a liability rather than an asset. There may be an austere environment with little infrastructure support available during your mission. Even if basic needs are covered by a sponsoring organization, one needs to be ready to be self-sufficient, often for a number of days.

Health screening, dental, and medical clearance ought to be completed for all deploying health care personnel. Preexisting medical conditions and pregnancy may preclude deployment to high-risk areas with limited medical capability to treat complications. Being prepared for international deployment is very important and often requires significant lead time for scheduling travel clinic appointments along with acquiring prophylactic medications and equipment. Vaccinations also need some lead time for building an immunity response. Most travel medicine sources recommend preparing a minimum of 4 to 8 weeks prior to the trip.² Having up to date vaccinations in advance can simplify the process. See Table 69-3 for suggested vaccinations and travel medications. Dates and duration of trip, location, expected activities, and accommodations during the mission will be necessary to plan accordingly. Bringing a medical records summary and medical condition bracelet with known allergies is suggested.

Utilizing medical intelligence, information that defines known health risks for destination countries or regions, personnel can mitigate endemic disease risks.³ This information is used to provide risk assessments to educate and to guide prophylaxis against vector-borne disease, diarrheal illnesses, and other regional conditions. Working abroad in austere and endemic disease environments requires behavior modification for many daily activities such as eating, drinking, and exposure to the environment as each may involve health risks that need to be avoided to prevent disease. Health concerns are of much greater importance when traveling to these areas. Behavior modification can serve to limit exposures to mosquitos and from potentially contaminated water or high-risk foods. “Boil it, peel it, or forget it” is recommended to reduce the chances for getting diarrheal illness. Do not eat raw foods, things that are not cooked, or that cannot be peeled. High-risk food sources include buffets, salads or other undercooked foods, street vendors, unpasteurized dairy products, and nonbottled, unfiltered, or carbonated water. When local dining options are unavailable, eating food that is cooked and served hot is safest. Bottled water may not be available so a water filter and chemical water purification method or boiled water should be utilized. Treated water should be used to wash dishes, brush teeth, and prepare food. Even with food and water precautions, you should still bring an antidiarrheal medication and antibiotic for treatment if symptoms occur. There are a variety of resources that provide regional information about known diseases and health concerns posing risk to deployed personnel. Please see Table 69-4 for a list of some available resources.

Some deploying areas may have significant tuberculosis (TB) and HIV/AIDS infection rates among populations. Respiratory and body fluid precautions with personal protective equipment (PPE) should be utilized as indicated during procedures and in clinical care. In high-risk areas, fit-tested masks or N-95 respirators should be used when potential exposures may occur.⁴ Tuberculin skin testing (TST) should be completed before deployment and 8 to 10 weeks after return.⁵ Risk assessments are also important to evaluate posttravel illness, which are discussed in the Postdeployment section.