Prioritising health in humanitarian work: the need for comprehensive and inclusive research

In hotspots for humanitarian crises, where millions of individuals are in need of assistance, especially in African regions, the Middle East, as well as Asia and the Pacific, humanitarian workers risk their lives daily to provide basic aid to the most affected. This rings true whether they are affiliated with United Nations organisations, international humanitarian organisations, or national disaster relief agencies. They work under tough conditions instigated by protracted wars, emerging conflicts, or climate change-induced environmental disasters. Images of aid workers are widespread across mainstream and social media: some crossing difficult terrains to support vaccination efforts in Afghanistan’s flood-hit, security-compromised areas; many providing crucial assistance in Lebanon, Sudan and Yemen, where protracted crises persist; and health workers assisting in the mpox outbreak across countries in Africa. These efforts bring to mind past humanitarian responses to the devastating floods in Libya, the aid provided to earthquake survivors in Morocco and Syria, and the support during the Ebola outbreak in West Africa. The multifaceted challenges faced by these countries, apart from the referenced emergencies, further complicate humanitarian efforts in the field.

In these intense and often dangerous environments, a pressing question arises about the wellbeing of these workers: How is their health faring? They work relentlessly to protect those in urgent need, but are they themselves adequately protected?

Research gaps in the health impact of humanitarian work

Most studies investigating the health impact of humanitarian work focus predominantly on mental health issues. Among the numerous studies published, findings reveal the increasing incidence of various mental health issues among workers in conflict-affected and environmentally challenging areas: psychological distress, burnout, anxiety, depression and post-traumatic stress disorder. Studies focused on the health aspects of humanitarian work also primarily target international humanitarian workers and often overlook the experiences of national workers and community volunteers. Country-focused studies on national humanitarian workers, including community volunteers, are generally scarce. And despite the physical dangers posed by humanitarian work, the documentation of physical health problems encountered by aid workers remains limited. Few research studies document workers’ exposure to infectious diseases, such as waterborne and foodborne illnesses in areas affected by poor sanitation and flooding, or their risk of exposure to hazardous chemicals in security-compromised zones. Not enough is known about the dangers heightened by humanitarian work in crowded settings in internally displaced persons and refugee camps or by environmental conditions prevalent in regions experiencing extreme temperatures and droughts. The area receiving most investigation and attention is attacks on aid workers and fatalities due to violence; once again, this is predominantly reported on for international humanitarian workers while overlooking national staff or community volunteers.

The need for comprehensive and inclusive research

A research body that centres only on the mental wellbeing of humanitarian workers, while neglecting the physical dimension, does not offer a complete perspective. Examining the physical risks associated with humanitarian work remains essential, as humanitarians often operate in environments where such risks are heightened. We often cite the issues faced by people affected by the crisis, but we do not offer enough observation of the challenges faced by those involved in the response. It is logical to assume that they are just as much at risk as the affected communities. We just need to have the scientific basis to back that assumption. We must have a full picture of the incidence of their exposure to waterborne diseases such as cholera and/or acute watery diarrhoea in countries like Pakistan, Syria, Lebanon and Yemen, where cases surged in the aftermath of war or environmental disasters, for instance. We must also assess whether workers are adequately protected against biological and chemical threats in violent contexts such as Syria and Iraq. We need to know the extent of the impact of extreme weather conditions on the respiratory health of humanitarian workers operating in such areas, which are often located in African countries.

Research that is not inclusive of all contributing to the humanitarian response is incomplete. National humanitarian workers and community volunteers are taking on a greater role in contexts where shortages of international humanitarian workers, including health workers, have led communities to step up their support in various relief efforts, as seen in Afghanistan, Gaza, Sudan and Yemen. The scale of this national and community-led humanitarian aid is likely to increase. Even in countries with less active community-led humanitarian action, like Somalia, there are voices calling for the implementation of participatory approaches. For these community members, many of whom lack formal health training and are not integrated into the response efforts, exposure to health hazards is significantly heightened.

Inclusive research that covers all health aspects can yield results based on which we can formulate country-tailored measures needed to prevent, mitigate and recover from challenges associated with humanitarian field work. There is extant research that calls for several recommendations to improve the health situation of humanitarian workers: the creation of supportive work environments within organisations to normalise help-seeking behaviour; continually monitored, needs-based preparatory pre-deployment training; revision of pre-travel guidelines and customisation of general health recommendations; and a more holistic approach through pre-, post- and ongoing training is another proposition. However, these recommendations fall short if they do not address the diverse physical health problems and their incidence among humanitarian workers, including international, national and community-based staff. In fact, there has also been a focus on the importance of high-quality data from the field to inform counter strategies, and these should not only be for attacks on health facilities. Expanding this data by including diverse perspectives is crucial to support better advocacy, protection and accountability.

A community-based approach to research

For this research in such tough locations, we might face challenges in collecting context-specific data as no special surveillance systems exist for the collection of information on the epidemiology of disease among response workers. For this reason, this should be collaborative research where we work with local entities and engage community volunteers who can help gather data using methods employed in community-based surveillance. These volunteers can have access to areas and people who otherwise are difficult to reach. Moreover, these volunteers could also facilitate the undertaking of qualitative research, which is essential to providing deeper insights into the personal experiences of humanitarian workers. These volunteers understand the local context and have the trust of their fellow community members. Engagement of the community in this research requires implementation of capacity-building initiatives and this includes training in surveillance, data collection and data reporting.

Final thoughts

What we need is research that is inclusive of all humanitarian workers: local, national and international. Similarly, we need to have studies that cover the different types of crises they are addressing as these are associated with different health risks: armed conflicts, natural disasters, and infectious disease outbreaks. Our prioritisation must be to regions with ongoing or recurring crises where health problems have been reported among affected communities.

Without such a comprehensive and inclusive understanding, any recommendations we make in support of humanitarian health will fall short. It is essential to prioritise additional research directly from the heart of crises to effectively inform and guide our efforts in supporting the health of humanitarian workers tackling the world’s most pressing emergencies.

Dr Mohannad Al Nsour is a medical doctor and an internationally recognised expert in field epidemiology, operational research and public health systems, and a fellow through distinction with the Faculty of Public Health (United Kingdom). Dr Al Nsour is the Executive Director of the Eastern Mediterranean Public Health Network (EMPHNET).