Recommendation for the safety and health of international collaborators en the 21 century

INTRODUCTION

It is essential to prioritize safety, health, and risk prevention among healthcare workers, as those who care for the population daily often overlook their well-being, failing to consider some of the risk factors to which they are exposed in the course of their daily care duties. The right to health is a universal and inclusive right that encompasses a wide range of factors contributing to a healthy life, including access to safe drinking water, adequate sanitation, safe food, and healthy working conditions.(1)

Health, as an essential right of every citizen, is guaranteed in Cuba and is a priority for the State. The existence of a National Health System that guarantees universal coverage and free care for all Cubans confirms our country's commitment to and fulfillment of human rights.(2) At the official opening of the Cuba Health 2018 International Convention, the Director-General of the World Health Organization (WHO) stated that the island is a model for other countries, as it demonstrates that health is a human right for all, not a privilege for a few.(3)

The current Constitution, in Article 50, states that everyone has the right to health care and protection, and the State guarantees this right by providing free medical and hospital care, in addition to mentioning the various facilities of the national health system and the plans, measures, and activities that guarantee this right.(4) The Cuban Journal of Public Health defends the idea that the draft of the new Constitution contains a broader and more modern concept of public health, with a more social character and much more focused on the well-being of the population.(5)

The safety and health of those who provide care are the responsibility and priority of the entire healthcare system, and the protection of healthcare workers must be a primary activity of this sector, focusing on protecting and restoring health while avoiding harm to both patients and workers.(6)

Unsafe working conditions, stress, or perceived lack of safety in some countries are among the main reasons for burnout among healthcare workers, exacerbating the shortage of healthcare personnel.(7,8) These result in occupational illnesses, injuries, and absenteeism, as well as representing a significant financial cost to the healthcare sector. In 2017, for example, the annual costs of occupational diseases and injuries in the social and health care services sector in Great Britain were the highest among all sectors, estimated at the equivalent of US$3,38 billion.(9) Improving the health, safety, and well-being of health workers reduces the costs of occupational injuries (estimated at up to 2 % of health expenditure) and helps minimize harm to patients (estimated at up to 12 % of health expenditure.(10)

There are international conventions and resolutions on safe and healthy working conditions for health workers. Respecting labor rights and providing a safe and healthy working environment for all workers, including health workers, is one of the global commitments of Sustainable Development Goal 8 on decent work and economic growth (SDG 8.8).(11) At the United Nations (UN) High-Level Meeting on Universal Health Coverage held at the 74th session of the UN General Assembly in 2019, all heads of State and government committed to intensify efforts to promote healthier and safer workplaces, to increase workers' access to occupational health services, and to take measures to improve the protection of their health, safety, and well-being.(12)

There is currently a global consensus on the importance of workers' health as a key element for the sustainable development of nations. The health of healthcare workers is critical. This sector employs more than 20 million workers in Latin America and the United States, carrying significant social and economic weight, representing over 5 % of the economically active population and 7 % of the average gross domestic product. This workforce is also essential to the performance of the region's health systems.(13)

In Cuba, a National Health System was established in the 1960s, within which human resources training was a priority. As a result, in 2021, there were a total of 510,781 health workers, including 106,131 doctors, 86,983 nurses, and 20,903 dentists, among other technicians and professionals who guarantee the health of the population. During this period, services have been provided in 165 countries with more than 605,698 collaborators. Currently, services are provided in 59 countries with 25,688 collaborators.(14) Since the Henry Reeve Contingent was established in 2005, 88 brigades have been deployed to 56 countries, with a total of 13,467 collaborators. Three brigades faced Ebola in West Africa, involving 265 collaborators, and 58 brigades have faced COVID-19 in 42 countries (15) In this regard, emphasis should be placed on what is considered the working environment for international aid workers, as this goes beyond the doctor's office. The general environmental conditions of the geographical area and the ecosystem faced by these workers must be taken into account, especially when they are carrying out their missions in the wake of natural disasters or major epidemics. Although it has been a ministerial concern that workers assigned to international missions receive prior training, this has not always been feasible due to various reasons. However, it is now necessary to emphasize these measures to prevent accidents, illnesses, or disabilities among personnel performing these tasks abroad.

The safety and health of those who care for others is the responsibility and priority of the entire National Health System, but health personnel themselves must also internalize the need to protect themselves to protect others; in other words, we must take care of ourselves to take good care of the population, both nationally and internationally.(16)

Objective: to recommend a series of training and education actions that should be carried out before, during, and after healthcare professionals fulfill their mission abroad.

METHODS

A search was conducted on Google Scholar, PUBMED, SciELO Regional, SciELO Public Health, and SciELO Cuba. The search strategy employed the following terms: safety and health in the working population, resolutions, laws, and statistical yearbooks; Cuban medical collaboration; and internationalist mission. Draft Constitution of the Republic, for a total of 16 articles, updated by the topic under investigation. References that are more than five years old are included due to the connotation and historical evolution of the topic under investigation. The documents were analyzed and evaluated in depth, encompassing a total of 16 works referenced in the presented documentation.

DEVELOPMENT

The health sector is considered essential in any society due to its impact on the well-being of populations. Unfortunately, global economic development is not equally accessible to all its inhabitants, nor are the health risks present in all areas of the planet.

In Cuba, like the rest of the population, health professionals enjoy the right to health in every sense. However, as mentioned above, the health of these workers takes on special relevance when they become international aid workers.

The publication by Robaina et al.(16) raises seven questions, which have led to the recommendation of a set of preventive actions to increase the perception of risk among international aid workers in the face of adverse events that may arise in unfamiliar and potentially dangerous work environments.

1. Will this worker have an adequate perception of risk that allows them to identify risks in addition to their usual exposure?

Before: The aid worker must participate in practical training activities about the country where they will be working, including language, geography and topography, socio-cultural and natural environments, religion, most common diseases, eating habits, and other relevant aspects. If possible, each aid worker should have a safety booklet.

During: Once in the destination country, the head of each brigade must verify the received information and update it as necessary, in addition to complying with all disease prevention, promotion, and control measures provided for in each case.

After: Upon returning to the country, the volunteer must undergo a medical check-up to assess the risks to which they were exposed during their stay abroad. In this regard, volunteers traveling to countries with endemic malaria are required to undergo a complete antimalarial treatment before entering the country, which has prevented malaria from becoming endemic again in the territory.

2. Will the aid worker be physically and mentally prepared to face new risks and prevent them?

It is common for personnel providing medical assistance abroad to be young and in good health, as they are required to undergo a medical examination before departure and must be properly vaccinated against many diseases to which they may be exposed.

Consequently, the following must be assessed.

Before: Staff selection must be meticulous, and it must be the responsibility of medical cooperation managers and brigade leaders in each country to place young, fit personnel (young, able to swim, with no proven medical history) in high-risk areas to deal with any of these eventualities, which must be verified before they leave on their mission.

During: Upon arriving at their workplace, each aid worker will be responsible for identifying potential risks in the work environment and reporting them to the team leader, who will, in turn, inform the relevant parties so that they can be controlled or eliminated. In addition, appropriate protective equipment must be used whenever health personnel leave the clinic and have to travel to dangerous areas (river crossings, jungle, or other risky places).

After: All aid workers coming from high-risk areas must undergo a medical and psychological check-up before entering the country to assess their mental and physical health and rule out the presence of any endemic diseases in the area where they will be working.

3. Will the worker be aware of their responsibility to themselves, the medical brigade, and the Cuban population upon their return if they do not follow the rules for healthcare and protection?

Before: workers must be adequately trained according to the country and living conditions they will encounter during their mission. They must also be familiar with the language used by the local population in order to recognize warning signs of danger and to be able to call for help if necessary.

During: The worker must comply with mandatory disease prevention and control measures. If they are going to cross a river, they cannot do so without adequate means of protection. Suppose there are snakes, scorpions, or other poisonous animals or plants in the area. In that case, the medical team must have the necessary antidotes and medications to counteract a bite, as well as access to rabies vaccinations, if required.

After: Brigade leaders and collaborators on high-risk missions must prepare a manual to raise awareness of the different risk factors present in specific areas, to be used for training future aid workers. The experience of each mission should be used to improve risk identification in these conditions.

4. Will all adverse health events affecting each aid worker be adequately monitored?

Before: The medical check-up carried out on aid workers before they leave the country should include their destination and the possible area where they will be working. This will serve as a guide for the medical commission, which should be aware of the health risks present in the countries where medical assistance is provided. This check-up should be personalized, following the parameters of medical check-ups for any other worker.

During: each mission, the health of each worker will be monitored at least every three months, and their physical and mental condition will be assessed.

After: travelers must undergo a personalized medical check-up at the medical committee that evaluated them before they left the country. Once this has been done, the worker will be fit to continue with their work duties.

5. Are they adequately updated regarding pathologies and environmental conditions in the country where they are traveling?

Before: One solution to this question would be specific training courses that must begin before departure from the country, but must be periodically updated according to the conditions and health problems that arise. An example of this occurred during the Ebola epidemic in Africa at the beginning of the century. This epidemic began in countries where aid workers were stationed, and they had to be trained and learn how to take care of themselves on site. The brigade that was prepared in Cuba had time and excellent training, but those who were at the site of the epidemic did not have that opportunity. Another recent event was the COVID-19 pandemic, where the magnitude of the problem was greater, and aid workers once again had to put themselves at risk to fulfill their mission of saving lives worldwide.

During: training for medical brigades, updates must be ongoing and adequately maintained.

After: once back in their country, aid workers should serve as facilitators in training courses for personnel traveling on future missions to the country from which they came.

6. Will they adequately and systematically comply with prophylaxis in the presence of certain diseases to prevent their spread?

Before: In this regard, it is critical to train aid workers on the protective measures they must take in each territory. They must also be informed about the risks they may encounter in the country they are traveling to, based on the potential health issues that may arise there.

During: Prophylaxis and preventive measures must be strictly adhered to. This is the primary responsibility of the aid worker and each brigade leader. In this regard, carelessness or indiscipline can affect the health and life of any member of the brigade, and violations in this regard must be severely punished.

After: They must continue once the mission is over, if necessary. Their health status must be assessed upon their return to the country by international health surveillance guidelines.

7. Were the prior skills and aptitudes of the aid workers considered for placement in areas of environmental risk?

Before: as mentioned in question 2, workers must be able to cope with most of the problems they may encounter, but how can this be achieved? How can we prevent aid workers from being afraid of snakes, crocodiles, lions, and wild monkeys that inhabit the jungles of Africa and America? These animals inhabit their natural environment and are integral to the flora and fauna of those places. In these cases, it is humans who are invading their habitat. Therefore, as a law of the ecosystem, we must learn to live in harmony and achieve the right balance, so as not to harm the environment, while also ensuring the health of the aid workers. It is necessary to know at least which animals may be poisonous, their behavior, what to do in their presence, and the personal protective measures and equipment required to avoid harm.

Suppose an individual who is afraid of animals such as snakes, spiders, or scorpions knows the characteristics of the specimen in question, its behavior, and what to do in the event of a sting. In that case, they can avoid the dire consequences of panic in the event of bodily injury. There are statistical reports of the high frequency with which injuries of this type result in self-injury that is more serious than that caused by the venom itself.

During: their travels, it should be emphasized that aid workers sometimes visit places that are rarely visited and where nature has a diverse range of plants and animals that may or may not be harmful to humans. For locals, traveling through these areas is not risky because they are familiar with the characteristics of each region, including its rivers, forests, and animals, and they know how to interact with them in a way that does not put them at risk and allows them to respond accordingly. These observations play a crucial role in mitigating the various risks to which workers may be exposed in these environments. It is challenging to determine the specific characteristics of each site where aid workers will be deployed. Still, if they can be trained in general measures to take in response to these dangers in the areas where these risks exist, the negative consequences will be mitigated.

In this case, the environmental risk factors to which they are exposed should be discussed in depth with the existing personnel in each brigade and reinforced with personnel from the country in question to serve as guides. The characteristics of river crossings or other waterways should also be discussed with the locals.

After: upon arrival in the country, brigade leaders should prepare a practical guide on these little-known aspects, which can only be learned through experience in the field, to enrich the training of personnel who will be sent in the future to collaborate in an area with similar characteristics.

CONCLUSIONS

This article presents a series of recommendations for the care and protection of healthcare workers collaborating abroad, to address some previously raised concerns about the safety and health of these workers in the current century.

Success in ensuring the health and safety of healthcare workers in special conditions, particularly international aid workers, must be approached from the perspective of the right to health, where preventive work begins before they depart to carry out their mission, continues throughout their stay in the territory, and continues after they return to their country. Training, discipline, and monitoring play a fundamental role in this.

It is essential to monitor all adverse health events, detect them early, control them effectively, and provide specific care. The right to health for these professionals lies in the fact that prevention and health promotion in this area are permanent, and feedback upon return to the country is essential for the preparation of future aid workers.

RECOMMENDATIONS

Given the importance of this issue to the authors, it is recommended that a training program be developed based on these recommendations, involving relevant institutions to achieve these objectives and ensure continuity.

References

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