Twenty years after Novye Atagi: A call to care for the carers

In October 1996 I was appointed Head of Office at the ICRC war surgical hospital in Novye Atagi, a small Chechen village south of Grozny in the foothills of the Caucasus mountains in the very south of the Russian Federation, where ICRC had opened a hospital on 2 September 1996 to care for the war-wounded in the Chechen conflict. The delegation and the hospital in the same compound was a busy place with a multitude of building projects going on at the same time. There was an international team of experienced medical staff running the hospital, and a number of supporting staff engaged in the construction and administration of the operations. Often the sub-delegation was visited by other supporting specialists, like dissemination and security, working across all the Northern Caucasus delegations. For security reasons we were almost exclusively confined to the delegation compound, and a humming social life had developed among those who worked and lived there.

Two and a half months into the mission, in the early hours of 17 December 1996, everything changed.

When I woke up that day it was dark in my room. Almost. Lying in bed I could see a few strips of light reflecting on the wall, the streetlight from the courtyard shining through the blinds. There were also sounds. Voices, and what seemed to be banging noises.

Immediately I thought of an incident about two weeks earlier, when I also woke up at about 5am from sounds of voices and walking footsteps. At the time, wondering if it was a late-night party, I got up and descended from my bedroom to see what was going on downstairs, I walked straight into a burglary. A large group of armed men was in the process of carrying boxes of material out of the building, including radio equipment and computers. Once they noticed me, they forced me into a corner and to the floor, kicked me a few times and finished with their business.

This time, however, something was different. I felt a sense of dread. Not knowing what I should do, I sat up in bed and started pulling on a pair of trousers. Before I could finish putting on my trousers, the door opened and a dark figure walked into the room. In the dim light I perceived a person with a military style jacket and a black balaclava on his head. Immediately I thought of the most severe threat and danger that I could think of: kidnapping. I thought that resistance would be futile and decided to go along with whatever would happen next. The figure couldn’t approach me to more than about three meters, because I had a table in the middle of the room, somewhat obstructing access. So, I lifted up my hands to about shoulder height and said something like “Ok, Ok, ….”

Then, looking at the person, the next thing I saw was him a pulling his right hand out of the pocket of the jacket, pointing a gun at me — then and a red-yellow flash of light erupted. Almost instantaneously I felt a piercing pain in my shoulders, seemingly hot and cold at the same time. Instinctively I moved my hands to where the pain was, letting myself fall back onto the bed, turning to the wall. In what seemed to be an eternity, I started wondering what would happen next? What should I do? Without seeing him, I imagined that the person would approach me and come next to my bed. If so, should I fight back? When nothing happened immediately, and I couldn’t think of any successful course of action, I remembered to calm down my mind, and I started a simple meditation routine, repeating a short mantra, and simply resigning myself to go with the flow of whatever might happen next.

In what seemed to be yet another eternity, I listened to the sounds of mayhem in the building. Gunshots, heavy banging on doors, occasional shouts and crying until they started to fade away. I don’t know how long I was lying there, eyes closed, holding my shoulder, and listening. Maybe minutes only, yet it felt like a space outside of time. Then it took still a bit more time before I dared to move my body. Clearly nobody was in my room anymore.

Then slowly my intense awareness of my surroundings started to weave together with others, as the radio sprung to life with voices calling out, at random at first, but soon connecting into exchanges and conversations. Slowly the horrific proportions of the massacre of international medical personnel at the Novye Atagi hospital, who were murdered intentionally and in cold blood, became apparent. It was only then when I realized that the assailant intended to murder me too, had left me for dead and that I had miraculously survived the ordeal. The sparkling blue sky over the calm snow-dusted landscape of this rising winter morning stood in crass contrast to the bloody mayhem this place had just experienced.

That day six delegates of the International Committee of the Red Cross were shot dead in cold blood by unidentified gunmen at their quarters at the hospital in Novye Atagi. Their mission had been peaceful and humanitarian. They were:

- Fernanda Calado, an ICRC nurse of Spanish nationality;

- Hans Elkerbout, a construction technician seconded from the Netherlands Red Cross;

- Ingeborg Foss, a nurse seconded from the Norwegian Red Cross;

- Nancy Malloy, a medical administrator seconded from the Canadian Red Cross;

- Gunnhild Myklebust, a nurse seconded from the Norwegian Red Cross;

- Sheryl Thayer, a nurse seconded from the New Zealand Red Cross.

There were thirteen other expatriate workers present at the sub-delegation that night. Those colleagues of mine were all potential targets of the assailants[1]. They were either behind safely locked and sturdy doors in their bedrooms, or sleeping in other buildings within the compound. They survived with emotional and psychological scars. They, too, carry the memories of hearing the shooting, banging, shouting and crying during the attack, and the visual impressions of the aftermath, finding their dear colleagues murdered in a bedroom next to theirs. They also carry the memories of feelings of fear and helplessness and maybe guilt of a situation where it was impossible to intervene and protect someone close to them. There were also several local staff members in the compound that night, however, when the attacker encountered them, they were told to stay away and that the attack was exclusively directed at the expatriate workers, not at them.

This is the story I usually tell when someone asks about what happened. Many other people will have a story from that day. Some have a close-up experience of that day, many were touched from afar. Each of the stories is unique and worth listening to.

The other story

“Trauma is an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives”. (American Psychological Association)

I have another story to tell, one that is closely linked to the one above, and one that is as important as the first one. It is a much less sensational story. It is drawn out, long, difficult, and seemingly without end. It is the story of recovery and healing. Writing this article has become part of this story. This story is very personal, and I suspect that many of us live a similar story of recovery and healing from physical, mental and/or emotional hurt and injury.

It is the story that began the moment the first story finished.

On that early December morning in 1996 it took me some time to realize what happened to me and others around me. During the first 24 hours I felt that both the worst and the best sides of humanity were revealed to me. Once my colleagues discovered me in my room, lying in my bed, injured, there was not a minute where there was not someone present next to me, in touch, literally. Feeling that caring presence, with a hand on my arm or shoulder all the time, gave me a sense of grounding and infinite safety. I’m still grateful today to the nurses and all the others who accompanied me on that first day. That sense of grounding, connectedness and presence started to evaporate only about 24 hours later, once I had arrived at the hospital in Geneva where the bullet was removed from my body.

The clinically clean and empty space at the hospital soon started to make me feel left alone, cut off and pondering thoughts that I wished I could have shared or developed with others. The emptiness of the next 5 days was only occasionally punctuated by short visits and reports of heartfelt ceremonies at the airport and at the cathedral, commemorating the deaths that occurred at the horrible event — ceremonies I could not be part of. It was an important time for other survivors to congregate, to find meaning and answers, to talk, and to mourn.

My rational mind understood: I had an injury, my lung was punctured, the doctor said that I needed rest and should not overexert myself. The deeper layers of my being however had a craving, needed another medicine than what I received, isolated in a hospital bed.

Thus started my next journey — the one of healing and recovery. It is a journey where I was walking in the dark for a long time, where it was left entirely up to myself to make sense of what I had just experienced. A journey where I certainly learned a lot and yet whose purpose defied me for a long time. When I think and talk about this story, I feel vulnerable, and it seems to be very self-centred. It was difficult to find a helpful community that would support me.

Today I feel strong enough to share this story. This story is important because many humanitarians experience trauma, and while I cannot speak for others, connection (or lack thereof) with my group and community has been the recurrent and defining theme of my journey of healing and recovery .

Looking back, I realise how important a collaborative approach to healing from trauma could have been. I’ll share with you some of the milestones of my journey, and I’ll propose and discuss an integrated approach to addressing stress and trauma, whereby organisations can better support their staff comprehensively, through objective support, an improved systemic environment, the internal organisational culture and the allowing of subjective experience of the recovery by the individual.

Healing and community

Judith Lewis Herman, in her book Trauma and Recovery: The Aftermath of Violence — From Domestic Abuse to Political Terror, explains:

“Traumatic events destroy the sustaining bonds between individual and community. Those who have survived learn that their sense of self, of worth, of humanity, depends upon a feeling of connection with others. The solidarity of a group provides the strongest protection against terror and despair, and the strongest antidote to traumatic experience. Trauma isolates; the group re-creates a sense of belonging. Trauma shames and stigmatizes; the group bears witness and affirms. Trauma degrades the victim; the group exalts her. Trauma dehumanizes the victim; the group restores her humanity.”

On 17 December 1996, I was part of a group and community that felt like a big family. ICRC. That community, as a collective, suffered a trauma as well on that day. It was an unprecedented and unprovoked act of violence against itself and its workers. Difficult to deal with, and often seen as a turning point in terms, it signalled a the start of a period of decreasing security for the Red Cross Red Crescent Movement and the humanitarian sector in general.

What I felt the first time on the day of return, has over time become a pervasive reality, again sometimes punctuated by very meaningful events of belonging. In fact, the relationship with my employer at that time, my community, has been far from harmonious over the years. My belonging to ICRC has been put in question many times over, and a sentence from a recent email of one of the organisations representatives, probably reflects the organisational response to my attempts to ‘belonging’ quite succinctly:

“… the fact that he has not gotten in touch with you means that there is no concrete proposal for collaboration that could be envisaged at this stage.”

While the ‘he’ in this sentence refers to a particular person within ICRC, the communication however struck me as coming from the organisation as a whole, and I felt that it could as well say: “… the fact that we have not gotten in touch …”

This statement seems to encapsulate not only a response to a concrete proposal, but in my view also succinctly reflects the sense I have picked up from my employer over the years at my attempts to obtain the participation in a collaborative approach to healing from trauma.

The fact that the statement above is still hurting, shows that we both are still on a journey of recovery. If recovery and healing cannot start or is interrupted, then our lives will become an internal warzone, where injury after injury, trauma after trauma happen, and finding peace will be a very long journey and challenging task.

This is not to assign blame. I think at the time, all did the best, and in the best way we knew how. I started out, initially, completely trusting that my employer knew what to do, how to help and that they would point me towards the right direction, supporting me along the way. However, I soon found out that this was by no means the case.

I had no idea what to expect. My first focus was on getting my physical health back, to have my punctured lung working again and in general get my strength back. On a deeper level, things were much less clear. I often felt vulnerable, disempowered and misunderstood. I couldn’t quite communicate what I needed, beyond the restoration of my physical health.

While I progressed getting back my physical health, the effects of post-traumatic stress disorder (PTSD) seemed to arise more often. In unexpected moments, my body reacted to triggers, although seemingly without cause, breaking into sweat, blocking my ability of being able to talk without becoming emotional, feeling an unexpected loss of energy, shaking, and so on. The most difficult time of the day was going to bed, falling asleep and letting go of control, because it was during the night that it happened. How could I sleep without looking the doors, or without listening to the sounds in the corridor, or elsewhere in the building? However, once I fell asleep, I seldom dreamed about it. The effects of PTSD can be extensive, are individually different, and have been well documented. Without help, this is a difficult journey to navigate.

It was only much later I decided to seek professional help, and it was even further down the path that I started to perceive it as a learning and healing journey. It took time to gain insights on my contemplating the meaning of life and death and forgiveness. However, first anger and then frustration were long time companions on this journey.

At the very beginning I set the intention that this experience shall ultimately have a positive effect on my life, and on the lives of others. Yet, it took many years before I could see this intention as anything more than wishful thinking.

There have been many milestones along this journey — ups and downs. Over the years worked myself through the different stages, in my own perspective as the perspective of others, from “victim” through “survivor” to “normal” — whatever the meaning is of normal. And yet, still today, I often feel cautious talking about this healing journey for fear that it will be held against me.

Here are some of the most significant milestones over the last twenty years which have marked my life:

- The investigation. What did really happen and Novye Atagi? And why? And what were the consequences? I am sure an investigation took place — yet neither did I ever get an opportunity to contribute to it in a meaningful way, nor did I ever have the opportunity to read any resulting reports, or discuss the outcomes with anyone at the organisation, pieces of information I do not have. Not so much today, but for a long time I felt that it would help me make sense to know more of the background information of the incident.

- Deciding I needed help. I would have gone with pleasure on another mission relatively quickly to a place which was reasonably safe. Yet, coordination of that mission proved difficult and going to a dangerous place soon after being shot in Chechnya didn’t seem right, somehow. Then, when finally my mission was confirmed (and changed at the last minute), about 8 months later, I noticed symptoms of PTSD that made me question the choice to leave for another mission. I noticed that I had lost that deep sense of grounding I used to have; the sense that gave me direction in life and enabled me to make sensible decisions and evaluate safety and danger around me. That was the point when I knew I needed help.

- Resignation. Psychological help then revealed that in fact I had accumulated a lot of anger against my employer, who simply was not present as an active participant in my trauma recovery. But who to tell? Who would listen and understand? After a few attempts to communicate, I felt that as a last attempt to attract attention, I should send a letter of resignation. This was probably one of the most hurtful episodes of all — because nobody seemed to notice except for the intern at human resources who dutifully checked my bank account to insure the final payment did not get lost, nobody engaged in a meaningful conversation, or wondered why, after having taken a bullet for the organisation and being eager to deploy again, I now would be resigning. Maybe already then it was true that “… the fact that he [the ICRC?] has not gotten in touch with you means that there is no concrete proposal for collaboration that could be envisaged at this stage.” At that stage, the proposal would have been my healing and recovery, and with some imagination, the healing and recovery of ICRC, as well.

- Going on another mission. It would take me a number of years to realize that there were lose ends that prevented me from moving forward professionally. I felt that something was incomplete. Finally, I worked up enough clarity to realize that in fact on some level I had never fully completed my mission in Novye Atagi, that I had never emotionally finished that assignment. With that clarity in mind, I took the initiative to request another mission — on my terms. It was granted and I spent six months in the field. At the end I returned and concluded the mission like any regular assignment. Not only did it allow me to find a sense of self-empowerment, but it also allowed me to conclude that sense of limbo of an unfinished employment relationship.

- The tenth anniversary. The next milestone happened close to five years later. At this stage I tried to not think much about my experiences and to get on with life. However, when I was contacted regarding a 10 year anniversary event, I felt a strong reaction — going from rejection to seeing an opportunity for further recovery with a community to which I still felt a strong sense of belonging to. It was an opportunity for a review of the impact of this event on my life. Physically, psychologically, emotionally, spiritually, as well as economically. The 10-year commemoration event eventually provided me for the first time, unwittingly, with a platform at the ICRC for sharing my personal experience with others of the ICRC community. For the first time I felt that some significant pieces of the puzzle came together — personally and emotionally. Meeting others from ICRC who had their own story of Novye Atagi felt very healing.

- The awarding of the Henry Dunant Medal. That milestone was followed shortly afterwards with another one — the awarding of the Henry Dunant Medal in 2007. It felt that finally my intention for an ultimately positive outcome started to manifest themselves. This medal was an unprompted recognition of what I had been going through and an acknowledgement of my belonging to the wider Red Cross Red Crescent community. Psychosocially it was certainly a huge step forward on my healing and recovery journey. It meant that for the first time I could talk about my injury and the associate trauma without feeling it was a liability, now, I could start to maybe make my experience into an asset.

- Returning to the humanitarian sector. From here it would take another four years before I felt strong enough to actively start working on the issue of stress, burnout and trauma in the humanitarian sector. When the opportunity came, I thought long and hard before accepting the challenge of leading the Mandala Foundation in Melbourne, and NGO dedicated to the psychosocial wellbeing of aid workers. My next experience was working in a Human Resources function with Australian Red Cross coordinating field missions to conflict disaster areas. Both roles were important contributions to my healing journey, and opportunities to start giving back. When I got the chance to inspire and help leading the first event of recognition for Red Cross workers that were killed in the field on 17 December 2014 at Australian Red Cross, it finally seemed that a circle closed in on itself, and like the satisfaction of a deep craving, other pieces of my scattered self fell into place.

Looking back, those are events that loom large in my memory. Yet, in between there were long periods when life felt like it was going two steps forward and one back. Sometimes even one step forward and two backwards. As for belonging to ICRC and the wider Red Cross Red Crescent movement, I never seem to have achieved any continuous and lasting process of collaboration.

My journey, and that of the organisation, seem to go on parallel lines, and as in a true parallel, the lines do not touch, except at certain events as outlined in the list of milestones above. There was very little time invested in helping each other to understand what was happening, and making sense of that horrific event. Very little time was spent walking next to each other, supporting each other. Individuals have to live their journey by themselves — and the collective deals in its own way with traumatic events that impact it, although the collective is ultimately made up of individuals with their own personal feelings and experiences. I know very little how the collective (meaning the ICRC as an organisation) dealt with the shock, the pain and the trauma of Novye Atagi, for example.

I do not claim any special treatment because I was a “victim” or “survivor”. I suspect that there are many Red Cross delegates that had horrific and traumatising experiences during their career. And I suspect as well that they also need the sense of belonging to the wider community on their journey of recovery. How is the ICRC living up to its part of the responsibility — to be the community that helps the individual to regain their health and humanity?

I do experience a great reluctance by the organisation to engage in any activity that looks at the deeper emotional and spiritual hurt that is caused by the violence witnessed and experienced in the field. Whenever I speak up I sense a resistance, like an invisible barrier going up, as if there is a great reluctance to hear my voice, and as if people do not want to look at this side of the coin. Maybe this is because it does touch a nerve in so many humanitarians. How do we reconcile our personal feelings with the imperatives of the humanitarian and organisational mission and principles?

Today: Addressing the inherent stress of humanitarian work

It has been a big challenge for me to write this piece. The writing process has been a journey in itself. A few times I figured that it was just too difficult to write about something that is so personal, and I was tempted to give up.

But why is it important to talk about this? This story is more than just about what happened 20 years ago, it is also more than just my personal experiences of recovery. There are many others who have dedicated themselves to what they see as a noble cause: helping the suffering in a humanitarian context, and they have ended up suffering themselves.

Humanitarian work is inherently stressful. People working in the sector are sometimes exposed directly to traumatic events, more often indirectly. Indirect exposure is also known as vicarious traumatisation. According to studies, humanitarian aid workers have a much higher occurrence of PTSD than the average population. Up to 30% of aid workers seem to suffer in different ways.[1] The effects of PTSD can arise weeks, months or sometimes even years after the initial experience.

Statistics about security incidents do not paint a nice picture. In 2016, the security incident data published by the Aid Workers Security Database suggests that as of 9 October 2016 there were 120 victims.

Nor do the news. In 1996, an attack of the nature and scale such as perpetrated in Novye Atagi, where aid workers were deliberately targeted and killed, was very uncommon. Today, 20 years later, sadly the situation seems to have dramatically changed in this regard. Although the number of humanitarian workers injured and killed is not quite as high as it was in 2013, recent times have seen a number of horrific events where humanitarian operations were targeted repeatedly, seemingly on purpose. Examples that made headlines in the media are:

- On 3 October 2015: A MSF hospital in Kunduz, Afghanistan, was attacked by an American airplane.

- During 2015 and 2016 an unprecedented number of medical facilities in Syria and Yemen have been attacked and destroyed.

- On 1 July 2016: soldiers enter a Hotel in Juba, South Sudan and rape and harass aid workers who were seeking shelter from fighting.

- On 19 September 2016: an aid convoy of lorries is bombed from the air in Syria.

The statistics only record those who have directly experienced an incident, and so do the news. They do not take into account those aid workers who experienced trauma vicariously, at headquarters, and as friends or family members. Some know those who are killed, injured or kidnapped personally. Colleagues might be at other locations around the globe, and might have been involved in leading, coordinating or otherwise supporting operations from the distance. All will feel an impact, and nothing can give consolation to those who lose close family members.

There seems to be considerable disagreement as to whether the story of post-traumatic life can ever have a positive outcome, yet, with such a large proportion of the workforce potentially affected, it is an imperative that aid agencies take the impact of trauma very seriously.

There are a number of questions that arise:

- What are the responsibilities aid agencies are faced with nowadays?

- How does the humanitarian sector deal with such attacks on itself and its workers?

- What does it really mean to have a “duty of care”? Are organisations improving their practices mainly because of legal liabilities — both because of work health and safety laws in certain countries, as well as well as the threat of law suits brought against them?

- Who will be paying for the additional costs generated by the requirement to safeguard the psychological wellbeing of aid workers?

- What is the best approach — proactively dealing with the emotional and mental wellbeing of its workers, or fixing the damage after it has occurred, the proverbial ambulance at the bottom of the cliff?

Campaigns, such as Health Care in Danger that attempt to raise awareness and commitment to protect humanitarian operations in the field, are important. There were also attempts to raise the issue of staff wellness at the World Humanitarian Summit 2016 in Istanbul. The International Association of Professionals in Humanitarian Assistance and Protection (PHAP) organised on 30 July 2015 a global live online consultation event on the issue and published a report of the outcomes. Yet, the fact that the issue of aid worker wellbeing was not granted a suitable platform at the recent Summit , shows that there is a need for action on the side of agencies and non-governmental organizations (NGOs) working in dangerous environments.

An Integral approach to addressing stress and trauma

There are many different possible ways how the impact of violence on aid workers can be addressed, and in my opinion we have come a long way over the last twenty years in the awareness of the impact as well as the variety of methods available. However, there is no one solution that fits all. While we all tend to solve challenges from particular points of views corresponding to our own positions, we tend to overlook alternatives which can add to the effectiveness of already existing measures. While they are all different and sometimes seem contradictory, they are all necessary and could provide a rich set of responses, complementing each other. Similar support mechanisms are also advised for people working in natural disaster response, as suggested in a study by Jolie Wills from New Zealand Red Cross.

Interpreting the four quadrant system, I’d like to propose a holistic approach that could best be called integral. The proposed approach is based on an interpretation by the philosophy of Ken Wilber. It has following components to it:

- Objective support through professional services;

- Adaptation of the systemic environment;

- An aware and caring organisational culture; and

- Enabling the subjective experience.

Elements of each of the components need to be present to comprehensively address the challenge of NGO employers dealing with the short and long term impacts of stress, burnout and trauma.

Objective support

The organisation provides themselves, or makes accessible through others, support services including psychological counselling as well as alternative methods as appropriate, offering them to the individual to help deal with the impact of stress, burnout and trauma. That can also include mentoring and coaching.

For many, the most obvious way to address psychological and emotional stress and signs of trauma is to “treat” people and provide professional services. What does this mean?

Twenty years ago, the concepts of PTSD and psychosocial support were not yet very well known and there were few trained professionals. Since 1996 there has been a big development. Not only have there been a number of studies conducted that looked at the psychological impact of aid work,[2] but there has also been a shift of how mental health is looked at in general, and there has been a huge increase in acceptance of alternative ways of looking at mental wellbeing. Practices such as mindfulness, meditation and yoga for example have become all but mainstream.

It is important to help increase people’s resources and resilience instead of labelling people’s mental state, analysing and pathologising it. Today, people who have gone through hard experiences are called “survivors” rather than “victims”. This is a development in the right direction. Yet, it is still a label. To be even more successful would be to not at all pathologise aid workers who have gone through hard experiences, but to provide services to all as a matter of course.

Today there are specialized psychological service providers that are familiar with the humanitarian sector and provide appropriate services.

Systemic environment

Policies, procedures and processes are aligned and congruent across the organisation and the wider sector, providing an organisational context that effectively deals with the impact of stress, burnout and trauma on its members and the organisational effectiveness.

Stress is not only a problem caused by external influences, it is to a large extent an internal problem. Studies have shown that even in an environment of war, the stress inherent in the subordinate-superior management relationship is more severe, with a higher impact, than all the stresses produced by the threat of violence and general insecurity.[3] On my personal journey, the stress I experienced in dealing with my employer over the period of twenty years by far outweighs the stress I experienced on the field.

It is therefore essential that any organisation that is active in a conflict area has its own house in order. Part of this is to have comprehensive policies, procedures and operating standards in place that reflect the duty of care of an employer for its staff.

Those documents should cover all aspects that contribute to health, physical and psychosocial, like:

• Stress policies;
• Security protocols;
• Staff health guidelines;
• Human resources procedures ;
• Staff management; and
• Organisational structure and responsibility.

Another question to ask is: Are aid workers leaving for the field suitably prepared? Do they have sufficient personal competencies in dealing with pressure, lack of resources as well as unfamiliar environments and cultures?

There needs to be clarity about who is in charge of the different aspects of staff safety and wellbeing. My own experience has been that I was facing a large organisation that was struggling to live up to its role as compassionate employer. Especially in the early days after the incident in Novye Atagi, it was difficult to know who my contact persons were for any specific issue and regularly I was referred from one person to the next to the next. This is an additional burden that should not have to be shouldered by someone already dealing with the impact of stress and trauma.

There are an increasing number of resources, organisations and consultants that work on this field, many with humanitarian aid work experience themselves. They provide training and other specialist services.

Organisational culture

We, the organisational environment in which the individual is embedded, provide peer support mechanisms and explore the meaning of humanity and the collective impact of violence against ourselves and our co-workers as part of our work in the environments we are active in. That includes shared assumptions, values, and beliefs which govern how people and the organisation as a whole behave in a given situation.

Organisational culture is something hard to define. It is something that is different everywhere. In its most rudimentary it refers to the underlying values in an organisation, and how things are done. It tells about what is appreciated and what is expected.

“We need an organisational culture that values human beings beyond humanitarian slogans, and leads by example.” (Alessandra Pigni)

The recognition awarded to humanitarian workers, is part of this culture. The regular commemorations on 17 December is an excellent example. What other organisational activities are there that acknowledge the difficult and challenging tasks delegates encounter in the field? How do we support each other in making sense of what we encounter? How do we value the human beings that work for the movement, and those who have in the past? How does ICRC acknowledge those who belong and what are the underlying values we share? Telling stories and celebrating achievements is essential.

Another important aspect is peer support. Peer support groups have existed in many different contexts for a long time. Since internal support structures are often weak, humanitarian workers have started to self-organise across the sector, and started to use social media platforms to connect with each other[4]. Another cross-sector response is the Peer Coaching Pilot that WhyDev run in 2012/13. One of the outcomes cited for the participants is “feeling less stressed and isolated”.

Subjective experience

The individual humanitarian her/himself engages directly with the thoughts, emotions and perceptions caused by an experienced incident or ongoing situation and finds subjective meaning and personal healing from stress, burnout and trauma. The individual has both a supportive environment (community) and sufficient economic means to engage in his recovery.

Last but not least is the subjective experience of the person who experiences stress, burnout or trauma. In many ways this is the most challenging of the four components. How, as humanitarians, do we with good conscience pay attention to our own needs in the world where there are so many needs of others to address? The suffering of others is (almost) always more important that our own. For most of us, it is one of the most important reasons why we started working in this kind of work at the first place.

As an organisation, we need to be open to everyone having a different reaction to stress and trauma. Some may suffer quietly, some will self-medicate. Many will hesitate to admit it for the fear of losing their dream job. This will especially be true if other components of an integral way of responding are not appropriately developed, and if signs of weaknesses are interpreted as a pathology. Then there is a danger that a culture of silence may develop, to the detriment of both the individual as well as the organisation.

Without the cooperation of the suffering individual all the other work will ultimately have a limited impact only. However, if there is sufficient information available about professional as well as alternative support options, inside and outside of the employing agency, then humanitarian workers are more likely to engage and ask for this kind of support. If there are clear policies and safety procedures, et cetera, then humanitarian workers are less likely to suffer from stress, burnout and trauma at the first place. And last but not least, if there is a welcoming and respectful organisational culture, then we humanitarian workers are more trusting and honest about our own situation and state we are in, and are less likely to deploy to the field even though we are not in a state to do so. We will not fear dismissal as a consequence.

Conclusion

On a personal level, my journey of recovery is ongoing, although on a much more subtle level. I have developed a sensitivity for situations where staff wellbeing is impacted, not by maliciousness, but maybe by ignorance. Some time ago I started curating news reports and other Internet sources pertaining to psychosocial staff health issues in the humanitarian sector. It does reveal a darker side of humanitarian work.

While I feel that I had little support in terms of a community around me, there were nevertheless significant events where my path and ICRC’s and/or the wider Red Cross Red Crescent Movement crossed, and those events always contributed immensely to my recovery.

The invisible costs that individual humanitarian workers are paying can be immense: working in insecure environments, experiencing and witnessing acts of violence and the suffering they cause can have very adverse and devastating impacts. A recent survey by The Guardian revealed that up to 79 per cent of aid workers experienced mental-health issues as a result of their work. Nearly a third of all aid workers suffer from trauma — several times the rate of the general population, according to a study by the Antares Foundation.

These studies reflect my personal experience. It took many years to make sense of what happened to me and my colleagues on that fateful day now twenty years ago, and to overcome the effects of post-traumatic stress disorder.

From my perspective, the initial experience of being shot was a trigger to a much longer experience of recovery, which was much longer and more painful than it needed to be. The biggest failure that occurred along the way was the inability to establish a fruitful process where both the individual and the community co-created a healing journey. Even now, 20 years later, I acutely sense the need to belong, and how it arises from a craving to heal an injury that I have sustained on behalf of a much bigger community.

From an organisational perspective, and as outlined earlier, there is a lot that can be done to address the impacts of stress and trauma. There is a benefit for any organisation or NGO to build an internal culture of care and healing build on humanitarian principles. Why? Jolie Wills puts it quite simply: 1. It pays! 2. It’s risk management! 3. It’s ethically just the right thing to do!

I suggest that an integral approach to dealing with stress, burnout and trauma as suggested becomes a standard operating principle in the humanitarian sector for employers when dealing with their workers. I also suggest that employers in the humanitarian sector create and implement collaborative processes and become conscious and proactive partners in the healing journeys of their staff who got impacted by injury and trauma while doing their work for the institution and humanity as a whole.

This article is also published by the International Review of the Red Cross, at https://www.icrc.org/en/international-review/article/twenty-years-after-novye-atagi-call-care-carers or can be downloaded as a print-out in pdf format here: https://www.icrc.org/en/download/file/35281/twenty-years-after-novye-atagi-a-call-to-care-for-the-carers.pdf.

[1] Antares Foundation 2012, Managing stress in humanitarian workers. Guidelines for good practice, 3rd edition

[2] Lopes Cardoso et al (2012), “Psychological Distress, Depression, Anxiety, and Burnout among International Humanitarian Aid Workers: A Longitudinal Study”, PLOS ONE, Vol. 7, Iss. 9 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0044948, and UNCHR Mental Health and Psychological Support for Staffr : http://www.unhcr.org/research/evalreports/51f67bdc9/unhcrs-mental-health-psychosocial-support-staff.html

[3] The Antares Foundation bases their “Managing stress in humanitarian workers, Guidelines for good practice” on their own reseach (https://www.antaresfoundation.org/guidelines#.WD__tfkrJhE). Also the Mandala Foundation guidelines put a strong emphasis on management and human resources activities (http://www.mandalafoundation.org.au/psychosocial-resources/guidelines-managing-psychosocial-risk/)

[4] On Facebook there is a closed group called “Fifty Shades of Aid” with more than 8000 members, that sometimes serves as a spontaneous peer support platform. Access by invitation only.