Legal Ruling Helps Identify Strategies for Managing Discretionary Free Time

by Bill Frederick

When are college students responsible for their own health, safety and security while studying abroad and, under what circumstances is the school or the program responsible? This is not a simple question but a recent court case and its subsequent unsuccessful appeal should be heeded by administrators and used to inform their risk management strategies around student discretionary free time.

In 2009 Morgan Boisson, then an undergraduate student at the University of Arizona, along with 14 of 16 students spending the semester at Nanjing American University (NAU) in China, decided to travel to Everest Base Camp at 18,000 feet where Morgan subsequently died of altitude illness.

Elizabeth Boisson, Morgan’s mother, filed a civil suit against the Arizona Board of Regents, the State of Arizona and the provider, Nanjing American University (an Arizona LLC).

In a civil court case there is an underlying assumption that if you do something that causes someone harm, whether intentional or not, the harmed party is entitled to compensation from you. When educational programs are defending themselves in a civil court against a participant, the most likely charge is negligence. In order to establish negligence it needs to be shown that four conditions exist. 1. There is harm 2. There was a duty, 3. The duty was breached (not fulfilled) and, 4. Causation, i.e., the breach of the duty caused the harm.

The harm was clear in this case and no one would argue that a university or a program doesn’t owe some duty to their students or participants. However, the nature and extent of what that duty might be is very arguable. In this case it was the crux issue as questions of breach of duty and causation rest upon how the duty is defined.

The intricacies of civil law and what constitutes a duty is beyond the scope of this article. The Arizona court said that the trip was not an off campus school activity for which defendants owed Morgan a duty.  And, in that determination the court articulated some questions derived from Arizona case law that might be useful for all higher education study abroad programs to consider. While law varies from state to state, these questions may help to guide some decision making regarding how to structure program time versus discretionary free time:

  • What was the purpose of the activity (how related to program goals was it?)?
  • Was the activity part of the course curriculum?
  • Did the school have supervisory authority and responsibility during the activity?
  • Were the risks students were exposed to during the activity independent of school involvement?
  • Was the activity voluntary or required by the school?
  • Was a school employee present at or did any participate in the activity or was there an expectation that a school employee would do so?
  • Did the activity involve a dangerous project initiated at school but built off campus?

These questions suggest a strategic approach for reducing liability exposure.

Presumably, a program activity that is managed by the program will have the benefit of the institution’s health, safety and security strategies. There are other activities that students may engage in between the time they depart for the program and the time that they return from the program that are not managed by the program and for which program safety strategies are not operational. Some of these times are clearly the participants’ discretionary free time. However, should the program staff make recommendations for what to do during such periods, or provide support for those times, or should staff accompany participants during those activities, the status of those periods as being non-program time may become less clear. Programs clearly have responsibility for what happens during program time and they have maximal control over what happens during program time. The worst scenario from a liability perspective is when the program has allowed the boundaries to be so unclear that they have maximal responsibility for an activity, but minimal control over the activity.

In fact, in Boisson v. Arizona Board et al, a number of events were argued as demonstrating that the trip was in fact a school activity. In one instance a school employee had assisted the students in making their flight reservations. In another, some professors had adjusted their class calendars in order to accommodate the students’ travel. Those events were not enough to tilt the ruling in the other direction but it would be easy to see how just a few different factors might have made a difference. What if all the students had chosen to go? What if any staff member no matter how junior had accompanied the trip? What if a professor had provided assistance or advice or had made recommendations for lodging or transportation? It is also not difficult to imagine a student telling their parents that it is a school-sponsored event in order to secure their permission or their financial support for it. None of these by themselves is damning but each makes the status of the trip increasingly gray.

Strategically, it makes sense to reduce the gray area to the degree that is practical.

Most programs cannot entirely eliminate gray areas. A program that has transported its students to a particular locale for program purposes can’t simply declare their evening out to be non-program time and expect to be absolved of all responsibility and reliably free of liability exposure. But programs can find opportunities to build firewalls between program time and discretionary free time.

  • Be crystal clear about when and where programs start and end.
  • Be clear about when and where mid program breaks begin and end.
  • Don’t allow your program to become over-involved in students’ planning their break time or post program time and avoid having your staff participating in break time or post program times with students.

And, while we need to attend to liability issues, safety is the primary concern. It would be a particularly bad idea to withhold advice or information from your students when they are making personal plans owing to concerns about increasing liability, when you know that you might be increasing their risk by doing so. From a liability perspective the best strategy is to reduce the likelihood of harm to your students. No harm means no liability. Secondarily, it makes sense to build firewalls between program time and non-program time.

Legal Ruling Serves to Focus Program Health and Safety Strategy (Munn v. The Hotchkiss School)

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by Bill Frederick

In 2007, Cara Munn, a student attending The Hotchkiss School, suffered permanently debilitating tick-borne encephalitis while on a study abroad trip to China. In 2013 a Connecticut court awarded her $41.75 million dollars (Munn v. Hotchkiss School). There is an appeal underway and in August 2017 the Connecticut Supreme Court was asked to answer two questions pertinent to the appeal. The court said that: 1.) The public policy of Connecticut does not preclude imposing a duty on a school to warn about or to protect against the risk of a serious insect-borne disease when organizing a trip abroad and, 2.) The jury award to the plaintiff fell within the necessarily uncertain limits of just damages and did not warrant a remittitur. The case now goes back to the Second Circuit Court of Appeals. In her concurrence on the two questions before the court, Connecticut Supreme Court Justice Carmen E. Espinosa raised significant questions around foreseeability that suggests that it might be reconsidered in the appeal.

Regardless of how the overall appeal plays out, the Connecticut Supreme Court has made a statement. It may be specific to Connecticut and applicable to secondary schools and minors with the corresponding legal notions of custodial care and In Loco Parentis, but it suggests that all secondary schools (and perhaps gap year programs, higher education and all the subsets of international education to varying degrees) need to “warn about” and “protect against the risk of a serious insect-borne disease when organizing a trip abroad.”

There is a spectrum of measures across each category that might be undertaken to warn about and protect against the risk of vector-borne diseases.  Programs make the strategic error of doing the minimum. The logic is that whatever measure taken would demonstrate the performance of due diligence. However, the only sure way to guarantee your school or program’s protection from vector-borne disease related liability is to ensure your students don’t get these diseases. And, no matter what precautions you implement, there is still some chance of disease. Whether a school or program has done a great job of taking care of their students may be determined by a judge or a jury. Arguing that minimal measures should protect your organization from the letter of the law, when they obviously didn’t protect your student from a potentially serious illness, is not the argument that you want to be making. In the face of a potentially tragic event, you will be wishing that you were able to point confidently and competently at a well thought-out and robust strategy. Categories for warning and protection include:

  • Understanding the hazard
  • Warning
  • Preventative measures (before you go)
  • Avoidance measures (while you are there)
  • Response measures (what to do if someone becomes ill)
  • Understanding the hazard

In order to warn or protect from insect-borne diseases, every program and program leader need to know what diseases are endemic at their destination, which diseases pose a threat, and the best measures for prevention, avoidance and response. Different countries have differing recommendations for vaccines and chemoprophylaxis, but for U.S. based institutions and programs, the U.S. Centers for Disease Control (CDC) is the accepted authority. You can go to the CDC website for information or you can subscribe to a medical intelligence service like TravelCare® International, LLC that will organize the information in a very accessible format and which is consistent with the CDC. Additionally, if your school has a relationship with a travel medicine doctor, nurse or clinic, you can ask them to put together information summaries for staff. Some travel assistance companies provide vector-borne disease information to their clients. Finally, there are a number of online courses in travel health available and short courses for lay-persons in travel medicine (Travel Medicine First Aid) are also available.

Warning

There are degrees of warning. At a minimum you could forward a link to the CDC website to participants, and their families in the case of minors. A better approach would be to cut and paste the relevant sections into an email. Even better would be to use TravelCare® to forward a report to your participants. Orientations should include an overview of all the likely risks including insect-borne diseases and the best prevention and avoidance measures. Orientation content and student preparation processes should be well documented.

Preventative Measures (before you go)

The CDC makes recommendations for vaccines and chemoprophylaxis. A couple of vector-borne diseases are preventable with vaccines, i.e., yellow fever and Japanese encephalitis. The best preventative strategy for malaria is chemoprophylaxis (taking medication to prevent getting a disease). The CDC recommends 5 different drugs with varying regimens, effectiveness and side effects.

  • Chloroquine – Chloriquine resistant malaria has grown significantly around the world particularly in the most dangerous strain of malaria (P. falciparum) making this a less likely choice.
  • Doxycycline – Requires a daily dose. It once was considered to be inexpensive, but as the primary treatment for Lyme disease and having become the primary chemoprophylaxis for the U.S. military, it is no longer inexpensive. It has two particularly notable side effects. It can cause photosensitivity, making users very prone to severe sunburn. It also may cause fungal infections (vaginal and esphogeal). On the plus side it may also protect against some tick borne infections.
  • Mefloquine (Lariam) – Requires a weekly dose and is the least expensive chemoprophylaxis. It has a very notable side effect in that it frequently causes very vivid dreams and other neurologic issues. It is not recommended for anyone who has any history of mental health challenges or seizures. Some resistance is reported in Southeast Asia.
  • Atovaquone/proguanil (Malarone)  - A daily regimen. Not inexpensive. Anecdotally, there are comparatively fewer side effects reported, mostly gastrointestinal issues.
  • Primaquine – This drug should not be taken by anyone with a liver enzyme (glucose – 6 – phosphate dehydrogenase) deficiency and anyone considering should be tested for it. This drug kills the malaria parasites in the liver (as opposed to the bloodstream), which may make it a good choice if you are particularly concerned about P. ovale and P. vivax.

Avoidance Measures (what to do while in country)

When you know what the vector hazards are at your destination, it is then important to understand if the vector is primarily a day biter or a night biter. The mosquito that carries malaria; sand flies that can carry leishmaniasis; and the triatomine bugs that carry American trypanosomiasis (Chagas disease), are all primarily night biters. The Aedes aegypti mosquito, which carries dengue, Zika, chikungunya and yellow fever, is primarily a day biter (and urban dweller). In some regions where malaria is not a threat, it may still make sense to use chemically treated mosquito nets at night. And, whether you are concerned about day biters or night biters, avoid sitting outside at a café unprotected at dawn or dusk when mosquitos are most active.

It is also important to understand that not all insect repellents are created equally. If you went bug repellent shopping at a Walmart or an REI, many of the products you’d find are not very effective. There are there 3 products that research shows are effective: Products with DEET (N,N-Diethyl-meta-toluamide) with a concentration somewhere between a 25% - 35% are optimal foreffectiveness. The other two effective products are picaridin and IR3535. Additionally, there are products that sound like they might be good for your skin. They smell great and sound minimally toxic. Their ingredients may have repellent properties, but the time frame of effectiveness is so brief that by the time you’ve finished applying it, it is time to reapply it. Long sleeves and long pants afford protection. For additional protection, especially against ticks, you could apply permithrin, an insecticide, to your clothes.

Compliance with avoidance measures is another issue. Last month I was teaching a travel medicine course in Chiang Mai, Thailand where there is currently an epidemic of dengue fever.  It was hosted by a study abroad provider and course participants included a UN security officer, some researchers from Brunei, an aid worker from Myanmar and a number of study abroad practitioners. One of the host staff was just recovering from dengue fever and the director of the program and his whole family had had dengue in previous years. When surveyed, no one in the class was using insect repellent. “Preventative complacency comes with time, denial and the excuse of inconvenience” according to David Johnson the president of Wilderness Medical Associates. I would add peer perception to that. If you don’t see anyone else using bug dope then it must be ok not to use it. So effectively protecting students is more than just a matter of giving them the information.

Response Measures (what to do if you think you may have an infection)

Knowing what the vector disease exposures are, trip leaders should also have some idea of how they will respond if a staff or student becomes ill. Certainly no one would expect non-medical professionals to make a diagnosis of a vector-borne illness and the symptoms of most vector-borne diseases are similar to flu, but programs need to have identified acceptable medical facilities to bring their students to in the event of illness. It helps a lot if program staff have more than just CPR training under their belts and every program should have a medical professional available who has some understanding of travel and tropical medicine, of the medical infrastructure of low income countries and also is very familiar with U.S. standard of medical care. Some schools utilize a travel assistance provider. Some have an advisory physician who works at their school or is on their board. Some schools build a relationship with a travel clinic.                                         

Health, safety and security strategy starts with understanding the Safety Matrix® (who/what/where/when/why/how and how long) of a particular program. By the time a group departs to begin a program, you want a strategy in place that you can feel confident about. How do you know if your strategy is sound? If you can easily articulate why you did what you did and why you didn’t do what you didn’t do, and you wouldn’t second guess your choices even if someone did contract a vector-borne disease, then you likely have a robust plan in place.

Keeping informed in the social media age: How technology and intelligence platforms can help keep your students safe

In the social media age, news travels fast – very fast. Twenty years ago, the internet was still in its infancy and social media was non-existent. Today, the average parent of a study abroad student, with discretionary time and a computer, can locate an extraordinary amount of information about the hazard landscape of their child’s destination country. You can also be sure if a safety or security incident happens, Facebook, Instagram and Twitter will inform them instantly.

Given the ease with which people around the world can communicate and access knowledge now, both parents and students expect that the administration is keeping tabs on their overseas programs and that if there is a problem, the administration is aware of it immediately. So how do program administrators keep up with all of the important news that is relevant to every country in which their students are traveling, particularly given the laser-fast pace that social media spreads a story?

There are a several ways to manage your intelligence information. A number of travel assistance providers offer risk assessments and breaking news updates. Additionally, some may partner with security information services. For example, International SOS works with ControlRisks. Another option is to purchase a stand-alone intelligence platform. Finally, there are some easy ways to put together a DIY option using a variety of free and open source platforms.

If your institution is operating programs in a wide number of countries and regions, one solution may be an intelligence monitoring platform, such as Global Momentum or red24. Such platforms contain up-to-date, extensive information about health, safety and security around the world. Both companies have large and experienced global teams of analysts and sophisticated data mining technology that produces comprehensive – and constantly updated – news feeds that highlight new and evolving risks around the world.

Both Global Momentum* and red24 can also be customized so that you only receive information relevant to the regions in which your programs operate. The Global Momentum platform is particularly user-friendly and easy to browse quickly, with three display modes to view information. Their “24x7 Risk Monitoring Dashboard” provides updated news feeds from around the world, the “Crisis Incident Map” shows how events are unfolding in space and time, and the “Real-time Situation Room” provides breaking news, social media feeds and other intel on any particular critical incident.

Global Momentum and red24 also provide breaking news alerts, as well as daily and monthly overview emails of incidents that may affect travelers. In addition, red24 is the intelligence partner for Terra Dotta’s new Alert Traveler app, which not only provides country intelligence to administrators, leaders and students but also can send real-time alerts and allow students to check-in. Watch out for our review of this and other safety apps in our next newsletter!

If your program is large and travels to diverse regions, one of these platforms may be a very worthwhile investment, but if your budget cannot stretch this far, or if you operate in just a few, lower-risk countries, you might be able to set up your own low-tech monitoring system for free. This type of solution won’t give you the speed and in-depth analysis of a professional monitoring system, and it will take more time and effort, but it’s certainly better than not doing any information acquisition at all. Here are some tools that may help you set up your own monitoring system:

·       Symbaloo – This free app allows you to create your own dashboard/homepage. In addition, it allows for multiple tabs to further narrow the scope of information monitoring for easy access to information that may be relevant to your programs. For example, you might add local news channels for each region, weather forecasts, RSS feeds, twitter feeds, and other sources of local health, safety and security information that you can quickly browse to keep abreast of news and incidents. Although it takes a bit to set up, particularly because of all the pre-loaded links that need to be deleted, it is worth the effort.

·       Emergency and Disaster Information Service (EDIS) is a platform based out of Hungary which provides a map of the world to monitor global events that may cause emergencies and disasters. It is powered by GoogleMaps and sourced through information in the knowledge database, automatically processed data and manually processed data. It allows the user to choose a region or simply zoom in on different locations. EDIS also has Facebook, LinkedIn and Twitter links for easy monitoring.

·       Weather alerts – Some countries offer SMS or email alerts for extreme weather events. Try googling the local meteorological service and see if they offer such a service where your programs are located.

·       Google alerts – You can set up a google alert to be notified via email when a certain search term appears in the news. This is a slightly tricky tool to use to monitor news for a whole country generally, but if you can limit the search to a particular risk (say, hurricanes) then this might be useful, particularly for lower profile incidents that may not have yet made global news.

·       RSS Feeds – You can set up your RSS reader to include news sources and information feeds for areas of interest relevant to your programs. For a handy guide to RSS reader apps, here is an article from Zapier.

 

*Lodestone Safety International is partnering with Global Momentum and can provide a free trial. If you are interested, please contact Lodestone directly at info@lodestonesafety.com.

How to Make Safety Reviews Work for You

A safety review should reduce the likelihood of harm to participants, staff and property; serve as a vehicle for stakeholder education and improved institutional alignment; demonstrate a commitment to due diligence in safety; and boost morale among staff.

So why do many reviews, embarked upon with expansive optimism and openness, conclude with contention between reviewers and reviewed; real potential for increased future liability exposure; a demoralized staff; and program managers who regret having the review undertaken in the first place?

Safety reviews can have tremendous benefit, but they are not without risk. And usually, when reviews realize more risk than benefit, it is for the same recurrent reasons. And, an experience of a poorly managed review is one reason why program managers often prefer to avoid them.

International NGOs, international service/education programs, adventure education, sail training programs, etc. all share the challenge of operating with limited time, money and personnel. Sometimes one of the most compelling reasons to have a review is to get outside expertise to gauge the impact of the deferred maintenance and other compromises that are an adaptive effort to operate in the face of limited resources. However, it is also true that safety reviews require time, money and personnel, which is another reason why program managers can be unenthusiastic about undertaking a safety review.

However, the primary risk associated with having a safety review is the potential for increasing your liability exposure. Anything that appears in a report is discoverable should your institution be involved in a future lawsuit. It would not be in the organization’s interests should that report include unrealistic recommendations for unbudgeted expenditures; or damning statements about the program. A whitewash of safety issues is in no one’s interest either. Where you want to end up is with realistic, constructive feedback on your program with practical recommendations that translate into actionable plans.

The key to having a robust, productive process is understanding the various components of a review and being aware of the potential pitfalls within each:

            Goals – Realistically, what do you want to have happen during the review and what do you want the impact to be on your organization? Making your program “safe” is not a realistic option. Identifying opportunities to reduce the likelihood of harm is. Equally important is to identify what you do not want to have happen. Safety reviews look at the edges of an organization’s limitations. It is important to avoid having the review become the focus of all organizational conflicts. If you are not explicit about what the goals are and are not, then every agenda will find a purpose for the review to serve.

            Process – This is about deciding who will participate at what level and in what role. It is about how communication will be managed. Foresight and clarity at this stage are important. At the outset there is an impulse to commit to full transparency and participation. However, assume unforeseen sensitive issues will surface. It is preferable that the process become more expansive in its openness and inclusiveness as it progresses rather than heading in the other direction. It is recommended that early decisions about who is invited to participate at various levels; who gets to see the final report, etc. are conservative. This is about setting expectations. Be strategic.

            The Review Team – Having someone poke around in your organization second guessing decisions and evaluating performance is an intimate process and should be treated as such. While a review team should include outside parties, you need to have trust in the team. Hiring your friends is a little too cozy. Including board members can be excellent on a number of fronts but they can also be problematic. The team not only needs to have within its members the appropriate level of technical expertise, but should also contain sufficient administrative experience to appreciate the challenges of making decisions within budgetary limitations. One common mistake is setting up the review team to think that they need to document every aspect of safety or their integrity will be compromised in the discharging of their duties. The review team’s mission should be addressed in the goals and the scope. Communication and clarity are important. Roles, goals and process need to be explicit. The safety review works for the program and executes according to stated goals and scope.

            Scope – You may know exactly what issues you’d like addressed in the review. However, there are a number of ways to identify all the issues that your stakeholders view as important. A simple surveying tool can be distributed to field staff, admin staff and/or board members. Participant evaluations should be reviewed. Incident reports, end of program reports, etc can all be mined for input. Keep in mind that investigations of significant incidents rarely identify one poor decision or action as being responsible for the incident. More usually, it is a combination of events from multiple levels of an organization. Once you have a broad based list of potential issues, then you can make choices for putting together a productive strategy.

            Plan and Review – The specific plan for review should be defined by the scope and be consistent with your goals. Field staff and administrative staff interviews, document reviews, program observation, infrastructure and site inspections, etc. should be assigned to specific reviewers and executed.

            Debrief – This stage of the review may be particularly sensitive. Deciding who is invited to participate should be thought through accordingly. Reviewers should bring up for discussion all their observations, and analysis. They should share the rumors they’ve heard and their subjective impressions. Reviewers may share their ideas for solutions well beyond what should appear in the report. Everything useful may be discussed. In the course of this meeting, the shape of the safety report should be agreed upon between the review team and the program. One potential way to help encourage the frankness of the discussion without creating discoverable documentation of sensitive issues is to stipulate that all review notes be handwritten and destroyed once the written review is finalized.

            Report – The written report should reflect the stated goals and scope. It should document the goals, the process, the review team, the scope and the specifics of the review. It should then report its conclusions and recommendations. It is not in the organization’s interest to have unrealistically expensive and unbudgeted recommendations made, nor to have damning observations committed to print. It should include the program’s observed strengths as well as providing direction for changes. What is working well? What are the easy steps? What are the more challenging issues and the longer term, multiple front strategies? Recommendations should be general. There are occasions, most usually having to do with personnel and financial issues, when it may be appropriate and useful to have an additional confidential report prepared for the board or some subset of stakeholders.

            Report Response – The organization should document a formal response to the review summarizing the organization’s experience of the review and indicating degrees of agreement (strongly agree, agree, disagree, strongly disagree) with each specific conclusion and recommendation. Where there is agreement, the general implementation strategies should be included. Where there is disagreement, the rationale should be spelled out clearly. Any additional strategic moves resulting from the review should also be included here.

            Safety Plan – To maximize the benefit of the review, the organization should create a safety plan based on the review. It may vary from the reviewers’ recommendations and it may exceed the scope of the review. For each aspect of the plan, there should be a designated point person, a time frame and criteria for completion. Periodic reviews of the safety plan should be scheduled in as well.

Safety reviews should be an invaluable tool for any program. Maximizing the benefits and minimizing the risks is a matter of awareness, forethought and attention especially early on in the planning process. If you manage the details well early on, the rest of the process should unfold in a manner that helps your organization do what it does in a more effective, professional and safer manner.  It should also assist in building a stronger more integrated organizational culture with a heightened awareness of health, safety and security.

You want to go WHERE? You want to do WHAT? Risk Managment Challenges in Non-traditional Locations

by Adam Rubin

When I first started in the field of international education many years ago, international educators often lamented the fact that the vast majority of their students limited their study abroad choices to the United Kingdom, France, Spain, Italy, and other traditional destinations.  Thanks to the development of new program models and an increased spirit of global adventure, it has now become quite common for students to seek study abroad opportunities in less traditional parts of the world.  For some students, these destinations offer a chance to get off the beaten path to explore environmental issues, participate in meaningful service-learning projects, or develop stronger language skills.  For others, less traditional locations help a student experience new political perspectives, step outside their comfort zone, and do something “unique” that will help them stand out from the crowd in future job interviews.  The rapid expansion of international programs over the past ten years has been truly exciting and wonderful in many ways, and study abroad professionals are now celebrating the fact that nearly 40% of U.S. college students studying abroad in 2014-15 went to non-European destinations.[1]

At the same time, it’s important for educators to understand that non-traditional destinations often require additional planning and special attention to potential risks.  While we all acknowledge that there are inherent risks involved with any domestic or international program, institutions and individuals should devote extra time and consideration to the challenges involved with international programs in low and medium income countries, programs operating in remote locations, and programs in politically-unstable regions.  Here are just a few key areas and questions that should be considered:

●       Emergency Contingency Plans

○       What are your specific triggers for program changes, suspension, cancellation, or evacuation?  Do you have proper Political Evacuation and Natural Disaster (PEND) insurance?  Do you know how it works?

○       Have you trained your staff to manage emergencies?  Have your contingency plans been practiced and reviewed?

○       Does your plan include academic contingencies associated with program disruption or cancellation?

●       Health and Mental Health Infrastructure

○       Have you done a proper assessment of local hospitals and clinics?  Do you have access to appropriate facilities when your group is traveling outside of the host city?

○       What is the state of mental health care in your host city/country? Are there English-speaking counselors readily available?  Are psychotropic medications legal in the host country?  How might those medications interact with other necessary medications such as malaria prophylaxis?

○       Are there specific issues, conditions, or challenges that should be given extra consideration when screening students for your program in this location?

●       Transportation Providers

○       What are the safest modes of transportation available to your program? Have your local transportation service providers been carefully vetted?

○       Have you carefully prepared a list of vetted and recommended transportation options for students to use during their daily commute and independent travel?

○       How might the local infrastructure impact your program’s overall schedule and content?

●       Unstructured/Free Time for Students

○       How can your program monitor independent student travel? Does it make specific recommendations to students regarding transportation, accommodations, and security?

○       What are some of the local high risk activities that might attract students? (bungee jumping, surfing, swimming, sky diving)? How can you manage those risks? Can and should certain activities be prohibited on your program?

○       Does your program conduct a bystander intervention training workshop during orientation?

●       Program Leadership

○       Do you have appropriately-trained staff to lead your programs in these locations?

○       Have you vetted the staff used by partner institutions (i.e. host university) or local service providers to help ensure that they are qualified and competent enough to support your program adequately?

○       Who is going to answer the phone at 2:00 a.m.?

●       Program Housing

○       How are local homestay families screened and trained? How do cultural issues impact your ability to screen local families?

○       How might concerns about fire safety, security, and local environmental issues impact your selection of program housing (residence halls, homestays, hotels, hostels)?

While these are all important issues and questions that should go into the risk management planning for any domestic or foreign student program, they become increasingly important for programs in low or medium income countries, locations with specific environmental or political challenges, and programs that include significant fieldwork and travel in remote locations.  By taking the extra time to plan carefully, you and your team will be better prepared to assess, manage, and mitigate risk.  And, you’ll be in a much better position to respond confidently when parents, senior school officials, and institutional risk managers question you about the overall safety of your programs. 

[1] Institute of International Education. (2016). Open Doors Report on International Educational Exchange. Retrieved from http://www.iie.org/opendoors


Adam Rubin has worked in the field of international education for over 25 years, including more than 20 years with the Council on International Educational Exchange (CIEE). He is the former Executive Director for Program Development and Evaluation at CIEE and also served as Senior Program Director for programs in Africa, Asia Pacific, and the Middle East, Director of Campus Relations, and Resident Director of the CIEE Study Center in Japan. Adam is a member of the NAFSA Trainer Corps, former member of the NAFSA Health and Safety Subcommittee, and a member of the Forum on Education Abroad Standards Committee. He served for two years as a member of the planning committee for the Forum Standards of Good Practice Institute, “Beyond the Basics of Health, Safety, and Security.” Adam also served as a board member for the World Affairs Council of Maine. He has presented nationally and internationally on a variety of issues and topics, including program development, health, safety, and security issues, community engagement, and developing and managing programs in non-traditional locations. Adam received his MA in East Asian Studies from Stanford University and a BA in Economics from Whitman College.

Lessons for International Programmes from the Christchurch, New Zealand Earthquakes

by Dr. Laura Sessions

In February 2011, I was in Christchurch’s central business district on a lunch break when a 6.3-magnitude earthquake struck. An immense roar culminated in 10 seconds of violent shaking. Buildings swayed, sidewalks buckled, facades crumbled, and people screamed. When it stopped, we were surrounded by clouds of dust, piles of rubble and crowds of confused and scared people.

At the time, I ran a study abroad service provider, and luckily we did not have any students in the area, but most of our staff were in a fifth story office in the hardest hit area of the city. Somehow we all managed to escape uninjured and evacuate the central city, but we saw some harrowing scenes. Water and silt filled the gutters and streets until eventually we had to roll up our jeans and wade barefoot through the deeper pools, trying not to think about what was in the murky water. We passed cars swallowed up by sinkholes, and brick buildings that lost their entire front facades, ending up like dollhouses with every room visible from the street. People gathered in their yards to listen to radios, as a thick cloud of dust and smoke spread outwards from the CBD.

This earthquake was New Zealand’s third deadliest natural disaster, killing 185 people and causing widespread destruction. At least 6,600 people were treated for minor injuries and Christchurch Hospital alone treated 220 major trauma cases connected to the quake. A cordon prevented public access to the CBD for over two years. If this earthquake had happened in a low or middle-income country with less efficient emergency response and infrastructure, the toll would likely have been much worse.

New Zealand lies on an active fault zone and earthquakes are experienced regularly, but still none of us were prepared for the scale of this natural disaster. Here are some of the lessons we learned that may help you to prepare your students and staff in seismically active regions.

Preparing for earthquakes

1)     Create a plan for where to meet. I was on a lunch break when the Christchurch earthquake struck, and most of my staff were in the office. Luckily, we were able to find each other in the chaotic aftermath, but it would have been much easier if we had made a plan for where to meet, along with a back-up location if our first choice wasn’t possible. Consider what structures might become unstable and where is likely to be a safe, open space to shelter. If you have students spread throughout a wider area, it will be even more challenging yet more important to know where everyone should gather. Consider creating maps that indicate all student and staff residences and each student’s primary and secondary rally points. Your office(s) should be indicated on the map as well as the location of fire stations, hospitals, etc.

2)     Think about communication. Directly after the Christchurch earthquake, phone lines were down and cellphone networks were overloaded. Calling anyone was virtually impossible, but texts still managed to sneak through. Ensure that students understand that they should text the appropriate person in your organization immediately following an earthquake to check in and establish contact. You may also want to consider having key staff carry a satellite phone or satellite texting device.

3)     Prepare emergency supplies. We were without power for several days, water for over a week, and without an operating toilet for several weeks. It could have been much longer (and was in some parts of the city). Especially in low and middle-income countries, road damage often means that large-scale rescue efforts cannot easily reach communities that need emergency assistance. If local resources are overwhelmed, it may be a few days before significant help arrives. Supplies should include drinking water (at least three gallons per person), non-perishable food (three days per person), toilet paper, soap, flashlights/batteries, first aid supplies, blankets or sleeping bags, and a radio. You might also consider a generator and fuel. Be sure to schedule annual checks of your supplies to replace water and expired food.

4)     Assign roles and responsibilities and use staff who don’t live in the area if possible. Everyone in our office was affected personally by the earthquake. Some lost their homes, others had injured or traumatized family members to look after, and everyone was dealing with the emotional strain of what had happened and the ongoing aftershocks. None of us was in a great position to be able to help students with so much going on in our own lives. Consider whether you could bring in staff from elsewhere to help in an emergency (although local staff will almost definitely need to handle the immediate aftermath). Think carefully about who will be responsible for students, who will communicate with families and the media, and who can administer first aid – while also managing their own families and personal circumstances.

During an earthquake

1)     Stay inside until the shaking stops and it is safe to go outside. Several people were killed by falling concrete as they ran from buildings onto the street where I was standing. Drop, cover and hold on whenever you feel shaking.

2)     Beware of fire and fumes. I still remember the mixture of gas and crushed concrete that wafted over the city that day. Fire is the most common hazard after an earthquake. Never use a lighter or matches near damaged areas and leave the area if you smell gas or fumes from other chemicals. If you can do so safely, shut off gas and electrical lines.

3)     Don’t go back into unstable buildings. I’m ashamed to say that I learned this one from experience. My laptop and phone were both in the office, and when I realized I didn’t know anyone’s phone numbers by heart, I panicked and went back in to find them. I managed to get back out unharmed, but I was just lucky. With all of the broken glass, falling debris, potential for fires, and constant aftershocks, it could have ended very differently. Keep your phone with you, memorize at least one relative’s phone number and keep a backup in the cloud.

After an earthquake

1)     Expect aftershocks. In Christchurch, there were more than 361 aftershocks in the week following the quake, some as big as magnitude 5.9. There were literally tens of thousands more in the hours, days, months and even years to follow. You need to be sure staff and students will not only remain safe during aftershocks, but also that their mental health is not affected. This may be a factor in your decision of whether to keep the program in situ or arrange for it to be moved or cancelled.

2)     Ensure all important files are backed up and easy to access outside the office. It was over three months before we could get back into our office building. Even then, two people were given access for one hour and could take only what would fit into two garbage cans. Luckily, we had our complete file server backed up remotely, and we were able to get back up and running within a week or so. Think about what you would do if your office was destroyed or inaccessible for any length of time, and make a contingency plan. In particular, consider what files you would need immediately, such as emergency contact details. How would staff work with no premises and possibly no computers or equipment? What equipment would you need to replace? How would you handle communications?

3)     Be prepared for lots of international attention. The media love a good earthquake, and I had people ringing me from overseas before I had even spoken with my husband in Christchurch. Be prepared for a quick response to families especially, who will be concerned about their loved ones. Be sure you have an easy way to disseminate updates and be sure that all stakeholders know where to look for them beforehand. For example, you could have an emergency page created on your website that can be activated if needed or communicate via Twitter or Facebook.

NOTE: As a result of her experience following the Christchurch earthquakes, Laura authored the book Quake Dogs.

First Aid Kits for International Trips

Should I be carrying a first aid kit?

What should be in a first aid kit?

What about antibiotics and prescription pain medications?

Epinephrine?

Bhutan First Aid Kit.jpg
 

International trip leaders frequently ask us about what they should be carrying in their first aid kits. The answer is invariably, “It depends.”

The first step in putting together a first aid kit for international travel is to ask the Safety Matrix® questions: the Who/What/Where/When/How/How long of your program.

  • Who – What age group and how many? Pre-existing conditions of group members?
  • What – Are you taking classes in a Western European city or engaged in wilderness adventure type activities, water based activities or field research type activities? Will the group divide up sometimes making it sensible to have more than one kit?
  • Where – Climate considerations? Local medical resources? Remoteness? Altitude? Sun? Dry/Wet?
  • When – Rainy season when there may be more rashes, slippery roads and more mosquitoes? Tourist season which may entail more crime or at least more alcohol? Will it be warm or cold or both?
  • How – What is your budget? Are you staying in high-end hotels that have first aid supplies or in home stays? How much do you want to spend on first aid kits? Will the kit be exposed to weather or to being crushed, etc.? Do you need to carry it on your back? Can a large kit be carried in vehicle or boat and smaller kits be carried?
  • How Long – Can supplies be easily replaced or is what you bring what you have for the duration?

The answers to these questions dictate what you should have for a first aid kit.

For war correspondents, safety in conflict zones may mean being able to travel light and fast even as they schlep heavy camera equipment while wearing body armor. They are often at high risk for sustaining life-threatening trauma. It makes sense for them to carry minimal first aid supplies designed to help a victim of trauma survive in the short term. To that end they may carry military grade tourniquets, tape, trauma dressings, a chest seal and tension pneumothorax decompression needle (an advanced scope of practice technique that wouldn’t be appropriate for lay persons outside of a combat zone). They are also often more at risk for travelers’ diarrhea, infectious disease and dog bites, but can access necessary supplies away from the conflict zone.

Some off-shore sailing programs operate in very remote areas. They may be more than 5 days away from the nearest port and well out of reach of helicopter rescue. They are legally permitted to carry advanced equipment and medications.  That doesn’t necessarily mean that they should. Inexperienced and untrained persons should not be trying to put in intravenous lines or insert endotracheal tubes. Off-shore sailing vessels usually have excellent communications and can be in frequent contact with medical professionals so including prescription medications makes sense.  Weight is not a consideration per se, so carrying bottled oxygen makes good sense as well.

For educational travel, if your program is operating in a high income country capital city with excellent medical facilities, where emergency medicine is a distinct discipline and where an ambulance is likely to show up within 10 minutes of calling the equivalent of 911, it might make sense just to advise students to carry whatever over the counter medications that they might need and not bother with a group first aid kit. If you are in a low-income country and conducting research in a remote area, it might make sense to carry an extensive first aid kit.

RULES OF THUMB

  • Ready-made commercial first aid kits are not usually a good value. They appear as if they are well stocked, but the bulk of the kit is packaging for individual doses of over the counter (OTC) medications. They usually include items you don’t want and lack important items that you do want.
  • A good organizer is worth the expense. There are very good soft pouch style and belt-pack style organizers available from outfits like Conterra®
  • If you are operating in a marine environment, you’ll need a waterproof hard box style organizer, e.g., a Pelican Case. If you are on a limited budget, small stuff sacks or Tupperware containers will suffice.
  • Don’t bring anything that you don’t know how to use.
  • Don’t bring multiple items that do precisely the same thing. You might choose to bring more than one NSAID (non-steroidal anti-inflammatory drug) like aspirin and ibuprofen because, while they both are comparable for managing pain and fever, aspirin has higher anti-clotting properties for someone who might be having a heart attack and ibuprofen has superior anti-inflammatory properties for sports injuries, etc. On the other hand you don’t need to bring 3 separate products for fungal vaginitis, athlete’s foot or jock itch. One antifungal should suffice.
  • Utilize items that have multiple uses. A 60cc syringe (no needle) is excellent for cleaning wounds and for suctioning airways. In a pinch, it works great for administering an enema.
  • Don’t store non-medical items (sun block, bug dope, tampons, etc.) in the first aid kit.
  • Do not store personal prescription medications in first aid kit.
  • Don’t bring goofy stuff, i.e., snake bite kits or tick pliers.

BASIC FIRST AID KIT

The list below is put together with the idea of keeping it simple. You could easily double the number of items here by adding fancy tools, high tech bandages (Gore-Tex impregnated with antibiotics, etc.) and a broader range of over-the-counter medications. However, for most issues, the kit below should suffice. Quantities of bandages, OTC medications, etc. would be determined by length of program, nature of activities and destination country.

Tools

  • Multiple pairs of latex or vinyl gloves (blood borne pathogen protection)
  • Bandage scissors
  • CPR mask or NuMask
  • 30cc or 60cc syringe (wound irrigation)
  • Tweezers
  • Thermometer
  • SOAP notes (standardized format for recording and organizing medical information) and pencil
  • Safety pins

Bandages/Dressings

  • Major trauma dressings
  • 4 x 4 dressings
  • Roller gauze (3“)
  • Athletic tape (better than medical tape)
  • Band-aids
  • Elastic bandage (“Ace wrap”)
  • Triangular bandages (cravats)

Topical Medications

  • Povidone-Iodine or Betadine for wound care
  • Bacitracin/Triple Antibiotic Ointment
  • Hydrocortisone Cream – Anti itch cream
  • Antifungal cream

Over the Counter Medications

  • NSAIDS, (ibuprofen)
    • Aspirin – Do not give aspirin to children (Reyes Syndrome)
  • Acetaminophen (Tylenol)
  • Imodium
  • Pepto-Bismol
  • Antacid tablets
  • Diphenhydramine (Benadryl)

Other

  • Epinephrine – EpiPens or ampules/vials with syringes for use in the event of life threatening system allergic reactions (anaphylaxis). Requires training and a prescription in the U.S.

NOTE: A number of programs do not do this because their participants with a history of anaphylaxis bring their own epinephrine. Understand that while food allergy history is predictive to a significant degree, 50% of people who die of anaphylactic reactions to bee stings and other hymenoptera exposures, have no history of significant allergic reactions.

Optional Recommended Additions

  • Trauma shears
  • Stethoscope – For listening to lung sounds if spending significant time in water based activities or at high altitude
  • Kelly Forceps – May be useful for stopping bleeding or wound exploration and cleaning
  • Small Magnifying Glass – To assist in wound cleaning and for distinguishing small ticks
  • MoleFoam or 2nd skin - For blisters if hiking
  • Burn dressings
  • Small flashlight

ADVANCED FIRST AID KITS
If you are traveling in low/middle income countries and/or in remote locales, it might make sense to consider carrying a few prescription medications. These should be managed either by protocols written out by the prescribing physician or preferably by digital communication oversight (tele-medicine). Do not put program leaders into a position of practicing medicine. There is a reason why physicians undergo extensive schooling.

Antibiotics might include 1 – 3 broad-spectrum antibiotics, each intended to address a particular type of issue. One for butt/belly problems, one for wound infection and one for ears eyes nose and throat, etc. Your advisory physician might decide to include prednisone to stabilize an immune system if a student had an anaphylactic or asthma problem during the program.

Prescription pain medications are not generally recommended for most first aid kits. Carrying them can engender legal complications and there is potential for abuse.

Bill Frederick is the Founder and Director of Lodestone Safety International

What Do You Mean That Trail Was Safe? Cross-Cultural Risk Management in Developing Countries

What Do You Mean That Trail Was Safe? Cross-Cultural Risk Management in Developing Countries

Risk management in any context can be challenging, and crossing cultures can add some unexpected twists on risk management. This essay seeks to talk about some of the unexpected challenges and ways to deal with risk management in a cross cultural and developing country setting.

In a same-culture setting risk management is challenging enough. Clients have different backgrounds and don’t always fully disclose physical or mental health issues, the environment may have unexpected hazards, and rules and regulations can vary widely within a country or state.

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Should Study Abroad Programs Carry Epinephrine?

Mari Dark of Naropa University recently posted a question to the SECUSS-L listserv asking if members included epinephrine in their medical supply kits for faculty led trips. She received 13 responses: 9 argued against it and 4 were for it.

She reported that the majority of respondents’ programs did not provide epinephrine. Presumably that also means that their programs do not authorize carrying epinephrine. This distinction is important as illustrated by the University of New Hampshire faculty leader whose trip to Nicaragua was cancelled in 2013 and whose appointment was not renewed by the University after it came to light via her submission of an invoice that she carrying unauthorized epinephrine on program.

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Safety vs. Liability in International Risk Management

In most aspects of international risk management, safety and liability fly in formation. When you are working to improve safety, you are reducing your liability exposure and vice versa. However, there are some areas where safety and liability come into conflict.

Safety is generally spoken of as a good with the implication that more is better. And, while safety specifically refers to freedom from accidental harm, it is most generally used to refer to freedom from all harm (folding in both illness and intentional harm).

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