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Health in North Caucasus - Feb 2000

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Newsletter on International Humanitarian Health Assistance
Compiled and distributed by the World Health Organization
A War on Public Health

In launching the UN appeal for North Caucasus in Geneva in November, Gro Harlem Brundtland, the Director General of WHO stated: "Every conflict, every war is a war on public health." - This is certainly true in this conflict, and even worse, the invisible injuries might be the most damaging.

Public health in emergencies is not only water, food, sanitation, statistics, communicable diseases and vaccines. Public health is to be seen in a holistic perspective, including physical, social and mental wellbeing, in needs assessments and responses.

The notions of vulnerability and resilience at the individual and community levels and of risks and protective factors underscore the complexity of the interaction between the violence of war and the psychosocial impact of war, the development of psychosocial dysfunction and trauma. There is no simple cause-effect relationship that explains mental distress and pathology.

Today, there is sufficient evidence of the fact that the majority of war-affected populations do not develop mental disorders as a result of the violence that they directly or indirectly are subjected to. Yet their distress and suffering, the psychosocial and economic destabilization should not be underestimated. These conditions, if not attended to at the earliest, may cause long-term individual and community disability to the extent that economic survival, peace and reconciliation are affected.

The most vulnerable, the children, the elderly, the unaccompanied minors, the orphans, the chronic mentally ill, the disabled, the widows, the tortured and sexually abused, always pay the highest price.

An extraordinary effort is currently being made by the host communities and national relief structures in the Caucasus to respond to the plight of the displaced populations. Much is being done, with very limited resources, to help the displaced simply survive and to prevent aggravation of the trauma and to bring some normalcy in the psychosocial life of the displaced.

To regain hope and dignity, to feel part of a whole that cares is very important. Certainly this does not heal the scars. But it is a step forward to recovery and normalcy. The international community, including UN agencies and international NGOs, support these efforts. But much remains to be done.

UPDATE ON HEALTH STATUS AND LIVING CONDITIONS OF IDPs

Tuberculosis

TB rates have been increasing steadily in recent years in the North Caucasus. In Ingushetia, the incidence rate (new cases detected) in 1997 was 67.8 per 100 000 population; in 1998, it was 82.2 per 100 000. For 1999, official figures are not yet available but are certain to show an increase.

In Chechnya, incidence rates have not been reported to federal health authorities in the last few years, and no treatment has been available, so that needs have been accumulating. (According to Ministry of Health, Ingushetia (MoH/I), the TB rates in Chechnya are twice the Russian Federation (RF) average of 73.9 per 100 000). A large number of IDPs are therefore now seeking medical assistance in Ingushetia.

Until 1 January 2000, screening efforts initiated by the MoH/I, resulted in 9241 IDPs X-rayed, and 103 TB cases diagnosed, of which 7 were children. 264 smear exams were done on the IDPs, only 14 (or 5 %) are described as positive. This low positivity rate is cause for concern, and is presumably a reflection of the state of the laboratory services.

Registering of TB cases is complicated, and the different figures given are not consistent. If we use the highest number of cases, as reported on 3 February, there were 197 cases among the IDPs in Ingushetia. Based on an IDP population of 200 000, this gives a rate of 95 per 100 000. This, however, expresses the prevalence, as it includes both new and old untreated cases.

In the Sleptsovskaya TB dispensary during the period from the end of September to the end of the year, we were informed they had diagnosed 71 cases of active TB, of which six were sputum smear positive. The chief doctor of the republican TB dispensary reported that many of the TB patients from Chechnya were presenting in late stages of the disease, and had been sent to other parts of RF for treatment. Several deaths have occurred amongst this group.

Tuberculosis in Stavropol

On 20-22 December 1999, a workshop was held in Stavropol regional clinical TB dispensary on microbiological methods of TB diagnosis. This was organized by WHO funded by the United Nations High Commissioner for Refugees. The workshop was attended by phthisiologists and laboratory assistants of medical facilities of cities and regions of Stavropol krai. The workshop consisted of practical sessions on TB diagnosis by direct microscopy. Participants were also provided with updated literature. At the end of the practical sessions, all the 93 doctors and laboratory assistants mastered the method of direct sputum microscopy. In order to study the working conditions in the field, the organizers of the workshop arranged a number of visits to hospitals and policlinics of Stavropol krai.

Microscopes for the workshop were provided by UNICEF. Upon completion of practical sessions, they were transferred to medical institutions of Stavropol krai.

Water and sanitation

Water supply in Ingushetia is a long-standing problem. Even in areas supplied through public water supply systems, water is available for only a few hours a day. In Aki-Yurt and Karabulak, there is one tap for 500 persons, with water running only two hours per day, supplying far below the recommended 15 liters/person/day. Presently, only 40% of total underground water capacity is utilized through the public water systems. Out of the waater produced, 40% is lost due to leakage from dilapidated water pipes. There is no capacity for treatment or monitoring of the water quality. With the influx of IDPs, the number of people in need of water has almost doubled. Not all camps have running water, and supply by water tankers has to be provided. The situation with sewage system and sanitation is even more critical.

According to the UNHCR household survey, on average 19 IDPs share one toilet/latrine. Some 12% of IDPs share one latrine with 30 others. In many of the camps, there are no showers and no facilities for washing clothes. For instance, in the Sputnik tent camp there are about 40 mothers with infants without opportunity to wash diapers.

The control of overall hygienic conditions in refugee settlements, health institutions, schools and social welfare facilities is an insurmountable problem for the state sanitary service. A high proportion of people with lice and scabies needs urgent treatment. The situation is aggravated with seasonal migrations of insects and rodents to human settlements. SES urgently requests assistance with disinfectants, anti-lice shampoo, insecticides, anti-mice and anti-rodent agents and a vehicle with a chamber for "de-pediculosing "of clothes and bed linen.

(WHO/UNICEF/IOM health assessment inIngushetia, 31-1-6.2.00)

This newsletter is not an official WHO publication. The information is compiled by the WHO Unit for Emergency Health Coordination for North Caucasus, and intended for public information. For comments, please contact: par@who.org.ru or Irina Tarakanova tel 8 (501) 414 08 25. Contact address of WHO in Moscow: 28 Ostozhenka str, tel. 8 (501) 414 08 25.

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