Russia

Health in North Caucasus - Jan 2000

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WHY NOT TUBERCULOSIS DRUGS ?
Any agency involved in health in North Caucasus, will be met with concerns about tuberculosis, and this regardless of whether you talk to health authorities or lay people. And indeed, the situation concerning TB in the North Caucasus is serious and rapidly deteriorating.

TB rates have been increasing steadily in recent years in North Caucasus. In Ingushetia the incidence rate (number of new cases detected) in 1997 was 67.8 per 100,000 population, in 1998 it was 82.2 per 100,000. For 1999 figures are not yet available, but are certain to show 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. A large number of IDPs are therefore now seeking medical assistance in Ingushetia, where there is a general lack of equipment and TB drugs.

In this situation, it might be difficult to understand that the health coordination meeting has decided not to supply anti-TB drugs. The reason for this is simple, and relates to the basic rule of medicine: "Do no harm!". Experience throughout the world has showed, that it is better not to do anything, than to provide drugs and treatment in an uncoordinated way that may give rise to further resistance to the common anti-TB drugs.

For this reason, WHO and UNHCR among others, have called on non-governmental organizations to stop distributing anti-TB drugs outside integrated TB control programmes.1

A TB control programme should not commence until after the immediate emergency phase, when mortality rates are normalized, basic needs are provided, and essential clinical services and supplies are available. It should be implemented only if the security situation is stable and the displaced populations are expected to remain for at least 6 months. Funding should be available for at least 12 months, along with sufficient medical supplies and trained staff.

The unstable migratory population flows in North Caucasus make DOTS or other treatment programmes not feasible for the time being, - with the possible exception of some small geographical areas or institutions, like prisons or long term mental hospitals.

Until migration in North Caucasus has normalized, external assistance would most wisely be directed towards more cost-effective diagnostics, such as training and laboratory equipment for sputum microscopy . Both the local stable population and the IDPs would benefit from improved diagnostics. Improved capacity for direct sputum microscopy would subsequently prepare the ground for later implementation of TB treatment programmes.

HEALTH PROVISIONS IN THE UN APPEAL FOR NORTH CAUCASUS

Health & Nutrition

UNFPA aims to ensure that IDPs have access to basic reproductive health services. Basic delivery care will be provided. The reproductive health infrastructure will be upgraded and local health personnel trained in the distribution and use of equipment.

UNICEF will support immunization services through provision of cold chain equipment, syringes and other vaccination-related supplies. Essential drugs for three months, basic health kits and essential medical supplies will be provided to primary health care facilities. Training of local health personnel in case management of acute respiratory infections and diarrhoeal diseases in infants and young children will also be undertaken in co-operation with health authorities in Ingushetia and Dagestan.

Supplements of micronutrients: Limited quantity of high-energy biscuits and a locally produced UNIMIX food equivalent for young children. Vitamin A capsules to all children in connection with measles vaccination. Iron tablets with foliate supplement will be provided for pregnant women.

WHO will supply kits containing essential drugs and medical supplies, coordinate an effective intervention from all humanitarian organizations in the health sector, assist in strengthening the capacity of the health care services to collect, analyse and disseminate accurate and timely information within the context of a complex emergency. WHO will also assist local health services in control and prevention of communicable diseases.

Water & Sanitation

UNHCR will focus on improving access to potable water by providing water tankers, repairing water pipes and establishing systems of garbage disposal, as well as emptying of latrines and septic tanks.

UNICEF will provide collapsible water bladders, jerry cans, water purification tablets and chlorine powder, medicated soap and disinfectants. In addition to training of volunteers in the camps, and social and health personnel on general sanitation and personal hygiene. Simple health and sanitation messages will be disseminated.

What is DOTS?

DOTS stands for Directly Observed Treatment Short-course, and is the most effective strategy available today for the detection and cure of TB. The strategy depends on five critical elements:
  • Government commitment to sustained TB control.
  • Detection of infectious TB cases using sputum smear microscopy and culture.
  • Standardized, short-course anti-TB drug regimens of six to eight months. Patient supervision by health worker to ensure that each dose is taken.
  • An uninterrupted drug supply for the treatment of all TB patients.
  • A recording and reporting system for monitoring treatment outcome and evaluating the programme.
IDPs IN HOST FAMILIES IN INGUSHETIA

During December 11 - 13, 1999, UNHCR carried out a random sample survey of IDP host families and spontaneous settlements(excluding IDP camps) in Ingushetia , which included a few questions relating to health. The main needs identified were:

  • To increase food deliveries from the present 12% coverage of standard needs
  • Protection against cold
  • Improve the water and sanitation situation

Water and sanitation were identified as some of the most urgent sectors to be improved. Some 20 % of the IDPs have no close access to running water and only every fourth family has a jerry can. On average there are 19 persons sharing one latrine/toilet and in a few families this figure hovers between 50 and 70 persons.

The most prevalent disease reported was ARI (17% of the IDP population) , which can be attributed to overcrowding, the exposure to cold and lack of adequate nourishment. 4,5% of the IDPs reported to have diarrhoea.

IDPs reported 13 cases of measles. 63 % of the IDP children had been vaccinated against polio, and 38 % against measles/diphtheria. On average the vaccination was administered one year ago. 57 % of the IDPs had to pay for the medical treatment they had received.

It is also worth noticing, although no questions relating to mental health were asked , that :

  • 7% of the IDPs had relatives who were killed or injured in Chechnya
  • 16% of the IDP family members remained in Chechnya, - the majority of the IDPs has no contact with their relatives inside Chechnya,
  • 13% of the IDPs indicated that they had witnessed harassment of women
  • 8% of the IDP children are separated from their parents and under the care of friends and relatives.

The survey report is available electronically at WHO information centre.
DEMOGRAPHIC DATA
  • female headed households: 70%
  • Avg. IDP family size: 8.23 persons
  • 44% of men, 56% women
  • Children under 18 years of age: 45%
  • Women and children: 78%
  • 36% of the children are in primary school and 34% in secondary school age
  • 48% of children in school age attend school
  • adult females (18-60): 61%
NEEDS

The most urgent identified needs indicated by the IDPs are (in order of priority):

  • food
  • adequate water supplies
  • improvement of sanitary conditions
  • winter clothes and shoes
  • medical care including vaccination
  • improvement of shelter conditions
  • sanitary napkins
  • beds, mattresses, bed sheets
  • fuel, kitchen sets, heaters
SECTORAL DATA
  • food assistance received by IDPs in host families covers 12% of caloric needs
  • 69% of the IDPs transport their relief items by foot for an average of 1,35 km.
  • 44% of IDPs received financial aid or other contribution
  • 19 persons share one toilet/latrine (avg.)
  • 12% of IDP population have to share a toilet/latrine with 30 or more persons
  • 80% have access to running water
  • 25% of IDP families own a jerry can
  • 2.8 m 2 covered surface per person (avg.)
DATA ON HOST FAMILIES
  • 38% of IDPs are related to host families
  • On average a host family accommodates 14.52 IDPs (usually 2-3 IDP families)
  • Average family size of host family: 5.51 persons
  • 27% of IDPs in host families contribute to upkeep
  • 1.2 % of host families have received humanitarian assistance.
Coordination of Drug supplies

In the interagency health coordination meeting in Moscow on December 3, it was decided that WHO should coordinate the drug supplies, in order to avoid gaps and duplications. For this reason, we request all agencies who are intending to supply drugs to send us information concerning:

1. name of drug
2. quantity
3. date of delivery
4. where delivery is planned

It is only if we get this information in advance, that we may be able to point to areas in greater need, and assist the agencies in prioritising.

Guidelines for Drug Donations

In cooperation with the major international agencies active in humanitarian relief, WHO has developed guidelines that describe "Good Donation Practice". These were last revised in 1999, the following is an extract of the main points. The full text is available electronically at WHO’s information centre.

All donated drugs should be approved for use in the country and appear on the national list of essential drugs or on the WHO List of Essential Drugs.

The presentation, strength and formulation of donated drugs should, be similar to those of drugs commonly used in the country.

All donated drugs should be obtained from a reliable source and comply with quality standards in both donor and recipient country.

After arrival all donated drugs should have a remaining shelf-life of at least one year. Dates of arrival and expiry must be communicated to the recipient well in advance.

All drugs should be labelled in a language that is understood by health professionals in the recipient country. The label on each individual container should contain the generic name, batch number, dosage form, strength, name of manufacturer, quantity in the container, storage conditions and expiry date.

Recipients should be informed of all drug donations that are being considered, prepared or actually under way.

Core principles for a donation

1. Maximum benefit to the recipient
2. Respect for wishes and authority of the recipient
3. No double standards in quality
4. Effective communication between donor and recipient

WHO INFORMATION SERVICE
for international health agencies, rendering assistance to North Caucasus

WHO has established a small information service to assist new agencies coming in to work/review the possibilities to work in the health sector in the North Caucasus. We can provide you with Ministry of Health’s detailed requests for assistance, WHO guidelines, assessment reports, useful addresses etc.

Also, if your organization has reports you think would be useful for others, and you would like to share them, we would be happy to include them on the list. Inquiries to: who@iom.int - If you do not have e-mail, please bring a diskette for copies.

Some of the available reports:

  • List of useful addresses
  • Minutes from health coordination meetings in Moscow and Stavropol
  • Handbook for NGOs in North Caucasus
  • Guidelines for drug donations (available also in Russian)
  • WHO Essential Drug List
  • WHO: Declaration of cooperation. Mental Health of Refugees and Displaced Populations in Conflicts and Post-conflict situations (available also in Russian).
  • WHO: Mental Health of refugees (only hard copies in Russian available)
  • WHO: Tool for the Rapid Assessment of Mental Health Needs of Refugees and Displaced populations (available also in Russian).
  • Vaccination schedule of the Russian federation
  • UNHCR’s household survey of IDPs in host families and spontaneous settlements
  • Infant feeding in emergencies/A guide for mothers
  • North Caucasus Emergency Health Update
  • List of requests for assistance from MoH/RF, MoH/D, MoH/I

Vital statistics of IDP population

Health data on the Chechen population has not been available at federal level for the last few years, we therefore, do not have a very clear picture of the health status of the population prior to the conflict. What we do know, is that much of the health infrastructure has been working on a low level, - if at all.

Based upon the data provided to us by MoH/Ingushetia, the CMR among the IDP population is not alarmingly high, we have calculated it monthly during the conflict to be less than 1 per 10,000 per day. Casualties due to the armed conflict are not included.

Perinatal mortality rates in the IDP population from Oct 1 st , that we have calculated to 36,9 per 1,000 live births - based on the data provided by MoH/I, compares relatively well with the rates of the home population of Ingushetia.

Maternal Mortality Rates are not available from MoH/I. In general, it is however, worthwhile noticing, that whereas the Ingush health authorities are overwhelmed by the influx of IDPs, and statistics not available or trustworthy, the Dagestani MoH - with more order in the paperwork: reports a significant increase in MMR. (1998: 46,5 per 100,000 ,- during first 9 months of 1999: 57.6.)

News in brief

Interagency coordination meetings for North Caucasus, covering Health & Nutrition and Water & Sanitation, are held twice a month in Moscow and once a month in Stavropol. All agencies with activities in these areas should link up with these. Invitations and information at WHO/ Emergency Health Coordinator for North Caucasus. Next meeting in Moscow on January 14 th at IOM, Second Zvenigorodskaya street no 12, at 14:00 .

There is also an Interagency Meeting on Health Co-ordination in Russia taking place in Moscow every last Thursday in the month. This meeting is chaired by the agencies on a rotation basis, Office of Special Representative of the WHO Director General is functioning as secretariat for this meeting. Next meeting Jan 27 th . The meeting will take place at the EU building at 16:00 hours.

WHO is weekly updating a web site on the emergency health situation in North Caucasus. You will find it at http://www.who.dk/Ch/Cor/welcome.htm

"North Caucasus NGO monitor" is an information bulletin produced by members of the Nonviolence International - Newly Independent "North Caucasus NGO monitor" is an information bulletin produced by members of the Nonviolence International - Newly Independent States (NI-NIS) that tries to explore new approaches for humanitarian activities in the community. You will find them at http://www.glasnet.ru/~ninis For questions, comments and additional information, please contact them on tel. (095) 206-8618 or 351- 4855 or on ninis@glasnet.ru

Mental health of refugees

This WHO/UNHCR manual aims to teach relief workers, health care personnel and schoolteachers who provide support for refugees, how to recognize people with high levels of stress and teach them how to cope with it, understand what "functional complaints" are and recognize and help people with such complaints, help women who have been raped, understand the development needs of refugee children, help victims of torture and other violence, recognize common mental disorders and deal with alcohol and drug problems.

Mental health of refugees has been translated into Russian, and is available from UNHCR in Kiev. 1000 copies are earmarked for North Caucasus. The WHO information centre for North Caucasus has a few copies for the first requests.

Footnote:

1 WHO/UNHCR: Tuberculosis control in refugee situations. An inter-agency field manual.