Russia

North Caucasus Emergency Health Update No.11

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Posted
Originally published
Health assistance to the population affected by the emergency.
Compiled by WHO.

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Health assistance within Chechnya

On 6 March, the All-Russian Centre for Disaster Medicine, "Zaschita", reported that 18 hospitals and 57 feldsher/obstetric posts (out of existing 27 hospitals and 70 feldsher-obstetric posts) were in operation in Schelkovsky, Naursky, Nadterechny, Gudermessky, Groznensko-Selsky and Achkhoi-Martanovsky regions of Chechnya. As of 1l February, a "Zaschita" field hospital started working in the city of Grozny. It has a staff of 43. As of 23 February, medical assistance had been rendered to 1200 persons. When needed, sick and wounded are evacuated to medical institutions in Argun, Mozdok, Znamenskoe and Nadterechnaya.

Medécins du Monde (MDM) provides basic medical kits to IDP camps in Sernovodsk and renders medical aid and mental health assistance in IDP camps in Gudermes and Argun. Has also provided surgical kit to Gudermes hospital.

According to MDM, the situation is extremely difficult with regard to food and medical aid.

Demographics

According to the Danish Refugee Council's (DRC) recent re- registration, there are about 185,000 IDPs still in Ingushetia.

An estimated number of 30 - 50,000 have returned to Chechnya.

There are 19 camps and 182 spontaneous settlements in Ingushetia, but the majority of IDPs are living within host families.

Both in Ingushetia and Dagestan, women and children make up an overwhelming majority. According to the UNHCR household survey, 78 % of the IDPs are women and children.

According to the DRC survey, vulnerable groups are composed of:

Pregnant and lactating women 1.5 %
Infants under 12 months 2 %
Children between12 -36 months 5.5 %
Physical or mental handicaps 2 %
Elderly over 65 years with out adequate family/social support 4 %
Children up to 14 years without adequate family/social support 0.7 %
Single -parent families 1.6 %
Totally dependent on humanitarian aid 83 %.

Health status

Based upon the data provided to WHO by Ministry of Health, Ingushetia (MoH/I), the crude mortality rate (CMR) among the IDP population is not alarmingly high. We have calculated the CMR monthly during the conflict to be << 1 per 10,000 per day. Casualities due to the armed conflict are not included, as such figures have not been available.

Perinatal mortality rate in the IDP population in Ingushetia from 1 October to the end of the year, is 33.06 per 1,000 live births. This compares relatively well with the rates of the home population of Ingushetia: 40.6 perinatal deaths per 1,000 live births.

Maternal Mortality Rate of the total Ingush population is 100,5 per 100,000, - based on 7 maternal deaths, 2 of whom were IDPs.

The MDM report on the health status of the survivors from Grozny states: "The psychological trauma is serious for 100 %, skinniness for 80 %, - of whom 20% are extremely thin, anaemia 70 %, gastrointestinal problems 40%, dermatosis 30%."

Morbidity

In the IDP settlements the most widely spread diseases are lice and scabies, anaemia, acute respiratory infections, diarrhoea, urinary tract infections, nervous complaints, and exacerbation of chronic diseases.

Public health

Communicable diseases:

So far, we have not witnessed any serious acute epidemics among the IDP population. The main problem is TB.

In Dagestan, the number of cases of acute dysentery and viral hepatitis have increased, and infectious diseases not encountered for many years are re-emerging, i.e. tularaemia, anthrax, rabies, malaria.

Also in Ingushetia, there is an increased risk of plague and tularaemia (particularly in the Malgobek region) due to seasonal migration of rodents from fields to settlements. One case of malaria was reported in 1999.

HIV/AIDS is not as yet a big problem but with the inadequate blood testing and transfusion services, the increasing drug abuse, the chronic sexually transmitted infections, there is every reason to introduce preventive measures.

Vaccination

MoH/I has performed catch-up immunization of more than 22,000 IDP children. Vaccine has been supplied by MoH/RF.

Shortages in supply of syringes and needles are reported, as is a lack of hepatitis A and rubella vaccine.

Tuberculosis

TB rates have been increasing steadily in recent years in North Caucasus. In Ingushetia, the incidence rate 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 increase.

In Chechnya, incidence rates have not been reported to the federal health authorities in recent 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. Many of these are presenting in a late stage of the disease, and several deaths have occurred in this group.

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. Two hundred and sixty-four smear tests were done on the IDPs, of which only 14 (or 5%) are described as positive.

As reported by the MoH 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, includes both new cases and old untreated ones.

In Dagestan, the TB incidence rate for the first nine months of 1999 is reported at 62.2, down from 77.7 in 1998.

Water and sanitation:

In Chechnya centres of state sanitary epidemiological inspection in the Naursky, Nadterechny and Schelkovsky regions exercise sanitary and bacteriological/ chemical control of drinking water.

In Ingushetia, water supply is a long-standing problem. Even in areas supplied through public water supply systems, the 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. Presently, only 40% of total underground water capacity is utilized through the public water systems. Of water produced, 40% is lost through leakage in 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 IDP camps have running water, and supply by water tankers has to be provided. The situation with regard to sewage systems 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.

A high proportion of people with lice and pediculosis need 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 chamber for "de-pediculosing" of clothes and bed linen.

Dagestan likewise has a general problem with the quality of the drinking water. Waterborne infectious diseases are common, including typhoid and hepatitis A.

Ecological situation of Chechnya

The ecological situation in Chechnya is extremely poor. The soil is soaked with oil and toxic by-products, rising with the ground waters. The land had barely recuperated from the last war.

Mental health:

There can be no doubt that recent events will have a long-lasting impact, not at least on children, - some of whom have just relived their second war experience and had wounds reopened.

From the UNHCR household survey of non-camp settlements:

  • 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.
CPCD provides psychosocial assistance to children in four IDP camps (1 in Sleptsovskaya, three in Karabulak). MDM has psychological rehabilitation centre for children in two IDP camps in Ingushetia and two in Chechnya.·

The clinical impression after interviewing a number of health personnel and teachers is that there are lots of untreated serious mental health problems in the IDP population. Psychotropic medication has not been widely available prior to the conflict, and also in Ingushetia it is not easily accessible.

Drug abuse has increased in Ingushetia lately, and is said to be linked to the much wider abuse inside Chechnya.

According to MoH/I data for 1999, there are 26.4 registered cases of drug abuse per 100,000 population.

Reproductive health:

In Ingushetia, poor antenatal care, lack of basic materials and hygiene supplies contribute to high maternal and perinatal mortality rates.

Three quarters of all pregnancies in 1999 were complicated by disease.

There is a high proportion of deliveries with surgical interventions (62% of all deliveries in 1999). This is reflected in the structure of post-neonatal mortality: 31% new-borns with CNS trauma, 33% with ARI, 11% with other infections.

The reported death rate at the paediatric intensive care unit was 59.4%.

Relief agencies report numerous cases of breastfeeding disorders among IDP women with infants. IDP mothers state stress and overcrowded conditions as a major reason for the cessation of breastfeeding. Infant formula is expensive, but widely available.

Drugs and supplies:

Rational drug use would reduce the needs

Medécins san Frontières-Holland's (MSF-H) patient interview in Ingushetia found the average number of drugs rescribed per patient to be 6.6.

Less than half of the drugs prescribed were included on the MSF list (43.1%).

The most common drugs not on the MSF list were also those most usually needed by patients, i.e. Analgin (metamizole sodium), Dimedrol (diphenhydramine), Procaine, Vitamin B1, B6 and B12 injections, Heparin, Potassium and magnesium asparate injections, and Captopril.

Many of the prescribed drugs that patients buy are not essential drugs. Rational drug use by the doctors and patients would likely reduce the amount of drugs prescribed as well as the amount needed to be bought by the patients.

In general, hospitals are better stocked than ambulatory health posts, as the central pharmacy is located at these facilities. The central pharmacy then redistributes the medical supplies to several ambulatory facilities. This may partially explain the higher proportion of drugs given free in the hospital compared with the polyclinics.

Health care services

For several months now, Ingushetia's health care system, normally providing for about 320,000 inhabitants, has been faced with additional 200,000-250,000 persons. The extra workload on an already exhausted service, with depleted stocks of drugs and expendables, represents a formidable task. The MoH, Russian Federation (RF) covers more than 95% of the health care budget.

The total number of medical institutions in Ingushetia is 64. In 19 IDP camps, there are 10 medical points. Nine camps have both doctors and nurses, and six have only nurses.

Hospitals

All in all, there are 1880 beds in Ingushetia, i.e. 5.9 per 1,000. The average length of stay is 13.5 days, and hospital mortality 1.3 %. The total number of ambulatory examinations performed in 1999 was 760.773, and the total number of home examinations 79.009.

The Ingush Republican hospital in Nazran has 528 beds, the Central District hospital in Malgobek 375, and the Sunzhenskaya Central District hospital 276 beds. The rest of the institutions are fairly small, with 40-70 beds but, although the distances between them are only a few kilometres, public transport is not well developed.

Access to health care services

IDPs in Ingushetia are complaining about the lack of access to basic health care due to payment requests. There are numerous examples of rejected patients being accepted if money is provided. Statistics show that 50% of the hospital beds are utilized by IDPs. Some drugs are not available for free and must be bought in the market by both the resident population and the IDPs.

Human resources:

Ingushetia has 810 doctors (2,6 per 1,000 population, excluding IDPs ) and 1759 nurses.

In the IDP population, there are 92 doctors, some of whom are engaged by the international agencies rendering medical assistance to the IDPs.

Medécins du Monde (MDM) has permanent medical staff in four camps: Sputnik, Severny, Bart and Karabulak.

The Russian Red Cross has one medical unit in Nazran, and two mobile clinics working in the surrounding areas of Nazran, in Plievo, Yandar, Troitskoe, Kantyshevo, Dadakovo and Altievo.

The Islamic Relief Agency works in Karabulak, Severny and Sputnik Camps. They have three emergency vehicles fully equipped.

"People in need" also provide medical assistance in one of the camps.

Equipment

There is a great need for surgical and obstetric equipment, and equipment for paediatric emergencies. Where equipment is available, it is often old and defunct.

All oxygen stations in Ingushetia are privately owned. Oxygen bottles are expensive and often inaccessible for patients.

Both chemical-biological and bacteriological laboratories are lacking the most basic reagents for everyday diagnostic and therapeutic needs.

Basic infrastructure

The water quality in the hospitals is not satisfactory.

The Republican hospital in Nazran and the Sunzhenskaya hospital do not have functional generators, whereas the Malgobekskya hospital does. Electricity cuts are often a problem.

Several medical institutions have no telephone, and no established communication channel for disease monitoring data.

Additional health activities in the area

The main activity in the health field has so far been carried out by EMERCOM/MoH " Zaschita"(the All Russia Institute of Disaster Medicine).

ICRC/Russian Red Cross (RRC) has rendered medical supplies to a number of hospitals in the area. UNICEF has so far provided basic drugs covering 300,000 persons for three months. MSF-H has likewise supplied basic drugs kits to hospitals and polyclinics.

Mobile clinics

As many IDPs live far from medical institutions, some agencies have introduced mobile medical teams. Mostly they use a cyclic schedule of work: the teams receive drugs and supplies in a base station and then circulate between distant settlements or IDP camps. RRC has a mobile team which provides medical assistance to Nazran, Karabulak and Troitskoe. One MSF-Belgium mobile clinic (another is planned) active in Malgobek district. It has one internist, one gynecologist and a nurse, and soon to be joined by a paediatrician. ARD run a mobile team which includes an internist and a pediatrician, and operates between Karabulak, Troitskaya and Sleptsovskaya. The Saudi Committee for Humanitarian Assistance (SCHA) plans to deliver five emergency care vehicles and use three as mobile first aid points and present two to the MoH/I.

WHO facilitated a meeting on 18 February at the Ministry of Health in Nazran , to discuss the geographical areas of coverage.

WHO INFORMATION SERVICE for international health agencies rendering assistance to the 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 the 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: i.tarakanova@who.org.ru

If you do not have e-mail, please bring a diskette for copies.

SOME OF THE AVAILABLE REPORTS:

WHO: List of useful addresses

WHO: Minutes from health coordination meetings in Moscow and Stavropol

WHO: 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

WHO: Infant feeding in emergencies/A guide for mothers (available also in Russian)

List of requests for assistance from MoH/RF, MoH/D, MoH/I

WHO: Comments to the list of Drugs for Donations to the Russian Federation (available also in Russian)

WHO/UNICEF/IOM Health Assessment of Internally Displaced population from Chechnya in Ingushetia. Jan 31-Feb 5,2000

MSF-H: Data on medical facilities of the Republic of Ingushetia and their capacities. Assessment of main hospitals.

MSF-H: Morbidity of IDP population in 1999. Breakdown by diseases.

Conference in Vladikavkaz. Protocol of the Business conference of the Ministers of Health of the subjects of the Russian Federation of the North Caucasus.

MSF-H/MDM: Health Facility Assessment form (available also in Russian).

MSF-H: Monitoring of Drug Distribution in Ingushetia

MDM: Chechnya - Ingushetia: testimonies and sanitary data. Feb 23, 2000.

COORDINATION

WHO coordinates the international humanitarian health assistance in North Caucasus. This is being done through the following mechanisms:

1) Policy meetings in WHO ,Moscow office every two weeks. Next meeting Mar 24 at 14:00 hours.

2) Field coordination meetings in Ministry of health in Ingushetia, Nazran, every two weeks. Next meeting Mar 31.

3) Information sharing through an electronic information service, a monthly newsletter in English and in Russian and this web-site.