Providing Prosthetic Assistance in the North Caucasus
World Health Organization
Emergency Assistance Programme for the North Caucasus, Russian Federation
Technical Field Report Series. March 2001
kinds were financed for more than 800 As a result of two armed conflicts in the invalids. To ensure the implementation of Republic of Chechnya during the last this assistance, two local technician were decade, approximately 7 000 citizens of trained at the St Petersburg Prosthetics the republic have lost or damaged a limb Research Institute. and are currently in need of prosthetic
and/or orthopaedic care. In addition, WHO will continue to train additional staff approximately 400 amputees are among and ensure the provision of prosthetic the internally displaced population (IDP) components and equipment in the year in Ingushetia. 2001 as a part of a new project, “Mine awareness”, which has already been At present, there are seven initiated in close cooperation with UNICEF, prosthetic/orthopaedic workshops in the UNHCR, ICRC and Handicap International. North Caucasus region: in Nalchik, Rostov/Don, Makhachkala, Sotchi, Furthermore, WHO is financing the re - Krasnodar, Stavropol and Vladikavkaz. operation of defective amputation stumps at However, they are not accessible to the the Vladikavkaz hospital of orthopaedics and majority of Chechen citizens in need of traumatology. To date, 14 amputees have prosthetic assistance. had adjustment operations. These services are provided free of charge to all IDPs. Since the start of the international emergency relief programme in the North In October 2000, in connection with the Caucasus in 1996, WHO has been Vladikavkaz prosthesis workshop, a supporting prosthetic workshops. The first rehabilitation centre for invalids with injuries was in Nazran and, since 1997, in of the muscular-skeletal system was Vladikavkaz, the closest location to established by the Ministry of Labour and Chechnya and the IDP population. Social Welfare in North Ossetia. The centre offers physiotherapeutic services and During the current conflict in Chechnya, psychosocial support. WHO and UNHCR WHO has provided technical equipment, raw equipped the centre with physiotherapeutic materials for more than 120 prosthesis, and medical devices. transportation and accommodations to the Vladikavkaz workshop for the some 480 Finally, a new aspect of the project amputees from IDP camps in Ingushetia and considers the gradual re-opening of the for amputees arriving directly from former prosthetic workshop in Grozny. Chechnya. Orthopaedic appliances of all
The problem
Two armed conflicts in Chechnya during the outside of Chechnya, predominantly in the last decade caused numerous casualties Republic of Ingushetia. among the civilian population. It has also resulted in tensions on Russia’s southern The most recent conflict, in 1999-2000, border to the North Caucasus where there resulted in a tremendous increase in the are a growing number of amputees due to number of people in need of prosthetic shelling and bombing, gun shots wounds, and/or orthopaedic assistance. Current blasts from mines and unexploded observations indicate that mines and UXOs ordinance (UXOs). Some of the victims are will remain a major problem for the next now among the more than 150 000 IDPs few years for the population living and
2 working in Chechnya as de-mining efforts established the prosthetic workshop in are slow, even in inhabited areas. Grozny as an emergency effort for the Furthermore, the future status of the city of injured. In order to strengthen the capacity Grozny, including the reconstruction/de- of the emergency services, in 1996 WHO mining of the inner city, has not yet been decided to set up a mobile prosthetic decided on by the Russian authorities. workshop in Nazran, Ingushetia. Increased outdoor activity during the summer also probably led to an increase in Along with the British prosthetic company the number of mine victims. Blatchford & Sons Ltd., some 200 artificial limbs were provided for amputees from As collected from different sources (MDM in Ingushetia, Chechnya and North Ossetia. the summer of 2000, Chechen hospitals, the After the deterioration of the former director of the prosthetic workshop political/security situation at the end of in Grozny), at present, approximately 7 000 1997, the service was relocated to persons have been seriously injured during Vladikavkaz, North Ossetia, where the war in the Republic of Chechnya, of international relief agencies had already whom some 4 000 may need prosthesis. established a presence. The real figure is difficult to determine because many surviving victims are treated Of the seven prosthetic/orthopaedic at home, as they have no access to workshops, the workshops closest to the treatment at health centres. There are conflict area are those in Machashkala and about 400 persons in need of prosthesis in Vladikavkaz. For political and emotional Ingushetia. A survey carried out by WHO reasons, the workshop in Makhachkala does monitors in IDP camps in early 2000 not serve the Chechen population. The other revealed some 90 amputees. A database on workshops are essentially inaccessible due amputees in Ingushetian camps was to distance and political/legal (military prepared by WHO and distributed to control posts and lack of travel documents) interested NGOs. Area specific problems are and financial barriers. related to the increased migration of IDPs between Chechnya and Ingushetia Therefore, in April 2000, WHO started a new throughout the year. emergency programme on prosthetic assistance by supporting the prosthetic After the first conflict in Chechnya, several workshop in Vladikavkaz. international humanitarian organizations re-
The action
Since the majority of IDPs are in Ingushetia, field. Another medical doctor is currently the first steps undertaken by WHO were to being trained as a prosthesist in St strengthen the capacity of the Vladikavkaz Petersburg. workshop. This included the provision of basic equipment, capacity building, From May until December 2000, this staff transport/accommodation services to provided 121 new prosthesis and repaired amputees from Chechnya and Ingushetia, 36 old prosthesis. For the manufacturing of and the regular delivery of a new prosthesis, three consultations are prosthetic/orthopaedic components. normally necessary: 1. measuring, 2. fitting, and 3. final adjustment/training. The Two technicians from the workshop were consultations depend on the smooth sent to the St. Petersburg National Research transport of the amputees from their homes Institute for Prosthesis to be trained in to Vladikavkaz. The many outstanding prosthesis manufacturing. At present, the problems (no valid documents or travel workshop has four prosthetic technicians permits, no means of transport) were and one medical doctor specialized in this resolved through a special agreement with
3 the Ministry of Labour and Social Welfare of Orthopaedic services of all kinds (including North Ossetia and WHO. A mini-van was the purchase of crunches, canes and breast hired by WHO to pick up the amputees in iron support) were provided to more than Nazran and bring them with a UN/WHO 800 IDPs. convoy to Vladikavkaz. During the above- mentioned period, 457 amputees were WHO finances the re-operation of defect transported to Vladikavkaz and back to stumps, which are unfit for prosthesis Nazran. Amputees from Chechnya had to fitting, at the Vladikavkaz orthopaedic and provide their own means of transport to traumatology hospital. To date, this has Nazran. Since the summer of 2000, an been provided to 14 persons, who had only agreement with the administration of the received lifesaving treatment after being Vedeno region in Chechnya has allowed injured. Medical consultations for 33 invalids Chechen amputees to travel to Vladikavkaz were also financed by WHO. by a special mini-bus. During their one-day stay in Vladikavkaz, the amputees are Table 1. provides an overview of the served a hot meal. The transport and prosthetic/orthopaedic services provided to accommodation costs are covered by WHO. IDPs as a part of the humanitarian aid provided by WHO during the period May– November 2000.
Table 1. Prosthetic/orthopaedic services provided to IDPs Services provided May June July Aug Sept Oct Nov TOTAL Prosthesis 16 21 8 15 19 23 9 121 Prosthesis repair - - 13 6 3 9 5 36 Orthopaedic shoes 1 1 1 3 9 9 6 30 Orthop. assistance 24 31 124 29 179 358 64 809 Consultations - 3 3 7 12 8 0 33 Re-operation - 2 2 2 - 8 - 14
An important aspect of WHO assistance is International) state that while Russian the purchase of prosthetic components. The prosthetic material is normally of suffic ient workshop uses and combines prosthetic quality and less expensive, the quality and material from different national (e.g. duration of sensitive joints are better in Energia, Vita Orta) and international (e.g. those produced abroad. Nevertheless, the Blatchford, Otto Bock) companies to ensure use of basic Russian material and foreign the quality and endurance of the products. joints is, at present, an acceptable and cost - effective solution.
WHO provided the financing and facilitated the organization and delivery of all the prosthetic material and some of the orthopaedic material used in the workshop from May to December 2000. In total, from May to November 2000, WHO spent RUB 1 027 163 50 approximately USD 37 000 (equipment and training costs are excluded) supporting the Vladikavkaz workshop.
Due to the increasing needs of prosthetic An important aspect of WHO assistance is the purchase of prosthetic components. assistance and the limited manufacturing capacity of the workshop, WHO contacted The assessments of experts from different interested UN and other organizations to organizations (e.g. ICRC, Handicap
4 collaborate by pooling resources for prosthetic workshop in Vladikavkaz will be assistance in this area. turned into a regional centre.
At the end of October 2000, WHO invited all As a part of the UN mine awareness interested organizations to a co-ordination programme, WHO is the focal point for meeting on prosthetic assistance in order to public health aspects of assistance to define interests and to combine efforts. victims. This includes the development of appropriate standards and methodologies, Two prosthetic experts (Mr Eklund from as well as the promotion of health service WHO headquarters and Mr Betanjan from capacity building for sustainable assistance the St. Petersburg National Prosthetic to victims of war through the federal and Research Institute) advised the meeting on local Ministries of Health and Labour and technical matters. Social Welfare. Furthermore, this position includes the provision of technical public In agreement with UNICEF, UNHCR, ICRC, health support to the various UN partners Handicap International and the Ministry of involved in mine action and close Labour and Social Development of the cooperation with UNICEF, UNHCR, ICRC and Republic of North Ossetia, the WHO relevant NGOs.
UN mine action programme
The UN mine awareness programme is also include, where appropriate, information the umbrella for WHO’s cooperation with from the UNICEF Mine Victim Database; UNICEF and UNHCR. The outcomes of a · WHO will continue to purchase prosthetic recent meeting between the agencies were and orthopaedic components, equipment summarised as recommendations and an for the manufacturing of prosthesis, and action plan with clear tasks and timeframes finance the accommodation of patients. for all participating organizations. The third APW for the prosthetic workshop ensures the manufacture of Two goals were agreed on at the meeting: prosthesis; 1. to strengthen the Vladikavkaz workshop · WHO will finance the training of two as a regional centre; and additional staff members from the 2. to support the incremental re- workshop in St Petersburg at the establishment of the former workshop in National Research Institute for Grozny. Prosthesis in 2001; and · WHO will continue to finance the re - The current focus is on helping the operation of defective stumps of Vladikavkaz prosthesis workshop function as amputees at the Vladikavkaz hospital for a regional centre of excellence for orthopaedics and traumatology. prosthetics and orthopaedic assistance to victims of the war. UNICEF will:
WHO’s role was defined as follows: · provide, in close cooperation with WHO, psycho-social counselling at the · WHO will be the focal point for Vladikavkaz Centre for the Rehabilitation assistance to victims, in close of Disabled Persons; cooperation with the other participating · improve, together with WHO, the organizations and the Ministry of Labour transport of amputees from Chechnya and Social Development of North and Ingushetia to Vladikavkaz. UNICEF Ossetia; is considering purchasing a bus, which · WHO will maintain the computerised could then be shared with WHO, in order system of identification and registration to ensure the regular and safe transport of amputees in need of prosthesis and of patients; and
5 · share, with WHO, the purchase of · It was agreed to send two members of equipment needed for a further increase the former workshop for prosthetic in the manufacturing capacity of the training to the St Petersburg Institute, workshop. financed by WHO (to be possibly co- financed by ICRC); UNHCR agreed to: · Handicap International will provide orthopaedic material to the Grozny · share, with WHO, the purchase of workshop and to Chechen hospitals; and additional physiotherapeutic equipment · Handicap International will make an for the Vladikavkaz Centre for the inventory of items in stock and a list of Rehabilitation of Disabled Persons; and the most needed items for the basic · jointly sponsor, with WHO, a local repair of wheelchairs, crutches and medical doctor at the UNHCR IDP prosthesis. Counselling Centre in Nazran. The doctor will provide medical counselling and To ensure more comprehensive support of coordination for the medical treatment amputees with severe physical and/or of populations affected by war psychological trauma, WHO and UNHCR throughout the Russian Federation. agreed to support the Vladikavkaz Centre of Rehabilitation for Disabled Persons. The ICRC’s contribution to the enforcement of centre is a part of the Ministry of Labour the Vladikavkaz workshop is still pending. and Social Development of the Republic of ICRC was considering the possibility of North Ossetia and was opened in October sending international prosthetic specialists 2000. to increase the manufacturing capacity of At the centre, the muscular-skeletal system the workshop and to provide training to of disabled persons, most of them local staff. Furthermore, ICRC was amputees, are treated. The centre will also considering cooperating with WHO in accept IDP amputees as soon as the supporting the training of new prosthetic ongoing reconstruction allows for the specialists. accommodation of amputees (16 beds are planned). Handicap International (a French NGO) supports the workshop by delivering UNHCR has provided the centre with wheelchairs and other orthopaedic material, training equipment and WHO has provided including crutches and canes. medical (physiotherapeutic) equipment including electro-stimulators, for the The second important goal of the meeting rehabilitation of the amputees. In the near was the general agreement of the future, a further extension of the participants to support the incremental re- physiotherapeutic part of the centre and the establishment of the former prosthetic addition of a psychological component are workshop in Grozny in order to facilitate envisaged. A psychologist, specially trained access to needed aid and enable the by WHO in the mental health of IDPs, will production capacity to cover the region’s support the disabled. needs.
Conclusions
In the near future it is likely that there will large number of people still untreated. be an increase in the number of people in Moreover, those already treated will need the North Caucasus in need of prosthetic replacement parts and repairs. and/or orthopaedic assistance. This is due to the large amount of unexploded Therefore, there is a need to strengthen the mines/ordnance in the area as well as the manufacturing capacity of the Vladikavkaz
6 workshop with the aim of developing a Staff members of the Grozny workshop centre of excellence for the region. This should be sent for formal prosthetic training should include the purchase of modern Continuing on-the-job training could take equipment and the provision of quality place in the Vladikavkaz workshop. After the prosthetic training to two additional staff stabilisation of the political/security situation members at the workshop in St Petersburg. in Chechnya, there might be better possibilities for upgrading the Grozny There is also a need to gradually re- workshop to the status of independent establish the former prosthetic workshop in centre. Grozny. The first step will be to deliver basic material for the repair of prosthesis, Coordination meetings, initiated by WHO wheelchairs, crutches, etc. This should be and attended by UN organizations, NGOs, followed up by developing it as a satellite the ministry and representatives of the workshop for the Vladikavkaz workshop (i.e. workshops (Vladikavkaz and Grozny), will the measuring and fitting will take place in be held every second month to facilitate a Grozny, with the manufacturing being smooth exchange of updated information as carried out in Vladikavkaz). well as the coordination of the resources of participating organizations.
The number of people in the North Caucasus in need of prosthetic and/or orthopaedic assistance is likely to increase in the near future.
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