North Caucasus Briefing Update on Overall Situation and Health Activities

North Caucasus Briefing/Update Activity Report 4 February 2001

Since the onset of the conflict in October 1999, an estimated 300,000 residents of Chechnya have fled the country. Most of them have found shelter in the Republic of Ingushetia. At present, an estimated one third (about 38,000) of internally displaced persons (IDP's) are reportedly living in camps or spontaneous settlements, and the remaining 120,000 IDP's stay with host families throughout the country. About 60% of all IDP's are children and adolescents.

During the winter of 2000-2001, IDPs' migration to Ingushetia increased. In January this number was in the range of 1,000-1,500. The reason to this effect is the aggravation of the security situation in the region. Action taken by federal troops and militia in Chechnya to suppress resistance by an array of militant groups and to cleanse villages turned out to be fruitless. The rebel leaders use guerrilla tactics i.e. ambushes, assaults, suicide attacks, mining roads and aggression on public places to inflict substantial casualties on the military, and Chechen "traitors" who serve the current administration. Innocent civilians often fall prey to this aggression. The feeling of growing insecurity prompted IDPs in Ingushetia to write a petition to President Putin asking him to protect their stay in safe Ingushetia (from a possible forced move back to Chechnya as was widely debated last autumn).

The latest event of 9 January 2001 with the abduction of an international staff member of MSF a few kilometers south of Grozny, without any success in attempts so far in getting him back, proved that the safety of the work of international staff in Chechnya cannot be guaranteed. UN organizations and the majority of NGOs, including those who are UN partners responsible for delivering food and other goods to IDPs in Chechnya, declared suspension of their humanitarian assistance on the territory of Chechnya, in the spirit of solidarity. According to UNSECOORD instructions, with the exception of a few fact- finding missions, which were organized with high precaution, UN Agencies have no direct access to Chechnya. Certain NGOs do not accept being accompanied by armed guards even when working for the UN. In conjunction with this, John McCallin, United Nations Humanitarian Coordinator and Designated Official for Security issued the following message to all concerned, including NGOs and the donor community: "All NGOs who are working with or plan to work with the United Nations in the implementation of humanitarian programmes in the Russian Federation's republics of Chechnya, Ingushetia, and North Ossetia, must ensure that their expatriate staff are accompanied by armed security at all times, effective 1 February 2001. All other NGOs are strongly advised to do likewise." However, there no decision has yet been made when UN humanitarian assistance to Chechnya would resume.

In the meantime an estimated 170,000 civilians (out of a total of 370,000) are displaced within the Republic of Chechnya itself, a majority in the city of Grozny, living in severely damaged houses without electricity and a regular water supply. They need food, of which UN WFP was the major, if not sole, supplier. As far as the situation in Ingushetia is concerned, relief operations have been continuing there. Overcrowded, strained living conditions, and the sub-standard water and sanitation situation in temporary settlements are negatively influencing their health. The congested health services of Ingushetia can hardly cope with the mounting health problems of their own population and those of the IDPs.

The health services infrastructure needs considerable input to be able to provide a minimum standard of services for all in need. The World Health Organization, together with other UN agencies, is at the forefront of emergency humanitarian assistance provision to the North Caucasus region with a major bulk of activities in Ingushetia. The overall WHO objective is to reduce the most preventable causes of morbidity and mortality, and to alleviate suffering from disability among IDP's and host families as well as among affected populations in Chechnya itself.

This includes:  Coordination of health activities in the region by facilitating information collection and its timely dissemination with priority placed on the disease surveillance system to ensure an adequate early warning and response.  Enhancing access for all vulnerable groups to quality health care and rehabilitation by reinforcing the capacity of the existing health care facilities.  Improving the quality of health care by providing staff training, appropriate medical supplies, and health education in the community.

Accordingly, WHO is concentrating on their achievement through the following projects:

1. Coordination of international humanitarian assistance in health

Objective  To collect, analyze and exchange information among agencies, and to increase efficiency of emergency assistance to people affected by the armed conflict.  To ensure that the external assistance is in line with the national public health framework as well as international standards.  To provide technical advice to partners on the health and nutrition sector and to define public health priorities based on continuous need assessments.

Activities and progress Information is gathered continuously by core staff (teams in Moscow, Vladikavkaz and Nazran), monitors and short-term consultants engaged in project implementation. By-monthly health coordination meetings are held in Moscow and in Nazran (Ingushetia) for all partners active in the health sector. This also includes the facilitation of collaboration of international relief agencies (UN organizations and NGOs), with Ministries of Health RF and RI. Media coverage of WHO activities includes the publication of a monthly newsletter "Health in North Caucasus", the update of the WEB page on WHO's activities in the North Caucasus (http//par.who.dk), video documentation, interviews on local TV and press articles on ongoing WHO activities in the relevant parts of the North Caucasus. The establishment and monthly update of a map on medical activities of NGO's in Ingushetia contribute to a smoother coverage of medical care by international and national NGO's and provide newcomers with information on areas in need of medical care (i.e. Hammer Forum, Germany, has redefined its area of emergency aid in Ingushetia according to the "black spots" (medically uncovered areas).

A database of human resources on health workers among the IDP's in Ingushetia was set up by a subcontracted NGO (ARD), to form the base for possible recruitment for further WHO programme implementation.

WHO consultations with UN and NGO's on medical care are highly appreciated and well attended. Examples are consultations on reproductive health of IDPs (June), mental health of IDPs (July), physical rehabilitation of war-injured IDPs (October), control of Hepatitis A (October), drug policy in RF and WHO essential drug guidelines November, adaptation of the "food box" for IDP's (December).

2. Strengthening of communicable disease surveillance

Objective Strengthening the existing SES services (Ingushetia, later in Chechnya) to prevent/curb possible epidemic outbreaks by strengthening their capacity to collect, analyse and timely disseminate accurate information. To further improve the operational skills of SES through upgrading their laboratory and communication equipment and by training of staff.

Activities and progress On the basis of the epidemiological profile in the North Caucasus region, diseases with a potential public health threat were identified and priorities for surveillance were set up. WHO recommended case definitions, registration forms and a reporting system was provided and the existing surveillance system upgraded. An expert mission was carried out in November to review the process of implementation of the WHO proposed registration system in the SES in Ingushetia.

An expert analysis of the needs of district sanitary-epidemiological laboratories in Ingushetia, including needs of staff training, was made in May 2000. As a result, the most needed equipment and consumables have been purchased. Close collaboration between WHO and SES at federal level, and the chief-epidemiologist in Nazran, and UNICEF activities to support the Expanded Program on Immunization in Ingushetia and Chechnya were effectively pursued.

Contacts have been established with SES Grozny, presently, the only "working" SES in Chechnya . Through NGOs, a first assessment of most needed items was carried out and basic equipment was ordered by WHO. Because of the bad living conditions, the yearly emerging Hepatitis A outbreak in autumn 2000 was more severe in Ingushetia than in years before. A WHO expert mission to investigate the Hepatitis A outbreak was undertaken in November in Ingushetia. As an immediate response, WHO provided chlorine disinfectant to the SES in Ingushetia. In December, hand-washing facilities were installed in the camps of Bart, Sputink and Alina in order to improve hygienic conditions that contribute to the Hepatitis A outbreak. Furthermore, a training course on effective surveillance of communicable diseases was held for health workers in November.

3. Tuberculosis control

Objectives To upgrade capacities of local health care services and to improve skills of care providers to carry out effective TB prevention and control measures.

Activities and progress An expert fact-finding mission in North Ossetia, Ingushetia and Dagestan confirmed a high incidence of tuberculosis which is close to epidemic rates (up to 86-93/ 100,000 population). Essential needs in treatment provision, laboratory equipment and training of personnel for early diagnosis as well as for health education were assessed. Six training workshops were held during March - August on TB diagnosis, i.e. on direct sputum microscopy and microbiological tests, and generally presented DOTS strategy recommended by WHO. About 480 health workers from Dagestan, Ingushetia, Chechnya, North Ossetia and Stavropol were trained.

WHO has upgraded the laboratory services of Ingushetia and Dagestan through the procurement of 38 microscopes. WHO partner, IOM, has implemented a health education programme in IDP camps in Ingushetia and distributed laboratory supplies and equipment for main TB laboratories in Nazran (Ingushetia) and in Vladikavkaz, North Ossetia. A needs assessment mission consisting of WHO and MoH RF to Ingushetia will take place – at beginning of February in order to join efforts on TB prevention, detection and treatment. According to the outcome of the mission, a new strategy will be determined to channel activities and resources. Strengthening TB related surveillance according to WHO recommendations and improving diagnosis of TB with upgraded laboratory equipment and reactives for microbiological diagnosis and drug sensitivity.

4. Prosthetic assistance to war injured

Objectives  To strengthen the prosthetic/orthopedic workshop in Vladikavkaz to ensure regular and uninterrupted prosthetic/orthopedic assistance to patients with skeletal injuries/war wounded amputees in Ingushetia and Chechnya.  To further support local rehabilitation services for disabled persons among IDPs.  To support re-establishing the former prosthetic workshop in Grozny. All activities are also financially supported by UNHCR, UNICEF and Handicap International. Activities and progress

Physical rehabilitation needs of IDPs with limb loss staying in Ingushetian camps were identified by WHO monitors in May, and a database consisting of approximately 100 amputees has been created.

WHO provides continuous support to the prosthetic/orthopedic workshop in Vladikavkaz.

Since the start of the programme in 1996, over 400 prostheses were fitted and more than 800 people received orthopaedic assistance. Training of two technicians of the Vladikavkaz workshop at the St Petersburg Research Institute for Prosthesis as well as in-job training by two of its experts during two months in Vladikavkaz were financed by WHO. Other costs, i.e. purchase of prosthetic components, manufacturing of prosthesis and orthopedic material for IDP amputees, transportation and accommodation and re-operation of defect stumps are also covered by WHO.

A WHO database on amputees in need of prosthetic assistance among IDPs in Ingushetia and patients in Chechnya was created in accordance with the UN database on mine action.

UNHCR and WHO financed physio-therapeutical equipment for the Rehabilitation Center for Physically Disabled Persons in Vladikavkaz, which will also serve IDPs in Ingushetia and Chechnya.

WHO is financing jointly with UNHCR, a physician-consultant - at the UNHCR Consultation Center for IDPs, who gives medical counseling and facilitates referral treatment for other regions of Russia of such cases which is difficult to have in Ingushetia.

Handicap International is assessing the needs of the former prosthetic workshop in Grozny to re-establish this workshop incrementally depending on the security and political situation in Chechnya.

5. Procurement and delivery of medical supplies and medicines

Objectives To provide the existing health care system with essential equipment and medicines to ensure adequate/minimum standard quality response to population needs.

Activities and progress Regular assessment and monitoring of needs and the purchase of most needed equipment and pharmaceuticals (depending on the actual funding situation of WHO projects) for health care facilities in Ingushetia and neighbouring republics is carried out. WHO facilitated the dialogue between international aid organisations, health authorities and suppliers "to establish rules of fair procurement" of necessary medical items inside Russia to avoid cumbersome custom procedures for imported goods.

WHO purchased 10 surgical kits for hospitals of Ingushetia and Dagestan. The proper use of them was monitored by WHO field staff.

The WHO Collaborating Centre, based in the All-Russian Centre of Disaster Medicine "Zaschita", was commissioned for the procurement and delivery of pharmaceuticals and expendables to 5 hospitals in Ingushetia, 1 in Chechnya and 1 in North Ossetia for the total amount of USD 180,000. According to a special demand of MoH RI, WHO procured three oxygen concentrators to main hospitals in Ingushetia (Nazran Republican, Sunzhenskaya and Malgobeckskaya hospitals).

After the UN need assessment mission to hospital No.9 in Grozny an ad hoc procurement of one oxygen concentrator was done for this hospital. The delivery is still pending.

6. Reproductive health

Objectives  In close cooperation with UNFPA to improve accessibility to and quality of ambulatory and hospital care in reproductive health by upgrading knowledge and skills of medical staff in Ingushetia, Chechnya, North Ossetia and Stavropol kraij.  To strengthen the material basis of relevant hospital units and medical points in camps in Ingushetia.

Activities and progress In collaboration with UNFPA, a project proposal and action plan were elaborated in order to improve the accessibility and quality of primary and secondary care in Reproductive health with special attention to Safe Motherhood, contraception/FP, prevention and case management of STIs and essential care of infants. All in all 176 doctors, nurses and midwives were trained.

Joint WHO/UNFPA/MoH RF assessments of logistics and training needs provided complementary information for implementation of agreed intervention strategy, and to increase the capacities of the existing health care services by training in areas of safe motherhood, neonatal care and breast feeding, family planning and STI control, provision of effective and safe means of delivery and ultrasound technology in pregnancy.

WHO and UNFPA have purchased and delivered needed clinical and laboratory equipment, as well as essential drugs and contraceptive means to hospitals and maternity homes in Ingushetia.

Purchase of literature on reproductive health (family planning, contraception and STI prevention) was performed jointly by WHO and UNFPA, which was distributed to Ingushetian hospitals and maternity homes. Jointly with UNFPA, WHO has held a round-table seminar for summarizing the results of the series of 9 training workshops on antenatal care, obstetric care and family planning/STI prevention.

A new aspect of this programme is child protection and nutrition. Until today two training courses took part on nutrition.

7. Psychosocial rehabilitation

Objective Promotion of a community-based psychosocial support and mental health care to war- affected persons among IDPs.

Activities and progress According to the project proposal developed by a WHO/HQ technical officer, a rapid review of mental health needs of IDPs and resources available in Ingushetia for emergency mental health response was undertaken in July 2000.

After extensive discussion on the issue with health authorities, and key professionals at both federal and local levels as well as with such NGOs as MDM and ARD involved in psycho-social rehabilitation (PSR) in IDP camps, an action plan for mental health rehabilitation with the prime focus on intersectoral and community-based activities was prepared.

A training course (training of trainers) on a community-based approach in psychosocial support was held for 40 PHC staff and other health professionals involved in mental health care.

1000 soft toys for IDP children were distributed in children hospitals, orphanages and camps.

Negotiations with all interested partners were undertaken in order to create a coordination committee for implementing and monitoring programs aimed at development and support of coherent primary mental health care projects.

Fine-tuning of a smaller pilot project on psychosocial rehabilitation for IDP children in a camp in Chechnya run by Chechen Psychologists and MDM under WHO supervision.

8. Strengthening PHC

Objective To upgrade the knowledge and skill of primary care physicians in the rational use of drugs. To ensure equity and access to care in emergency health care assistance. To diminish misery and avoidable pain in patients with selected chronic diseases. Activities and progress An interagency coordination meeting on drug supplies (with representatives of national authorities), was held and technical analysis of the drug list for humanitarian assistance prepared by local health authorities was done by WHO/EURO. The list was subsequently agreed with the MOH RF. Agreement was reached in principle that purchase of drugs (both locally produced and imported ones) could be realised in the internal market, though initiation of a tender remained a prerequisite.

In pursuing the objective of strengthening existing health services capacity in primary care, PHA EURO has prepared a preliminary proposal to organise training of trainers from local medical staff on essential drug use according to WHO standards.