Health

in the North Caucasus

NEWSLETTER ON EMERGENCY PREPAREDNESS AND RE SPONSE, APRIL 2001

Proposed Emergency TB Control Programme in Ingushetia

to maintain the TB related services (a TB hospi- As reported in the March issue of Health in the tal, including an additional 50 beds, out-patient North Caucasus, the main objective of the dispensaries, laboratories, surveillance and joint WHO/Ministry of Health RF mission to monitoring services, etc.). the Republic of Ingushetia in March 2001 was to assess the TB infection burden in the re- MoH RF will provide the needed X-ray equipment public, including that among internally dis- and quantity of TB drugs of the first and second placed people (IDPs), and to devise relevant lines. measures to curb its uncontrolled spread. The If the necessary funds become available, the local health care infrastructure is not able to United Nations will be responsible ensuring: meet increasing demands. The estimated inci- dence of TB is 278 cases per 100 000 IDPs in · the purchase and setting up of prefabricated Ingushetia. modules for a 50-bed hospital; · the provision of laboratory equipment and appropriate diagnostic media; In order to control the spread of TB, an action plan based on WHO recommendations has been · the training of personnel; elaborated. In this plan, the responsibilities of · health education campaigns; the three main actors, MoH RI, MoH RF and UN organizations, were clearly outlined. The pro- · social support of TB patients; and posed plan encompasses all obligatory elements, · overall management including three local from active detection to curative treatment. staff members and a manager at central The Ingushetian government has pledged to in- level. crease the number of local personnel by 20 and

Rehabilitation of the disabled By Zhanna Tsallagova, director

The Vladikavkaz Centre for Rehabilitation of the Disabled with Muscular-skeletal Problems was established for both physical and social rehabilitation as well as to increase the social status of the disabled in society and with their family.

The centre plans to set up classes for the voca- tional training of the handicapped at their cur- rent place of employment with an Ingushetian company and by creating at-home jobs.

1 Apart from suffering from their inability to serve reading room and deliver books to the disabled themselves fully in everyday life, the disabled at home. are also discontent with their inability to make a Last year, for the first time, a team from our living for themselves and their families, all of centre successfully participated in the Sports which fosters an inferiority complex. Games for the Disabled. This led to the idea of Given their varying intellectual and physical ca- establishing a professional sports team, which pabilities, it is planned to set up a computer would participate in competitions at various lev- class and rooms for learning jeweller’s, carpen- els. ter’s, knitting and sowing crafts. There will be Regional significance the possibility of some form of employment fol- The Vladikavkaz centre is of regional signifi- lowing completion. cance, because it is the only institution of its The centre is already trying to sign contracts type in the North Caucasus. In North Ossetia with some institutions of higher learning in the alone, there are about 2 000 handicapped in republic, stipulating enrolment quotas for the need of the services provided by our centre. And disabled in the daytime education and corre- there are even more unattended in the spondence learning d epartments. There will also neighbouring republics. Given the situation in be a library at the centre, which will have a the North Caucasus, we anticipate an increase in the number of disabled.

By yearend, our centre will be radically restruc- tured in order to obtain additional beds and a catering unit, and become able to admit p atients from both remote villages of our republic and the North Caucasus region at large. This will e n- able us, if respective equipment and facilities are provided, to improve significantly the quality of the services.

The issue of patient transportation to the centre and back home is also of critical significance. We will soon start using ambulances to provide transportation. However, following the recon- struction of the centre, the number of disabled undergoing rehabilitation will be increased to up to 40-50 persons at a time. We are already look- ing for the possibility of acquiring bigger ambu- lances from abroad, because no such vehicles are manufactured in Russia.

Nevertheless, in spite of our ambitions, we still lack experience. To remedy this, in the near fu- ture we will contact similar centres in Russia and abroad in order to organize study tours for our In North Ossetia alone, there are about 2 000 employees. This will help make our centre more handicapped in need of the services provided by the Vladikavkaz centre. professional and more successful.

2 Obstetric and gynaecological services of the Chechen Republic in 2000 (based on the MoH Chechnya performance review for the year 2000)

Due to the fighting in the Chechen Republic, many of the health institutions (primarily in Grozny), except for the central district hospi- tals in Goudermes, Shelkovskaya, Naour- skaya and Nadterechnaya, reduced their a c- tivities and provided only certain outpatient care at some polyclinics. As of the beginning of the year 2000, only 229 obstet- ric/gynaecological beds were in use in the republic, including 106 for the pregnant and for women in labour (versus 1 410 and 607, Maternity Ward No. 2 in Grozny, April 2001 respectively, for the same period in 1998).

women was 4.1 (compared to 5.0 per 10 000 in Facilities and equipment the Russian Federation) versus 4.8/10 000 in As the situation in the republic stabilized, the 1998. In the districts, this indicator is much obstetric/gynaecological service bed capacity lower, a maximum of 2.9 per 10 000, although was expanded. By 1 January 2001, the number the majority of women live in rural areas. of obstetric/gynaecological beds totalled 804, The 70 OB-GYNs in Grozny (per 50 017 women with 435 for the pregnant and women in labour. population) and 14 in Argun (10 605 women) All inpatient care departments were in dire need are almost triple the republic’s average. The ru- of repair, though with relatively fair sanitary and ral districts (Vedensky, Shatoevsky, Nozha Yur- hygienic conditions. They are without central tovsky, Atchoy Martanovsky, Naursky, Grozny heating, water and a sustainable electricity sup- Region, and Nadterechny), on the other hand, ply. The sewerage system is in need of repair have only one third of the required number of and there is a lack of disinfectants, detergents, OB-GYNs, which is reflected in all service per- furniture, linen and medical instruments. formance indicators.

In 2000, almost no diagnostic or rehabilitation equipment was supplied to the gynaecology o f- fices at polyclinics, women’s counselling offices and inpatient care facilities. Today, there are no appropriate conditions for pre-term baby care (though in the hospitals in Goudermessky, Kourchaloevsky, Urus Martanovsky and Argoun four incubators have been retained).

Similarly, there are no services for blood han- dling, cytological, serologic, histologic and intra- uterine infection testing, determination of hor- monal quantification in women and hys- The main building of Maternity Ward No. 2 in teroscopies. X-ray facilities are not available in Grozny is still functioning. all districts.

Medical professionals Preventive care As of 1 January 2001, the Chechen Republic For disease prevention, medical and diagnostic (455 320 women in total, of whom 164 675 are service provision to women, including those of of reproductive age) had 191 OB-GYNs (vs. 244 reproductive age, as of 1 January 2001 there in 1998). The number of OB-GYNs per 10 000 were 26 women’s counselling offices (13 in rural

3 areas and 13 in Grozny). The total number of The number of abortions per 1 000 women of gynaecological offices was 69, with 15 in Grozny reproductive age averaged 9.2, compared to 53 and 54 in rural areas. per 1 000 for the Russian Federation as a whole.

Out of the total number of 191 OB-GYNs work- The quality of counselling and medical services ing in the republic, 69 (36%) worked for ambu- provided to pregnant women was considered to latory care/polyclinics, of them 19 in Grozny. be of extremely low quality, because of testing limitations and the medical personnel’s low level Reproductive health of training (many professionals are not special- More that 90% of pregnant women had ex- ized or have not taken refresher courses in o b- tragenital pathologies over the year 2000. stetrics/gynaecology). Anaemia was registered in 78% of the cases, kidney failures in 11.5% and circulatory diseases Drug supply in 3.4%. There was no targeted funding for drug pro- curement for gynaecologic patients, the preg- The total number of babies born in the republic nant and women in labour. The drugs and dress- in 2000 was 10 205. Early neonatal mortality ings were supplied mostly as humanitarian aid equalled 17.5%. The number of Caesarean sec- and, partly, by MoH RF. They were primarily tions per 1 000 deliveries was 68. Perinatal mor- pain-killers, antibiotics, spasmolytics, vitamins, tality in the republic was 35/1 000 (compared to injected medications and dressings. No drugs 29/1 000 in 1998). were provided on a regular basis. Only 30% of BCG was administered to 82% of immunised the needs were met. babies and polio to 69%. Lab service Approximately 39% (3 914) of all babies were The existing lab facilities of the republic tested delivered at home (without a follow-up hospital the pregnant and women with gynaecologic p a- visit). Such a high number of home deliveries is thologies on a limited scale due to a lack of re- accounted for by the fighting in the republic and agents. No in-depth biochemical tests, including the night-time (and sometimes daytime) travel serology, were performed at any hospital. restrictions, as well as the lack of communica- Many health institutions (except the Goudermes, tion with administrative centres. Shalinsky, Urus Martanovsky, Naoursky and Nadterechniy central district hospitals) did not determine the blood group or Rh-factor.

INGUSHETIA AND THE NEIGHBOURING REPUBLICS

Health update As reported by several NGOs (MDM, PINF, IR), IDP patients are often refused hospitalisation by In early April, some NGOs reported an increas- medical institutions of Ingushetia, while no ing number of cases of diarrhoea in the sponta- documented reason for refusal is given. In some neous settlements Ptitseferma, Novaya Pod- cases the IDPs are turned down due to the stantsiya, MTF-2 (Troitskaya) and MTF-2 (Alti- shortage of vacant beds in the hospitals, in evo). However, the Sanitary Epidemiological other cases a negative response is given for no Service (SES) of Ingushetia did not report an particular reason. overall increase in cases of diarrhoea throughout the republic. It carried out a water analysis, which showed that the quality of water was quite poor and might become a potential source Morbidity statistics of infection during the coming hot season. The latest available morbidity statistics provided by MSF-B and IR for the month of March shows

4 that the leading causes of morbidity among the for pregnant women. MSF-B will also promote IDP population are still acute respiratory infec- the expanded programme on immunization (EPI) tions, diseases of the alimentary system and during consultations. Community health workers cardiovascular diseases. identified by MSF-B will undergo one week’s training in April.

During the month of March MSF-B, donated Disease surveillance drugs to Nazran Republican Hospital and health On 27 March 2001, the Russian State Sanitary centres in the Malgobeck district (MSF-B). and Epidemiological Surveillance Service re- RRC: The Russian Red Cross has organized sev- ported the following: Aiming to prevent the eral locations where children can take part in spread of polio in the Russian Federation in the different social activities and play. The rooms event of wild virus strain importation from polio- are equipped with toys, games and books endemic countries and for broader coverage by (ICRC). relevant immunizations of the children of Chechnya and Ingushetia, and in pursuance of IMC: IMC has commenced its under five pro- the directive by the RF Chief State Sanitary Doc- gramme for monitoring the growth, develop- tor, the above republics will carry out, on 26–30 ment and general heath of children under five March 2001 (first period) and 23–27 April 2001 years of age in the spontaneous settlements a l- (second period), additional immunizations for ready served by the four IMC mobile health polio for children aged 0-5. Moreover, the teams. Two more teams are now operational, republics will implement an immunization cam- each of them consisting of a doctor, a nurse and paign for polio among newborns during 2001. a driver.

The heads of regional health departments and ARD: ARD regularly updates a database of chief state sanitary doctors of regional SES cen- handicapped people in Chechnya. tres must organize and carry out, within the Islamic Relief: Islamic Relief (IR) water carri- time periods indicated, an additional clean-up ers provide 24 tonnes of water to the IDP popu- immunization for polio among children aged 3- lation in the Spoutnik and Alina camps, in In- 36 months in the cities and districts where im- gushetia, on a daily basis. This brings the total munization coverage, in 2000, was under 95%. quantity of clean water supplied per month to over 1 million litres. The water is used for drink- ing, cooking, washing, cleaning and basing. Health services IR signed an agreement with UNHCR in which The oncological service of the Republic of In- UNHCR funds the IR shelter programme. Fifty- gushetia is represented by the Republican On- eight (58) new latrines will be constructed by IR cological Dispensary (20 beds) and oncological in the Spoutnik and Yandare camps. It is hoped cabinets in the Malgobeck and Sleptsovskaya that the new latrines will improve sanitation in central republican hospitals. At present, 22 on- those areas and will be more suitable for chil- cological patients are undergoing treatment in dren and elderly people (IR). the dispensary. UNICEF: Within the framework of UNICEF’s The highest morbidity rate for IDPs from Chech- agreement with DDG, for 40 weeks ‘training of nya is for leukaemia and skin cancer. Medical trainers’ courses on mine awareness education personnel attribute the rising number of on- are being held in Ingushetia for Chechen teach- cological diseases to the deterioration of the ers. ecological situation and general instability, lead- ing to psychosis, neurosis and somatopsychosis. UNICEF continues to organize mine awareness puppet theatre performances in Vladikavkaz. So

far, more than 6 000 children from the IDP Health assistance: recent update camps in Ingushetia have had the opportunity to MSF-B: Using cold chain material from UNICEF, see them (OCHA). MSF-B will now start anti-tetanus immunization

5 ICRC: In addition to publishing a comic book for The ICRC mine-awareness team also covers the children, based on the puppet show “The danger Chechen children who come to the sanatoria in of landmines – the new adventures of Cheerdig” several republics and regions of the North Cau- (explaining to children the danger of landmines casus as a break from the dire living conditions and unexploded ordinance and conveying basic in Chechnya. Mine-awareness presentations rules aimed at helping children diminish the risk were organized for children in Kabardino- of being wounded or killed by them), the ICRC Balkaria. The aforemenioned puppet show was has developed a leaflet on the same topic for put on for children in sanatoria in Kabardino- adults. The leaflet will be used during the ICRC Balkaria, Karachayevo-Cherkessia, North Ossetia mine-awareness sessions in IDP camps. and Stavropol krai (ICRC).

CHECHNYA

Security constraints Children constitute a large number of p atients in the oncological department, and the orthopaedic Restricted movement remains one of the main department, where most patients are children problems, as reported by NGOs and medical with cerebral palsy. personnel of health care institutions of Chech- nya. The restrictions significantly hinder the Central District Hospital of Achkhoi-Martan has work of medical personnel. For example, eme r- six departments (gynaecological, therapeutic, gency medical assistance after dark is nearly paediatric, surgical, infectious diseases and ma- impossible in many areas of the republic. More- ternity ward) with a total capacity of 217 beds over, MoH workers report difficulties on the road (plus 38 beds in the hospital's branch in even when travelling in official cars and with the Samashki). The building is in need of serious necessary passes. repair. Electricity and water are supplied on a regular basis. Medical supplies (in particular, for the operating room and laboratory) are needed. The hospital staff are qualified medical profes- Health facilities: a recent update sionals. The surgical department works around from selected major hospitals the clock; however, movement restrictions im- Municipal Hospital No. 1 of Grozny has three posed by the military significantly hinder the departments (oncological, orthopaedic and gy- response to emergencies. naecological) with a total capacity of 150 beds. Central District Hospital of Urus-Martan has nine Electricity is regular. The sewer system is func- departments (traumatological, surgical, tional. Water is supplied from Starosunzhensky gynaecological, infectious diseases, therapeutic, Vodozabor. The hospital has been operational neurological, peadiatric, reanimatological and a around the clock since December 2000 and is maternity ward), with a total capacity of 345 staffed by qualified medical professionals. beds. The building is in good condition except A lack of medical supplies and modern equip- for the paediatric department, which needs to be ment have been reported. The hospital receives completely rebuilt. The electricity and water little assistance from MoH Chechnya. No regular supply are centralized, and electrical generators assistance is known to be provided by the NGO have been installed. community. Central District Hospital of Shali has six depart- Medical assistance is free of charge, but in the ments (therapeutic, surgical, gynaecological, near future the patients will possibly be charged, paediatric, tuberculosis and a maternity ward) as X-ray film and lab and other supplies need to with a total capacity of 350 beds. The electricity be purchased. and water supply are centralised.

6 In all of the above hospitals, salaries are paid to WHO delivered an oxygen concentrator to Hospi- the staff with significant (sometimes up to a tal No. 9 in Grozny. year) delays. Water & Sanitation A water purification system in Grozny, provided by UNICEF and managed by PHO, produces 120 Health assistance: recent update cubic metres of clean water per day, which is UNICEF delivered operating room equipment and distributed to health centres, schools and other medical consumables to Hospital No. 9 in Grozny. general distribution sites in the city. UNICEF has UNICEF also supplied the hospital with six refrig- now provided the NGO with an additional water erators for the new central storage facility for purification unit, which will further increase water vaccines, built with the support from the agency distribution in the city (OCHA). (OCHA).

NEWS IN BRIEF

Mental health

First Interagency Meeting of the North Caucasus Mental Health Committee

On 10 April 2001, the First Interagency Meeting of the North Caucasus Mental Health Committee for IDPs in Ingushetia and Chechnya was held in Nazran. The meeting united representatives from ARD, CARE International, CPCD, Chechen Association of Psychiatrists and Narcologists, MDM, OSCE, Republican psycho-neurological and narcological dispensary of Ingushetia and WHO. The mental health of children is an ongoing The agenda included the adoption of the terms problem in the North Caucasus. of reference of the committee and an exchange of information on the on-going and planned processed by WHO and added to the field hand- activities. book of NGO activities in mental health.

Following WHO’s proposal, the participants ap- proved the terms of reference of the committee, Recent events which include gathering information about the In June 2000, OSCE launched a psychosocial ongoing mental health activities in Ingushetia rehabilitation programme for 100 children in the and Chechnya, coordinating the work of new Yuzhny tent camp in Znamenskoye. In April NGOs, exchanging experiences, finding solutions 2001, the programme was extended to include for emerging problems, coordinating and facili- 100 children from the Severny tent camp at the tating capacity building in the region and moni- same location. The project is being carried out in toring ongoing activities. cooperation with the local NGO “Serlo”. The In order to collect accurate and complete infor- OSCE Assistance Group also operates in the mation on the current activities and plans of all Znamenskoye village of Nadterechny district of mental health actors in Ingushetia and Chech- Chechnya. The programme includes various nya the participants were requested to fill out a types of therapy including collective video, play, special questionnaire. The information will be musical, educational and individual psychologi- cal.

7 WHO, in cooperation with the Chechen Associa- Upcoming events tion of Psychiatrists and Narcologists, opened a On 28 April-2 May CPCD is holding, in psychosocial rehabilitation centre in Grozny, in Sleptsovskaya, a seminar on art therapy. The mid-March. The centre is staffed by a psycholo- seminar is to be delivered by a lecturer trained gist and a professional singer and dancer, and is in art therapy techniques, from the Moscow In- open seven days a week. Seventy-one (71) chil- stitute of Psychotherapy and Clinical Psychology, dren are presently undergoing rehabilitation. for 25-30 participants, mainly from CPCD's Little Each course lasts for three months. In April, the Star programme. centre was provided with teddy bears to be dis- tributed to the war-affected children. Another On 14-19 May, WHO and Medecins Du Monde batch of teddy bears was d onated to a boarding will hold, in Ingushetia, a training workshop on school in Grozny, within the framework of the psychosocial rehabilitation for medical personnel WHO mental health rehabilitation project. from NGOs and MoH Ingushetia and MoH Chechnya. In addition, in April a seminar on psychosocial rehabilitation was carried out for 20 people in On 14-21 May, CPCD is arranging, in the Cri- Grozny (students, professional psychologists and mea, a seminar in art therapy and the use of parents). music and relaxation exercises in psychosocial rehabilitation work for children. This seminar will A new NGO, “Dom Druzei” (House of Friends), be held for the 50 counsellors and psychologists from Moscow, launched a psychosocial rehabili- working at CPCD's Little Star programme in tation programme in the Malgobek district of Chechnya and Ingushetia. Another seminar on Ingushetia through its local partner “Lastochka”. art therapy and music will be held in Ingushetia In Nazran, on 22-24 and 26-28 of April, CARE in June. Qualified trainers from Great Britain and International held the fourth module of its train- Holland will conduct both seminars. ing course for teachers. The programme is tar- The next Interagency Meeting of the North Cau- geted at teachers from high schools in places of casus Mental Health Committee will be held on compact residence of IDPs in Ingushetia and 15 May 2001. teachers from orphanages and high schools of Chechnya.

WHO INFORMATION SERVICES

The WHO information service assists agencies · Field handbook. Health care activities of working in the health sector in the North Cauca- NGOs in the Chechen Republic; sus. This service includes an electronic library in · Field handbook. Health care activities of which most manuals are available in English and NGOs in the Republic of Ingushetia; Russian. Furthermore, hard copies of the English version of the Emergency Health Library Kit are · Field Directory. Ingushetia; and available for copying at the WHO office in Mos- · Map of activities of medical NGOs in the Re- cow (see contact information below). The list public of Ingushetia. below is only the most recent document.

New documents: Please contact WHO for a complete list, to con- · WHO: Improving Women’s and Children’s tribute or to receive a document: Health in Ingushetia. Technical Field Report ([email protected]). Series. February 2001;

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Health in the North Caucasus is a newsletter of the List of abbreviations: Emergency Preparedness and Response programme at the World Health Organization Regional Office for ARD: Agency for Rehabilitation and Develop- Europe. The information is compiled by the WHO ment Humanitarian Assistance Programme in the North ASF: Danish Peoples Aid Caucasus, the Russian Federation. CPCD: Centre for Peacemaking and Community Development All rights are reserved by the organization. The DCA: Dan Church Aid document may, however, be freely reviewed DDG: Danish De-mining Group abstracted, reproduced or translated in part or whole, DRC: Danish Refugee Council but not for sale or for use in conjunction with EMERCOM: RF Ministry of Emergencies commercial purposes. This newsletter is not an IR: Islamic Relief official WHO publication. The views expressed in it ICRC: International Committee of the Red Cross do not necessary represent stated policy of WHO. IRC: International Rescue Committee IMC: International Medical Corps Correspondence and inquiries should be addressed MDM: Medecins du Monde to: Irina Tarakanova [[email protected]] MoH I: Ministry of Health of Ingushetia Russia Office of the WHO Special Representative of MoH RF: Ministry of Health of the Russian Fed- the Director General in the Rusian Federation eration 28, Ostozhenka, MoH Ch: Ministry of Health of Chechnya 119034 Moscow MSF-B: Medecins sans Frontieres-Belgium The Rusian Federation MSF-F: Medecins sans Frontieres-France MSF-H: Medecins sans Frontieres-Holland Tel.: (+7) 095 787 21 52/12 OCHA: Office for the Coordination of Humani- Fax (+7) 095 787 21 19 tarian Affairs OSCE: The Organization for Security and Co- Chief Editor: Dr Vladimir Verbitski [[email protected]] operation in Europe Editors: Jeffrey V. Lazarus [[email protected]] and Irina PINF: People in Need Foundation Tarakanova [[email protected]] PHO: Polish Humanitarian Organization RRC: Russian Red Cross SARCS: Saudi Arabian Red Crescent Society SES: Sanitary Epidemiological Service UNFPA: United Nations Population Fund UNICEF: United Nations Children's Fund UNHCR: United Nations High Commissioner for Refugees WFP: World Food Programme WHO: World Health Organization Zaschita: All-Russian Centre for Disaster Medi- cine "Zaschita"

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