- Open Access
The trauma of ongoing conflict and displacement in Chechnya: quantitative assessment of living conditions, and psychosocial and general health status among war displaced in Chechnya and Ingushetia
© de Jong et al; licensee BioMed Central Ltd. 2007
- Received: 18 December 2006
- Accepted: 13 March 2007
- Published: 13 March 2007
Conflict in Chechnya has resulted in over a decade of violence, human rights abuses, criminality and poverty, and a steady flow of displaced seeking refuge throughout the region. At the beginning of 2004 MSF undertook quantitative surveys among the displaced populations in Chechnya and neighbouring Ingushetia.
Surveys were carried out in Ingushetia (January 2004) and Chechnya (February 2004) through systematic sampling. Various conflict-related factors contributing to ill health were researched to obtain information on displacement history, living conditions, and psychosocial and general health status.
The average length of displacement was five years. Conditions in both locations were poor, and people in both locations indicated food shortages (Chechnya (C): 13.3%, Ingushetia (I): 11.3%), and there was a high degree of dependency on outside help (C: 95.4%, I: 94.3%). Most people (C: 94%, I: 98%) were confronted with violence in the past. Many respondents had witnessed the killing of people (C: 22.7%, I: 24.1%) and nearly half of people interviewed witnessed arrests (C: 53.1%, I: 48.4%) and maltreatment (C: 56.2%, I: 44.5%). Approximately one third of those interviewed had directly experienced war-related violence. A substantial number of people interviewed – one third in Ingushetia (37.5%) and two-thirds in Chechnya (66.8%) – rarely felt safe. The violence was ongoing, with respondents reporting violence in the month before the survey (C: 12.5%, I: 4.6%). Results of the general health questionnaire (GHQ 28) showed that nearly all internally displaced persons interviewed were suffering from health complaints such as somatic complaints, anxiety/insomnia, depressive feelings or social dysfunction (C: 201, 78.5%, CI: 73.0% – 83.4%; I: 230, 81.3%, CI: 76.2% – 85.6%). Poor health status was reflected in other survey questions, but health services were difficult to access for around half the population (C: 54.3%, I: 46.6%).
The study demonstrates that the health needs of internally displaced in both locations are similarly high and equally unaddressed. The high levels of past confrontation with violence and ongoing exposure in both locations is likely to contribute to a further deterioration of the health status of internally displaced. As of March 2007, concerns remain about how the return process is being managed by the authorities.
- Traumatic Event
- Sexual Violence
- Health Complaint
- General Health Questionnaire
- Generalise Anxiety Disorder
The conflict in Chechnya has resulted in over a decade of violence, human rights abuses, criminality and poverty. Since the start of the second war between Chechnya and Russia in 1999, thousands of civilians have been killed or have disappeared, all in a climate of impunity.
Years of conflict have resulted in severe destruction of health infrastructure. Many doctors have left the country, while those who remain in Chechnya often fear for their personal safety. Lack of experienced medical personnel, especially in remote rural districts, is one of the biggest problems facing Chechnya's health system today.
The last decade of conflict in Chechnya resulted in around 260,000 Chechens being displaced to neighbouring Ingushetia, most finding shelter in tent camps and collective squats (Kompakniki) or spontaneous settlements – farms, sheds, train wagons, and factories. Living conditions in tent camps and spontaneous settlements have been poor. In a 2003 survey carried out by Médecins Sans Frontières (MSF) , 54% of the families interviewed in tent camps in Ingushetia stated that their tents leaked, did not have protection from the cold, or had no flooring in conditions where temperatures regularly fall bellow -20°C.
The Ingushetian and Russian governments have increased pressure on the Chechen displaced population to repatriate. Physical, psychological and administrative harassment, the cutting-off of basic services such as gas, water and electricity, and intense propaganda about imminent camp closures, were all used to compel people to return to Chechnya . 'Repatriation' was pushed forward despite the fact that people did not want to return to Chechnya due to the continuation of the conflict and insecurity, and the lack of proper shelter and adequate health services in Chechnya.
To inform the future direction of assistance programmes MSF undertook quantitative surveys among the displaced populations on both sides of the border – both in the spontaneous settlements in Ingushetia and temporary accommodation centres (TACs) housing returned internally displaced within Chechnya. As a consequence of poor health infrastructure and limited external assistance, the health status of internally displaced in Chechnya and Ingushetia is poorly documented; to our knowledge no systematic data on the general and psychosocial health status of this population have been previously published.
In the following reporting of findings, the Chechen Temporary Accommodation Centres (TACs) and the Ingushetian spontaneous settlements (Kompakniki) are shown in the text by using: 'C' for Chechnya and 'I' for Ingushetia.
256 people in Chechnya and 283 people in Ingushetia were interviewed. None of those approached for interviewing refused and no interviews were interrupted (i.e. 100% completion). The vast majority of interviewees were Chechen; despite randomisation more females were interviewed then men (C: 70.3%, 180; I: 65.4%, 185). To a lesser extent females were also over-represented in the general population (C: 52.5%, I: 55.4%).
Displacement mainly occurred in two periods, consistent with periods of severe conflict in Chechnya: 1994/1995 and 1999/2000. The majority of those interviewed had been displaced for at least four years and had changed location between two and five times. Most participants indicated a wish to return to their place of origin. The two groups stated different reasons for not returning. For those living in Chechnya lack of shelter was the main reason for not returning to their hometown (200, 78.4%) while insecurity was less important (25, 9.8%). For those interviewed in Ingushetia insecurity was rated much higher (139, 49.1%) and lack of shelter (129, 45.6%) was rated lower.
The main stated reason for those who left Ingushetia to live in the Chechnen TACs were: the poor living circumstances in the spontaneous settlements, homesickness and the prospect of compensation offered by the authorities.
In Ingushetia, lack of proper shelter (C: 11, 4.3%, I: 108, 38.2%) and inability to keep warm (C: 47, 18%, I: 113, 40%) was reported more frequently than in the Chechnen settlements. The two sites were equally poor in terms of toilet facilities (C: 184, 72.4%, I: 255, 90.1%) and food was a problem for one in ten (C: 34, 13.3%, I: 32, 11.3%) Almost all respondents were dependent on charity. It should be noted that while the TACs were intended for short stay only, a substantial number of people had been there for one to two years (87, 34.1%, n = 255), or longer (33, 12.9%).
Confrontation with violence
Month prior to the survey
experience of traumatic incidents occurring in the month before the survey
n = 256
n = 283
Fears for personal safety
Exposure to violence
Directly targeted by violence themselves
Loss of nuclear family memberi in past 2 months
Since start of the conflict
Overview of participants' experience of traumatic incidents occurring since the start of the conflict (1994). (Participants could report more then one event)
n = 256
n = 283
Exposure to violent events
No exposure to conflict
Attack on house/village
Taking risks to find food
Burning of houses
Known instances of rape
Detention and hostage
Injured by mine
Extended family, friend, neighbour
Loss of house
Loss of all possessions
Respondents from Chechnya and Ingushetia witnessed a similar number of violent events. More than one in five witnessed the killing of people (C: 58, 22.7%, I: 68, 24.1%) and nearly half had witnessed maltreatment (C: 144, 56.2%, I: 126, 44.5%). Several people had been witness to torture (C: 14, 5.4%, I: 16, 5.6%). While many people had heard about incidences of rape (C: 181, 71.1%, I: 204, 72.1%), only a few had witnessed it (C: 2, 0.8%, I: 7, 2.5%).
In Chechnya 88 (34.4%) respondents had personally experienced violence since the onset of the conflict. In Ingushetia this was slightly lower, at 80 (28.3%). The type of self-experienced violence was similar in both locations, the most frequently reported events being maltreatment, detention, arrest, and forced labour. Torture and mine injuries were also reported. Disappearances among members of the nuclear family (partners, siblings) affected one fifth of the interviewees (C: 57, 22.3%, I: 54, 19.1%).
Nearly all respondents reported losing all possessions including their house (C: 254, 99.2%, I: 268, 94.7%).
Mortality in the previous two months
Human loss reported by participants
n = 256
n = 283
Mortality in the 2 months preceding the survey
Loss of nuclear family memberii in past 2 months
Mortality since the start of the conflict
Reported Deaths (classified by participants relationship to individual affected)
Nuclear family (parents, children, siblings)
Mortality since the start of the conflict
Since the start of the conflict one third of the respondents in both Chechnya and Ingushetia (C: 101, 39.5%, I: 95, 33.6%) reported the loss of at least one nuclear family member (Table 4). Over two-thirds of people had lost a friend and/or neighbour (C: 189, 73.8%, I: 200, 70.7%). Many respondents actually witnessed the violent death of those close to them.
General Health Questionnaire
Subjective health reports
Self reported health and health complaints over the past six months (maximum four complaints per participant).
Subjective (self reported) health
n = 255
n = 282
Often feeling unhealthy in general
Health not a concern
Health problems experienced in last 6 months (percentages from total number of complaints)
n = 659 complaints
n = 752 complaints
Availability and accessibility health services and drugs
A considerable number indicated that medical services were rarely (C: 96, 37.5%; I: 77, 27.2%) or not at all accessible (C: 43, 16.8%; I: 55, 19.4%). Over half reported difficulties in accessing drugs, stating they were rarely (C: 92, 35.9%; I: 85, 30.0%) or never available (C: 66, 25.8%; I: 70, 24.7%).
Coping mechanisms of the participants (maximum of three answers possible)
n = 256
n = 283
'Turn my head' (see footnote vii)
n = 256
n = 283
n = 255
n = 220
Support of family members
-Talking to others
Suicide is considered a sin in the Muslim religion (as in many other societies) and therefore a taboo subject. Nevertheless, nearly one in ten respondents (C: 21, 8.2%; I: 28, 9.9%) knew somebody who had attempted suicide (although several respondents could be referring to the same incident).
When asked what advice respondents could give MSF regarding its activities most responses advised MSF increasing their counselling activities (C: 81, 31.6%; I: 114, 40%). Some suggested MSF increase its medical activities (C: 50, 19.5%; I: 27, 9.5%). Notably, a number of people wanted MSF to advocate on their behalf (C: 38, 14.8%; I: 53, 18.7%).
To our knowledge this is the first publication of the general and psychosocial health status of Chechnen's internally displaced. The self-reported health conditions and the general health questionnaire showed high levels of medical and psychosocial needs. Access to health care (including mental health) was poor in both locations. The most frequently used coping mechanisms for psychological distress (denying the problem, praying, support of family members) did not seem to be effective. Living conditions in the Ingushetian spontaneous settlements were rated worse while people in the Chechnen TACs had more security problems (feeling less safe, more incidents in the last month, most violent deaths in the last two months).
Our findings on the General Health Questionnaire 28 (GHQ 28)  indicated that nearly all IDPs were suffering from health complaints such as somatic complaints, anxiety/insomnia, depressive feelings or social dysfunction when applying the recommended cut-off score for this questionnaire. Even when a higher cut-off score was set, still around 80% of respondents were found to suffer from general health problems. This is substantially higher than findings from elsewhere: for example a study from Iran using the same instrument (with a normal cut off) found a prevalence of 17% . Subjective health impressions further confirmed the poor general health found in the GHQ 28, with half of respondents in both locations reporting to often feel unhealthy. Also, the average number of complaints pointed in the same direction.
The types of complaints reported are associated with a high level of (traumatic) stress, with non-specific physical signs like headaches and muscle/joint/body pain commonly reported . Cardiovascular complaints represent one quarter of all complaints mentioned; however, to what degree these are linked to the stress or the general situation of conflict is unclear, as incidence of cardiovascular complaints in the former Soviet Union is generally high.
For displaced populations, the length of stay in temporary (and often precarious) accomodation is associated in other studies with higher likelihood of developing symptoms of psychological distress [22–24]. The average length of being displaced in both locations was five years. Most people had to move at least two times.
Chronic exposure to traumatic events is associated with higher levels of mental health problems and poorer physical health [25, 26], and witnessing and self-experienced extreme violence is also associated with psychosocial and mental health problems, including depression , generalised anxiety disorder , and post-traumatic stress disorder [11, 12, 31, 32]. Both survey groups had experienced similar levels of violence since the start of the conflict (exposure, witnessed, self-experienced), possibly contributing to ill health outcomes.
Nearly all of the people interviewed wished to return to their place of origin. In Chechnya, lack of shelter was the main reason for not returning; in Ingushetia, insecurity was the most important concern. This difference may be explained by the fact that for people in Chechnya insecurity was a daily reality which cannot be changed, whereas for those in Ingushetia the security situation in Chechnya was perceived as a threat to avoid.
Caution is required to avoid facile labelling the survey population with physical or mental diagnoses. There is a tendency to report on the mental health consequences in terms of psychiatric or psychological disorders often using post-traumatic stress disorder (PTSD) as the pathway to show the mental health consequences of war. It is incorrect to reduce the experience of conflict and violence to the individual using bio-psycho-medical terminology , and it may be unnecessarily stigmatising to label someone with PTSD when PTSD which is not the only possible disorder that can result from a traumatic event, even according to the DSM IV system (Diagnostic Statistic Manual for Mental Health Disorders number IV, ). Co-morbidity, most notably depression  and generalised anxiety disorder [30, 35, 36] has been found to be more prominent in trauma-affected people than was originally assumed. Another consideration is that although nearly all people confronted with war will suffer various negative responses such as nightmares, fears, startle reactions and despair, they will not all develop mental disorders. There are individual ways of adapting to extreme stress  that should not be overlooked. Lastly, transfer of Western conceptual frameworks of psychological stress and mental disorders to different countries and cultures is problematic .
Nevertheless, attention must be paid to stress and distress in the survey population since prolonged states of either can cause changes in patterns of living that are associated with physical and mental damage [19, 38]. The need for health (including mental health) support is further indicated by the fact that over a third of respondants in both locations indicated that MSF should increase their counselling activities. In response to these findings, MSF began a psychosocial intervention in the TACs in Chechnya in February 2004.
Possible limitations to the survey
The sampling method has been satisfactory. Despite the sensitivity of the questions the completion rate was high (100%). There are, however, a number of potential limitations that merit consideration.
Compared to the overall population data of the authorities the number of people interviewed in Ingushetia was higher then the planned sample size (283 versus 257) suggesting that population figures given by the government are an underestimation. In both studies women were over-represented despite the sampling procedures. The most plausible reason for this is the timing of the interviews: survey teams only worked during the day, when most males were away from the household trying to find work; however, due to security concerns the survey times were limited to daylight hours. The high number of women may have resulted in an overestimation of health needs as women generally report more frequent health concerns compared to men. However, because of the female bias the values on the GHQ might be somewhat lower for the entire population, the main conclusions remain valid. Another possible consideration is that the survey timing may also have caused selection bias of ill people because they tend to stay home.
The survey has no precedence and therefore the GHQ 28 had not been validated for use in the region. We do not believe that this invalidates its value. Health data were assessed through three different methods (semi-structured, questionnaire, open-ended questions), with all findings pointing in the same direction, and triangulation of information generated from different health related topics (displacement, living conditions, confrontation with violence, loss, general health, coping) together establish a picture of violence-related suffering of those enduring the ongoing conflict on the Caucasus. The use of other approaches such as structured clinical interview and clinical examination would certainly have added weight to the validity of our findings, but for operational security reasons this was not possible.
This survey included historical questions over a long timeframe (1994–2004), in addition to questions in the more recent past (30 or 60 days). Recall bias is always a potential confounding variable, particularly when reporting traumatic events. However, an important recent study  has shown that refugees remain consistent in reporting major traumatic events such as those we recorded, with more variability occurring in recall of minor historical details. Thus we believe that this bias does not pose a serious threat to the validity of this study.
The category of questions relating to exposure to violence may have included some events that should have been classed as self-experienced or witnessed events despite instructions to interviewers to exclude them from the exposure category, and this may have caused some over-reporting in the data on exposure to violence. Nevertheless, presentation of all categories including exposure remains relevant because proximity to violence is associated with increased risk of health problems or even pathology [11, 31]. The high level of war-related violence is also reflected in hospital admission data. According to hospital statistics around one in 20 admissions (783 out of 15,602) to the hospital and outpatient trauma point in Grozny in 2004 were for war trauma. Of those, 384 (50%) were gunshot wounds and 276 (35%) were mine or other explosive wounds. Around a third of these patients died inhospital.
The findings on rape may be underreported. Sexual violence is a taboo topic in Chechnya, but is known to occur. Other organizations working with Chechen refugees have reported a high incidence of repeated sexual violence. In those surveys, it may be that women only felt free to bring up their experience because they were abroad, far away from potential community repercussions . In our survey many people had heard about incidents of rape but only a few had witnessed it, and only one person reported being raped. According to Muslim and local traditional laws, a raped woman is often stigmatised and her whole family becomes a victim of the rape. A Chechen man will be very unlikely to admit to having been raped .
While time was taken to carefully explain the terms used in the questionnaire to both survey staff and respondents, we cannot entirely exclude subjective interpretation by interviewer or interviewee. Specifically, for sexual violence we used in our survey the World Health Organization's definition of sexual violence as being "any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic a person's sexuality, using coercion, threats of harm or physical force, by any person regardless of relationship to the victim, in any setting, including but not limited to home or work" . Given the strict religious and cultural norms on sexuality and the comments of our staff we were confident it was in agreement with the popular understanding among Chechens. Although we have no indications this assumption was wrong it is possible that some respondents used their own interpretation. Nevertheless, more objective definitions of questions relating to sexual violence would be useful for such studies.
Despite these potential limitations the survey provides valuable data on the confrontation with violence-related health problems from a conflict where data are near absent due to non-functioning surveillance systems and limited access for external actors.
Implications of our findings
Recent developments in the Caucasus have overtaken the situation surveyed in early 2004, with the authorities rapidly closing the spontaneous settlements in Ingushetia and sending the IDPs back to the Temporary Accommodation Centres (TACs) in Chechnya.
Our survey data showed that many who returned to Chechnya from Ingushetia were simply changing their status from being IDPs outside to being IDPs inside Chechnya. The fate of those IDPs accommodated in TACs remains an important longer-term question. As of March 2007 concerns remain about how the authorities manage the return process and whether considerations on the wellbeing and health of this group are being taken into account while planning this process.
International humanitarian assistance is an important external support to the population, both in Ingushetia and in Chechnya. However, the extremely high levels of insecurity threaten the aid operations in the Northern Caucasus: since 1995 more than 50 international humanitarian and workers have been abducted, and some of them have been murdered. As a result the number of international and national staff working in the region has been dramatically reduced. Due to the highly insecure context MSF has had to conduct "remote control" (minimal contact) operations in Chechnya with minimal direct expatriate supervision.
Overview of demographic and socio-economic findings
Total population number in TACs, Spontaneous Settlements (official figures)
Interviewees (one per household)
Total number of family members in surveyed households
Average number of family members in surveyed households (official average in population in brackets)
Displaced > 4 years
-During first Chechnen War (1994–1995)
-During second Chechnen War (1999/2000)
Displaced < 4 (missing data)
Displaced more than once (2–5 times)
Wish to return home
Reason for not returning to place of origin
Lack of shelter
Reasons for returning to Chechnen TACs
Living circumstances in spontaneous settlements Ingushetia
Compensation offered by authorities
Directly forced to return
Indirectly forced to return (camps closed in Ingushetia)
Hope the situation improves
Other (missing data)
Living Circumstances in the Chechnen TACs, Ingushetian spontaneous settlements
Poor shelter against weather
Unable to keep warm
Poor toilet facilities
Insufficient food (defined as on at least 5 days a week, having 1 meal or less per day)
Dependence on outside assistance
Due to security constraints a number of contributors are not mentioned as authors despite their significant input in this survey. We would like to thank Clair Mills for extensive review and helpful suggestions during the preparation of this manuscript.
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