Keywords

In the early decades of the twentieth century, the Soviet Union consistently enchanted foreign visitors with its plans for radical transformation of humankind. Belief in the power of Soviet science to end suffering and disease was a consistent theme in the memoirs of idealistic travelers (Hollander 1998). In 1928 one enthusiastic visitor predicted the combined wisdom of Lenin and Pasteur would soon eradicate all hunger and disease. “The future!” he exclaimed, “is our victory … the victory of communism signifies the salvation of humanity” (Carbo 1928: 70).

Over one hundred years later, it is understood that the Soviet Union did not bring about the salvation of humanity or the perfection of human health. Instead, the USSR collapsed into conflict-ridden rubble after decades of economic stagnation and authoritarian repression. But there are still a number of important lessons to be found between the hopeful beginnings and violent ends of the Soviet experiment. Once excavated these lessons have the potential to help contemporary researchers understand the kinds of health and humanitarian crises that emerge in the aftermath of armed conflicts.

This book presents an extended case study of one ethnic conflict and associated epidemiological crises from the southern Caucasus. The Karabakh war took place in rugged mountainous territory between Armenia and Azerbaijan. The area is approximately 4800 km2, approximately 1.5 times the size of the US state of Rhode Island (Croissant 1998: 10). The mountainous region is heavily forested while the valleys are generally occupied by croplands, vineyards and orchards (see Fig. 1.1 for a detailed outline map of the conflict area).

Fig. 1.1
3 maps. 1. Conflict area has borders with Georgia, Russia, Ukraine, and Kazakhstan in the north and Turkey, Syria, Iraq, and Iran in the south. 2. The Karabakh L O C is to the east of Karabakh Rayon, close to the Iranian border. 3. Karabakh Rayon shrinks in the southern end post reconfiguration.

Outline map of conflict area. The Nagorno-Karabakh line of contact was downloaded from the website of the Armenian Ministry of Foreign Affairs (digitized on GitHub by https://github.com/mkudamatsu/data_karabakh-map). The country borders and the original Nagorno-Karabakh boundary are from the ESRI country and disputed boundaries databases. We have conflated the shapefiles of the line of contact to the country and Nagorno-Karabakh delineation

Full size image

Hostilities began in 1987 and despite several peace accords, tensions remain high in the region. This makes the Karabakh conflict the most prolonged territorial dispute in post-Soviet Eurasia. The most intense phase of fighting lasted from 1988–1994. New hostilities have broken out repeatedly since that time, with major escalation in 2020 and periodic outbreaks of violence through 2022.

As Mary Kaldor described, the Karabakh conflict represents a new kind of warfare that is different from the nation-state wars that defined the early decades of the twentieth century. “New Wars,” (as she termed them) are typically waged between non-state or sub-state actors, involve ethnic or religious violence as well as violence against civilians (2007, 2012). New Wars often have an economic substrate in the informal economy with combatants financing their insurgencies in ways that can intersect with international organized crime. “New Wars,” Kaldor concludes, “are associated with state weakness, extremist identity politics and transnational criminality” (2012: 8). A growing number of conflicts fit this pattern and their expansion coincides with the decline of twentieth-century institutions of nation-state governance in many parts of the world (Bunker 2015; Trabulsi 2015; Gilman 2014).

Kaldor and other researchers have described how non-state actors often take on informal governance functions in territories fragmented by New War conflicts, and these activities can become quite profitable over time (Kaldor 2007; Mandic 2021). This creates an array of perverse incentives for prolonged conflict and instability as war-making can become more lucrative than peace-making (Andreas 2010). For these and other reasons, state-building in the aftermath of New Wars can be difficult and vulnerable to failure.

Because New Wars involve indiscriminate attacks on civilians and social institutions (including schools and health care facilities), they can be challenging for researchers to study in real time. Quantitative survey research can be difficult in an environment with limited infrastructure. Qualitative information from conflict zones is fragmented and security risks to researchers can be high. After his extensive work on the Chechen conflict of the 1990s, for instance, anthropologist Valery Tishkov concluded that conventional ethnographic methods are ineffective in New War environments, “…Information obtained under such conditions is full of slogans, manifestos and intense emotions absent in a calmer climate. Informants may be in such an agitated state that one can record only the background noise of an imposed reality that is often mistaken for ‘hard reality’” (2004: 4).

For these and other reasons we developed a set of spatially and temporally distanced methods to undertake a retrospective analysis of the Karabakh conflict. Qualitative historical and anthropological methods were combined with quantitative geospatial research and census data to reconstruct key elements of the conflict and explore its effects on the natural environment. The goal was to better understand the relationship between New Wars, environmental change and population health crises. These methods are detailed in Appendix A.

During the most intense phase of the Karabakh conflict in the 1990s, there was an epidemic of Plasmodium vivax (P. vivax) malaria in Armenia and Azerbaijan. This was the first recorded outbreak of this ancestral vector borne disease in the Caucasus since malaria was declared eradicated by Soviet authorities in the 1960s. Malaria is one of humanity’s most persistent pathogens (Carter and Mendis 2002; Packard 2007; Shah 2010). There are several varieties of malaria, with P. vivax best adapted to transmission in northern latitudes (White 2011). The disease was once endemic in the USSR, and devastating epidemics were common in the river valleys of the southern Caucasus in the early years of the twentieth century (Hackett 1937; Johnson 1988; League of Nations 1934; Packard 2017). Soviet authorities undertook aggressive eradication campaigns after World War I, but did not succeed in fully controlling the disease for many decades (Johnson 1988).

The reappearance of malaria in the Caucasus during the conflict period of the 1990s indicates that a number of environmental changes took place in a short period of time to make the region newly hospitable to the anopheles mosquito vector. These changes escaped the attention of journalists and scholars embedded in the conflict, who were naturally more focused on the humanitarian crises, territorial instability and fragile political coalitions of the newly independent Caucasus republics.Footnote 1 Once malaria was detected in Armenia a team of epidemiologists from the Centers for Disease Control in Atlanta was dispatched to work with Armenian health authorities to control the outbreak (Centers for Disease Control 1998). But these efforts were primarily focused on the basic work of identifying cases and reducing transmission in a time of extreme crisis. Public health professionals in Armenia did not have an opportunity to explore the larger social or environmental changes that allowed the disease to return to the region after such a prolonged absence.

The Karabakh conflict also merits renewed attention for geopolitical reasons. As Michael Croissant wrote in 1998, “Not only is the Armenia-Azerbaijan conflict one of the bloodiest and most intractable clashes to emerge from the breakup of the Soviet empire, but it is also the only remaining post-Soviet conflict that poses a potentially explosive threat to peace and security on a regional—as opposed to a local—scale” (p. xi). In other words, the southern Caucasus region is located at the intersection of alliances and rivalries between a number of regional powers including Russia, Iran and Turkey. Ongoing tensions in the region signify the potential for a much larger conflict to emerge in the future (Cicero 2020; Crisis Group 2022a, 2022b, 2022c).

What will happen in the Caucasus if widespread instability and armed conflict return to the region? Unfortunately, our research suggests the potential for synergistic outbreaks of old and new pathogens. In addition to malaria, the Karabakh conflict triggered resurgent epidemics of tuberculosis, measles, diphtheria and typhoid fever (Dudwick 1997; Grigorian 1992; Shapiro 1993). Since that time, there have been multiple PHEICs (Public Health Emergencies of International Concern) as global environmental instability, climate change and urbanization continue to accelerate the evolution and spread of new diseases (Hotez 2009; Shah 2016). These developments suggest that any future conflict could easily result in higher mortality from infectious disease than from combat itself (Price-Smith 2008).

Even without formal hostilities, the next few decades are likely to see accelerating waves of human migration and global health risks due to climate change. These population flows will increase risks of other tropical diseases emerging or re-emerging in northern latitudes (Hotez 2016). The United Nations and the World Health Organization recognize human mobility’s relationship to conflict, the changing climate and global health. They urge the development of a comprehensive migrant health agenda that accounts for both long term and acute human mobility (WHO 2018; IDMC 2020).

Remote sensing—the use of satellite images to understand land cover and land use changes—and other distanced methods offer indirect ways to assess the impact of New War conflicts on the environment and vulnerable human populations. Changes in land use, for instance, are recognized as one of the most important variables in the emergence of novel pandemic pathogens (Keesing et al. 2010). Several researchers have also developed techniques for using satellite data to track changes in mosquito habitat, and this work has been usefully applied to assess risks of dengue fever, malaria and West Nile Virus (Anno et al. 2019; Chuang and Wimberly 2012; McMahon et al. 2021; Wimberly et al. 2021). Remote sensing data has also been used to measure rates of abandoned cropland in Eastern Europe and Russia—a key variable in the formation of new mosquito habitat (de Beurs et al. 2016; de Beurs and Ioffe 2014; Griffiths et al. 2014; Lioubimtseva et al. 2013; Meyfroidt et al. 2016; Prishchepov et al. 2017) as well as in Central Asia (de Beurs and Henebry 2004; de Beurs et al. 2018; Horion et al. 2016; Prishchepov et al. 2017). Fewer studies have been focused on the Caucasus (Buchner et al. 2020; Melkonyan 2014, 2015), but they reveal significant forest cover changes as a result of the first Karabakh conflict (Baumann et al. 2015; Buchner et al. 2020).

When combined with qualitative historical and anthropological research, remote sensing data have the potential to create an “expanded epidemiology” to improve analysis of population health crises in New War conflict zones or other regions that are difficult for researchers to access. This extended case study method situates anomalous disease outbreaks deeper in time, across broader geographies, and within more richly contextualized environmental and social histories than conventional work in public health. Remote sensing also allows environmental instability to be rendered visually, in the form of maps that reveal changes in cropland, population flows, water resources and forest cover.

This small book seeks to integrate these environmental, epidemiological and social analyses together in a transdisciplinary framework that we hope will be useful for other researchers interested in the relationship between armed conflict, environmental change and population health. The work is organized into five chapters. Chapter 2 presents a qualitative historical overview of the Caucasus region during the Soviet and post-Soviet conflict periods, including its time as a malaria hotspot in the early twentieth century. One of the goals of this chapter is to remind contemporary audiences that controlling P. vivax required decades of authoritarian social and environmental engineering across broad swaths of territory in the USSR and Europe (Hackett 1937; Johnson 1988; Shah 2010). Much of this history has been forgotten, and malaria is typically categorized as a tropical disease by contemporary global health scholars (Packard 2017). This errant classification may blind contemporary researchers to the vulnerability of Russia and the Caucasus republics to new outbreaks of P. vivax.

Chapter 2 also connects the institutional and ideological decay of formal Soviet institutions—including the institutions of centralized economic planning—to the emergence of an extensive kin-based informal economy in the late Soviet period. As several scholars have described, the informal economy in the Soviet Union functioned as a space of anti-Soviet resistance while also preserving an array of pre-Soviet institutions and regional cultural practices (de Waal 2013; Dudwick 1997; King 2008; Koehler and Zurcher 2003a; Zurcher 2007). Over time, these informal institutions configured “a parallel social order” that often superseded the official institutions of the formal Soviet system, which remained paralyzed by inefficiency and bureaucratic inertia (Koehler and Zurcher 2003b: 150). Once the formal Soviet system collapsed, these informal systems quickly formalized in ways that intensified ethnic and clan-based divisions. Tensions were especially acute in Karabakh due to its status as an Armenian enclave located within the larger political geography of Soviet Azerbaijan.

Chapter 3 presents a compressed historical overview of the first Karabakh conflict period from 1988 until the cease fire agreement in 1994. When the USSR collapsed in 1991 the Karabakh conflict expanded into formal warfare between neighboring states. Both sides were armed with sophisticated Soviet weaponry (Goltz 1998). As Mary Kaldor described, “The war involved fractions of the Soviet army, volunteer militias and paramilitary groups, and criminal gangs as well as the newly established armies of Azerbaijan, Karabakh and Armenia” (2007: 159). In a few short years, there were massive population displacements and repeated cycles of ethnic violence and forced migration. A detailed chronology of the conflict is provided in Appendix B.

Chapter 4 explores the health and humanitarian crises generated by the Karabakh conflict. The UN International Organization of Migration (IOM), a leading inter-governmental organization on migration, stresses the increasing importance of human migration and its role as a social determinant of health (WHO 2018). It is estimated that approximately one million people were displaced from Karabakh and neighboring rayons because of conflict, with the vast majority being Azerbaijani (UNHCR Report 2009). Many of these displaced persons settled in Baku and other regional centers, but hundreds of thousands were also placed in UNHCR camps in regions east of NK and in lowland areas of Azerbaijan.

In addition to malaria, Armenia and other war-torn countries in the Caucasus suffered a number of epidemics of preventable diseases during and after the conflict period in the 1990s, along with prolonged food and energy shortages. Most of the disease outbreaks were controlled with vaccination campaigns and the restoration of public health and municipal services. Malaria, however, is a complex vector-borne disease that cannot be understood without a broader environmental analysis that includes water systems, population mobility and land use patterns.

Overall our remote sensing data reveals the Karabakh conflict had lasting environmental impacts on forests, towns, farmsteads and agricultural production. Logging and forest fires were widespread and many formerly productive croplands fell into a semi-permanent state of abandonment after the 1994 peace accord. Failure to maintain irrigation systems created expansive new mosquito habitat. Even today much of the region remains underpopulated due to ongoing tensions and low intensity conflict.

The Karabakh conflict erupted again in the fall of 2020 with intense fighting over six weeks. Thousands of people were killed and many more displaced. Russia brokered a cease fire agreement that led to an uneasy peace, followed by periodic outbursts of violence. The 2020 peace plan included significant territorial reconfiguration, with areas controlled by Armenia since the 1990s scheduled to be returned to Azerbaijan. In the fall of 2022 protests took place in Armenia against the transfer of these lands. These events are detailed in Chap. 5, which includes a longitudinal analysis of environmental change in the Karabakh region due to years of intermittent violence coupled with multiple rounds of forced migration and resettlement.

In his history of the Karabakh conflict, Thomas de Waal states, “It will take many years for a full picture of what happened in Armenia and Azerbaijan after 1988 to be assembled” (2013: ix). This work attempts to add several new pieces to this complex picture by incorporating information from above and below the human level of perception. Remote sensing data allows us to explore macro level environmental changes associated with the conflict. Incorporating historical and epidemiological research allows us to explore how the conflict facilitated the invasion of microscopic pathogens into vulnerable human bodies.

Overall this work reveals the benefit of integrating material from multiple fields of study to address the connections between armed conflict, environmental change and population health. Specifically, we believe New War conflicts are likely to interact synergistically with climate change in the coming years to generate epidemics of infectious and vector borne diseases that were successfully controlled during the twentieth century. The decline of nation-state governance and erosion of public health prevention measures in many places over the past two decades could easily amplify local outbreaks into regional or global health hazards (Hirschfeld 2019).

If history is any guide the reappearance of these ancestral diseases in the Caucasus could also play a major role in determining the outcome of future conflicts. In analyzing the role of malaria infection among troops in World War I, for instance, malariologist L.W. Hackett described British, French and German armies as completely incapacitated by the disease in 1916, “We had the spectacle of three fine armies, backed by the most powerful nations of Europe and equipped regardless of expense with every modern appointment, virtually paralyzed [by malaria] before they could strike a blow” (1937: 2). For these reasons we believe widespread return of malaria to the Caucasus or Europe could accelerate what some social scientists have termed the “third epidemiological transition.” This refers to a lasting change in overall population mortality from non-infectious to infectious diseases, even in countries that have successfully achieved a “modern” health and mortality profile for many decades (Barrett and Armelagos 2014).