Keywords

2.1 The Caucasus

The Caucasus region consists of a mountainous land bridge that links Europe and Asia, occupied by dozens of distinct ethnic groups. The combination of rugged geography, strategic geopolitical importance and ethnic complexity has given the region a good deal of historical mystique, as well as longstanding patterns of violence and instability (Broers 2021; Croissant 1998; de Waal 2013; King 2008; Tishkov 1997; Zurcher 2007). Since the nineteenth century, various imperial powers—including Great Britain, Russia, Turkey and Iran—have tried to control the region and forcibly assimilate its diverse ethnic groups into their expanding empires, but with little success. Russia’s failed territorial incursions into the Caucasus in the late 1800s led to chronic violence, with “wholesale destruction of villages,” and widespread torture of resistant populations (King 2008: 76). Russian troops also engaged in repeated bouts of ethnic and religious cleansing, and a number of Muslim villages were forcibly depopulated in the 1860s (King 2008: 94).

In the late nineteenth century, the ethnic composition of the Karabakh region was predominantly Armenian while the surrounding territories were composed of ethnic Tatar (Turkic) populations (Saparov 2012; Russian Empire Census n.d.). The census results from 1886 and 1897 indicate that the composition of the territories and major cities was fluid during this time (Russian Empire Census n.d.; NK Census 2005). This fluidity is reflected in the instability of the region due to tensions and fighting between the Russian and Ottoman Empires and the shifting relationships between the Ottoman Turks and Armenian residents in the Eastern Ottoman Empire (Saparov 2012). After the end of World War I and the collapse of the Russian and Ottoman Empires, a period of transition saw the brief formation of a Transcaucasian state, followed by the newly independent states of Armenia and Azerbaijan. The international borders of these states followed the Russian and Ottoman boundaries, and the territory of Karabakh became an issue of immediate debate among surrounding states. Episodes of violence and destruction occurred, shifting the population demographics in the region (Saparov 2012; de Waal 2013).

Beginning in the 1920s, Soviet officials sought to divide the Caucasus into ethnofederal units ranked hierarchically into three administrative categories. As Broers has described, “Each tier possessed corresponding attributes of statehood in descending order, with union republics possessing a formal right of self determination” (2021: 24). These tiers included SSRs (Soviet Socialist Republics), ASSRs (Autonomous Soviet Socialist Republics) and AO (Administrative Oblasts) (Zurcher 2007: 25).

Armenia and Azerbaijan were both SSRs, and were considered semi-sovereign states, at least in theory. Each SSR had its own government, military and constitution. ASSRs were administrative sub-units located within the boundaries of SSRs but populated by ethnic minorities. Chechnya, Dagestan and Ossetia were all ASSRs during the Soviet era. In 1923 Karabakh was formally declared one of two AO (Administrative Oblasts) located within the larger SSR of Azerbaijan, and became known as NKAO (Nagorno-Karabakh Administrative Oblast). The second semi-autonomous region located within the AZSSR (Azerbaijan Soviet Socialist Republic) was the southern territory of Nakhichevan, which was transferred by Turkey to the USSR as part of a treaty negotiated in the early 1920s (Broers 2021).

One goal of these administrative divisions was to reduce opposition to Soviet rule by dividing ethnic territories across ethnofederal units. As Broers stated with respect to the Armenian and Azerbaijani SSRs, “each republic’s largest minority belonged to the other’s nationality” (Broers 2021: 24). This gave the USSR a potential “fifth column” to activate against an unruly SSR government who might seek too much independence from the Soviet center. Michael Croissant has also described the formation of the NKAO as resulting in Stalin’s “divide and rule” principle during his time as Soviet Commissar for Nationalities during the 1920s (Croissant 1998: 20).

2.2 Malaria in the Caucasus

Contemporary population health researchers may be surprised to learn that northern latitudes can be quite hospitable to malaria parasites. As historian Randy Packard has detailed, the designation of malaria as a tropical disease is a recent practice that came about following the successful eradication of temperate or seasonal P. vivax from northern regions in Europe in the mid-twentieth century (2007). The most severe form of malaria—P. falciparum—is a true tropical disease and cannot overwinter in northern climates. P. vivax, however, is an ancestral temperate strain that developed a remarkable ability to hibernate in the human body during winter months (White 2011). It re-emerges in the spring when mosquitos begin to hatch. In northern Russia, specialized arctic strains of P. vivax have been known to incubate in the human body for over a year (Johnson 1988).

Seasonal P. vivax malaria is much less likely to be fatal than tropical P. falciparum, but the disease can create significant morbidity, especially in agricultural populations during planting and harvest seasons (Bassat et al. 2016; Snowden 2006). In the memorable words of Sonia Shah,

[V]ivax malaria … was not a killer. Rather it enslaved its victims, imposing a constant and unrelenting tax in blood. The convulsions of fever and chills arrived every summer and fall, as soon as the first mosquitoes fed on the blood of an obliviously relapsing carrier of dormant parasites. P. vivax infected the placentas of growing fetuses. Infected babies withered, with stunted immune defenses that rendered them vulnerable to diarrhea and pneumonia. Under the spell of chronic vivax infection, grown men and women weakened to the point that their ambitions drained away and they became anemically prone and wan, just vital enough to make more blood cells available for a later parasite feed. (Shah 2010: 32)

For these reasons, societies with uncontrolled P. vivax often have high rates of food shortages, poverty and economic stress (Sachs and Malaney 2002; Litsios 2002; Shah 2010; Snowden 2006). Because of its unique qualities as a blood parasite, malaria infection negatively impacts overall immunity, especially for young children (Anvikar et al. 2020; Bassat et al. 2016). High rates of P. vivax infection also increase overall mortality from all infectious diseases. In his analysis of malaria and demographic change in Italy, Frank Snowden stated, “Longevity and life expectancy data … revealed a terrible toll in radically foreshortened lives” (Snowden 2006: 15). Widespread malaria dramatically amplifies the health and mortality impact of many childhood diseases. One study in Malaysia, for instance, revealed that “disrupting malaria transmission sent other infectious diseases—diarrhea, dysentery, nephritis, accesses, tuberculosis, convulsions—plummeting as well” (Shah 2010: 178). A promising vaccine has been developed for P. falciparum malaria, but there is still no vaccine for P. vivax Drug treatments can be complicated due to ancestral genetic adaptations like G6PD deficiency (Carter and Mendis 2002). P. vivax is under-researched compared with P. falciparum, even though it is the most common form of malaria with an estimated 2.5 billion people considered at risk worldwide (Bassat et al. 2016).

2.3 Early Public Health Work in the Caucasus

One of the most significant obstacles limiting Russia’s imperial incursions into the Caucasus in the 1800s was the presence of widespread epidemic malaria (Hackett 1937; King 2008). Malaria was very common throughout Europe and the Caucasus in the nineteenth and early twentieth centuries (see Fig. 2.1 for a historic map of malaria case density in the Caucasus). Malariologist L.W. Hackett once described the disease as “a great lake inundating all of Europe” (Hackett 1937: 3). Seasonal epidemics were especially devastating in the lowland Kura and Araks River valleys in the early decades of the twentieth century. In 1913 an unnamed public health officer described a “malignant” form of malaria widespread along the Volga River, with over five million cases per year estimated to occur in the region. The author asserted that no province in Russia was free of the disease, but cases appeared to be most heavily concentrated in the southeastern part of the country. “The slow flow of the Russian rivers,” the officer wrote, “creates numerous swamps along the borders of the rivers, and this circumstance, if accompanied by excessive heat during the summer months, is the cause of the presence of millions of mosquitoes” (Public Health Reports 1913: 207). In his report, he concluded that malaria was the “chief obstacle to successful colonization of the Caucasus and Turkestan” and overall “the cause of serious injury to the economic welfare of the population” due to its seasonal impact on agricultural labor (Public Health Reports 1913: 207).

In the early 1920s another report estimated malaria was a “widely prevalent … scourge in the Caucasus republics … and … the most important of all communicable diseases in Armenia” (Public Health Reports 1924: 223). A report from the League of Nations Malaria Commission noted that in 1923 malaria cases in the USSR were estimated to be over 13 million, whereas before World War I they averaged only around 3.5 million per year. In the southern Caucasus over one million people were estimated to be seasonally infected “most of whom were not receiving medical treatment” due to the high cost of quinine (Public Health Reports 1924: 224). In districts with high rates of malaria, it was not uncommon for up to 40% of the population to be affected in spring planting and fall harvest seasons (Johnson 1988: 34).

The USSR experienced a series of devastating famines during the 1920s, accompanied by epidemics of typhoid, typhus and cholera that spread into Eastern Europe (League of Nations 1922; Tarassévitch 1922). In 1925 the British Medical Journal linked the rapid increase in epidemic malaria in Russia to “vast movements of the population due to famine” as well as “climate conditions favoring the mosquito” (British Medical Journal 1925). In other words, the combination of increased population movements and increased population vulnerability led to explosive epidemics. Russia’s post war outbreak soon spread internationally with cases exported to England, Germany and even far northern arctic regions (Hackett 1937: 2).

This pattern is common with P. vivax, which can have major fluctuations in virulence and prevalence configured by environmental conditions, varying population immunity and underlying population health (Hackett 1937). The disease usually produces mild symptoms in familiar populations, but can be deadly to new arrivals, undernourished hosts or vulnerable migrants. This is one of the reasons malaria created barriers to foreign colonization in the Caucasus: invading forces inevitably included soldiers with no prior exposure and these individuals suffered debilitating malaria infections while local populations were still able to fight. Fluctuations in weather patterns also interrupted seasonality of P. vivax, so that collective immunity was never fully established in the Caucasus, and devastating epidemics could appear after years of minor outbreaks (Johnson 1988; Hackett 1937).

2.4 The Caucasus: Ethnicity and Health in the Soviet Era

The Soviet Union completed its takeover of the Caucasus region in 1924, and immediately began campaigns to control infectious diseases and to subjugate the unruly ethnic groups that had historically proven so resistant to colonization. At this time, the population of NGK was predominantly Armenian. The first Soviet period census of the region was in 1926. The NGK region was composed of 125,300 residents. Of these, 89% were ethnic Armenian, 10% Turkic and the remaining were Russians. Several

surrounding villages and cities (including Shusha) were composed of ethnic Azerbaijan residents (NK Census 2005). As Broers has pointed out, the original borders of the Nagorny-Karabakh Administrative Oblast (NKAO) were designed to maximize separation of ethnic Armenians and Azeris (2021). The 1926 census, for instance, revealed the population of NKAO to be almost 90% Armenian in an area that represented approximately 5% of the Soviet Republic of Azerbaijan (AZSSR) (2021: 26).

Fig. 2.1
A map of the Caucasus region highlights 3 countries and gives their malaria case densities. Georgia, Armenia, and Azerbaijan have increasing values in order.

Map of malaria case density in the Caucasus 1920s. (Data is taken from League of Nations Malaria Commission reports, 1920s)

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In the 1930s, ethnic groups in the region were targeted for aggressive cultural “modernization” by Soviet authorities, and these programs included forced suppression of many ancestral cultural practices. Traditional subsistence practices, marriage patterns, clan affiliations, and religious practice were denounced by Soviet authorities as “crimes of custom” punishable by property confiscation, fines or prison (King 2008: 190). Ongoing resistance to Soviet control eventually led to wholesale deportation of thousands of Chechens, Balkars, Ingush and other groups from their ancestral lands to barren regions of Central Asia (King 2008; Tishkov 2004: 23). More than 300,000 Chechens and 80,000 Ingush were forcibly relocated in the 1940s, and their depopulated villages were resettled by Russian migrants, increasing local pressures for assimilation and Russification (King 2008).

Ethnic populations remaining in the Caucasus were eventually assimilated into quasi-ethnic administrative states that tolerated minor expressions of identity but outlawed any real challenges to secular Soviet homogenization. As Christopher Zurcher described, “On the surface, the Soviet type sovereign nation-states that were created as building blocks of the Soviet Union looked ‘modern’ but as with many other Soviet modernization projects, they were, in fact, more of a simulacrum of modernity” (2007: 31).

Soviet public health programs were developed with similar ideology of authoritarian modernization. Health campaigns in the first and second Five Year Plans were designed to rapidly assimilate rural areas under Soviet rule. Much emphasis was placed on the construction of hospitals and health facilities, and the creation of favorable reports detailing rapid progress in the control of preventable infectious diseases (Cockerham 1999). In some instances these Soviet public health efforts were “simulacra” or artificial monuments that reflected the ideology of health modernization but were ultimately bereft of key resources (Feshbach and Friendly 1992; Garrett 2000).

Malaria was not subject to the same level of politicization as Soviet campaigns against typhus, plague or cholera (Cockerham 1999; Johnson 1988). Instead, Soviet malariologists undertook complex environmental engineering and drainage projects designed to reduce seasonal flooding along the Volga basin and limit breeding grounds for anopheles mosquitos. There were also elaborate engineering projects in Armenia near the border with Turkey designed to funnel surface water into large waterways, eventually draining into the Araks River.Footnote 1 These efforts improved the agricultural production and reduced the pools and waterways used by the anopheles mosquito vectors. These efforts were paired with programs to improve housing, screen windows and limit outdoor sleeping (a common practice in peasant communities in summer months). Medical stations were established to provide regular doses of quinine to rural peasants in order to eliminate dormant parasites hidden in human bodies, but with mixed success (Tchnesova 1998).

The key innovation that finally led to lasting malaria control and eradication was the development of DDT, an insecticide that became available shortly after World War II (Shah 2010). At this time, political leaders in the United States and Europe recognized the devastating impact of malaria on military operations during the war. The German army, for instance, intentionally engineered an epidemic of malaria in Italy by flooding marshlands with brackish water to create expansive breeding grounds for the mosquito A. labranchiae. They also confiscated Italy’s stockpiles of anti-malaria drugs before retreating from the region at the end of the war. The resulting epidemic infected over 100,000 people (Shah 2010: 215). Malaria also impacted US military operations in the Pacific and decimated troops in New Guinea and Guadalcanal “felling more soldiers than enemy combat” (Shah 2010: 215).

DDT was far more effective than previous generations of chemical pesticides because of its environmental persistence. It was cheap to manufacture and did not require an extensive workforce since spraying could be done only once per season due to its remarkable persistence in the environment. As malariologist Paul Russell stated in 1952, “The special virtue of these insecticides [like DDT] is their lasting effectiveness. Because they remain lethal to mosquitoes many months after they are applied, they make it possible to wrest a region from the insects and hold it against reinvasion” (1952: 23).

Widespread use of DDT led to a decline in malaria cases in Italy from over 400,000 per year in 1950 to fewer than 1000 in 1951 (Russell 1952). Similar declines occurred all over the Pacific, Latin America and in the United States. India’s caseload declined from seventy-five million before World War II to fewer than 100,000 in the mid-1950s (Shah 2010: 229). In Venezuela all homes in malarious regions were sprayed and the disease was “suppressed to insignificance” in just a few years (Russell 1952: 24). The Soviet Union also participated in these global efforts and finally achieved malaria eradication in the Caucasus in the early 1960s (Tchnesova 1998).

DDT was outlawed in the 1970s, and after that time malaria control in the USSR was maintained through regular disease surveillance and inspection of waterways.

Human mobility was limited during this time and Soviet borders were generally closed, so the potential for reintroduction of malaria to the Caucasus was low. These prevention and control measures were sufficient to maintain the region’s malaria-free status until the conflict period of the early 1990s.

2.5 Late Soviet Political Economy: Setting the Stage for Conflict

By the 1970s the centralized economic system of the USSR began to take on very different qualities than those envisioned by the original architects of the Soviet system. Specifically, the formal economic sector became increasingly hollowed out and the majority of goods and services were siphoned into exchange networks organized by entrepreneurs in the informal economy (Garrett 2000; King 2008; Ledneva 1998; Zurcher 2007). This happened for a variety of reasons, but most significantly from the inability of the centralized economic system to supply industries or individuals with basic goods essential for survival. In the Soviet system, factory managers were faced with rigid production quotas, even though the state could not provide the raw materials required for manufacturing. Criticizing supply chain failures was risky—equivalent to expressing political dissent—so a variety of improvised solutions developed that maintained the facade of Soviet socialist success, but further eroded any vestiges of institutional honesty or compliance with the dictates of the central government.

These improvised solutions included elaborate systems of informal exchange organized by extended kin groups and hierarchical patronage networks. As Friedrich and Brzezinski described, “[Soviet] Managers … maximize their achievements by taking shortcuts on standards or by actually falsifying records; they organize informal arrangements among themselves, based practically on bribery, to avoid control and to exchange necessary items… ” (1965: 212). Over time, these practices expanded into proxy expressions of political dissent. One anthropologist stated succinctly, “the [Soviet] regimes were constantly undermined by internal resistance and hidden forms of sabotage at all system levels” (Verdery 1996: 20). Daniel Chirot described how Soviet economies turn into “vast patronage pyramids” due to the fact that “each [factory] leader and administrator in the chain of command was trying to build up a personal clique of followers who could be counted on for support…” (1994: 162).

A number of scholars have described the effect of these developments on Soviet institutions and Soviet ideology in the 1970s and 1980s (Berger 1986; Chirot 1994; Davis 1989; Feshbach and Friendly 1992; Gleason 1997; Koehler and Zurcher 2003a; Kolakowski 1992; Malia 1994; Verdery 1996). A common theme in these analyses is the inevitable loss of faith that resulted from widening gaps between official versions of Soviet reality (as represented in state-controlled mass media) and observable dynamics of everyday life. Leszek Kołakowski described this duality as highlighting “the ridiculous emptiness of the official ideology,” and accelerating popular disaffection with Soviet rule (Kolakowski 1992: 46).

The ideological decline of the late Soviet period further energized the informal economy as a space of political resistance and entrepreneurial success. Political dissent remained criminalized, but diversion of goods from the state sector to private hands became a popular and lucrative activity—a profitable way to undermine the repressive apparatus of the state. Many analyses of this time period describe a powerful “shadow economy” operating within various sectors of the Soviet system that served to redirect valuable goods (including military equipment and construction materials) into private hands (Chirot 1994; Dudwick 1997; Gall and De Waal 1997; de Waal 2013; Handelman 1995; King 2008; Koehler and Zurcher 2003a; Koehler and Zurcher 2003b; Ledneva 1998; Zurcher 2007).

In the Caucasus region, local Party leaders were described by one journalist as “feudal lords who paid homage to the court in Moscow but ran their own fiefdoms at home” (de Waal 2013: 146). In Armenia, trusted kinship and family connections became an essential tool for accessing scarce resources (Dudwick 1997). Historian Charles King described how Soviet policies—specifically the inefficiencies of centralized planning and the development of a parallel informal economy—unintentionally revitalized the traditional clan-based social organization of the Caucasus,

These features of Soviet life strengthened familial and patron-client relationships, and the networks of debt and responsibility that are often given the label ‘clans.’ Clan networks were traditionally an important element of Caucasus society, both north and south of the mountains … One would have expected the importance of such premodern social conventions to decline with time, but in many ways the Soviet system strengthened them. In an economy of scarcity social networks were critical in providing access to goods and power, and the clan networks of the past served that purpose. (King 2008: 202)

Transactions in the informal economy take place within the territorial boundaries of an established nation-state, but they occur outside of political space, with no government oversight or control (Parrott 1997). This creates challenges in that there is no one in authority to enforce contracts or punish thieves—essential activities for maintaining trust and continuity in systems of exchange. Personal relationships, especially kin relations, become extremely important in this context. Kinship and family connections provide a pre-existing set of obligations that are life long and easily extended in ways that support collective business endeavors operating outside control of the state. As anthropologist Nora Dudwick described during her field research in Armenia, “The pervasive shortages [of the Soviet economy] encouraged a sense of competition and mutual distrust, further increasing the importance of the family as a dependable and trustworthy safety net” (1997: 74).

The importance of these kin-based patronage networks became even more acute following a devastating earthquake in Armenia in the winter of 1988. This natural disaster leveled the cities of Spitak and Stepanavan, and an estimated 1500 villages and 35,000 private dwellings were destroyed (de Waal 2013: 65). Hundreds of thousands of people were left homeless and approximately 25,000 died. Reports of widespread corruption—including diversion of essential humanitarian relief and reconstruction supplies by Soviet officials—led to further intensification of anti-Soviet sentiment throughout the region (de Waal 2013: 65; Dudwick 1997: 107).

As Soviet legitimacy declined in the 1980s, ethnicity and nationalism re-emerged to structure social and economic relations in the Caucasus. These trends increased ethnic tensions and separatist groups like the Karabakh Committee soon emerged as a “shadow government eclipsing formal Soviet institutions” (Broers 2021: 162). A visit by Soviet Premier Mikhail Gorbachev to Armenia a few days after the earthquake further inflamed tensions as he spoke out against Armenian nationalism and derided the leaders of the Karabakh Committee as “unscrupulous people, demagogues, adventurers, corrupt people, black shirts who were hungry for power” (de Waal 2013: 66). The separatist Karabakh Committee was arrested and sent to Moscow, further alienating local populations and fueling the expansion of the informal economy as a space of political resistance and cultural preservation.

Several assessments of the Karabakh conflict identify Soviet era extended kin networks, patronage systems and their respective activities in the “shadow economy” as key contributors to the violence that developed in the late 1980s (de Waal 2013; Dudwick 1997; Kaldor 2007; Koehler and Zurcher 2003a; Zurcher 2007). According to Thomas de Waal, the capital flowing through the informal economy in 1988 was estimated to be ten billion rubles in Azerbaijan and 14 billion in Armenia (de Waal 2013: 153). When Soviet institutions began to falter, underworld entrepreneurs took advantage of the power vacuum to expand their operations. Since much of the informal economy was organized on ethnic lines, this economic competition became manifest as ethnic conflict. As de Waal stated, “…what may have deepened the anxieties of the Karabakh Armenians in the 1970s and 1980s was that they were losing out to a more powerful Azerbaijani networks in the underground economy: as a minority they were not strong enough to claim a large slice of the pie” (de Waal 2013: 153).

Koehler and Zurcher have also used the term “ethnic entrepreneurs” to describe the fusion of political, economic and ethnic groups in the aftermath of the Soviet collapse (Koehler and Zurcher 2003b: 12). “State weakness,” they argue, “… unblocks access to resources and power … A key resource in power struggles can be ethnicity. Political entrepreneurs thus often turn into ethnic entrepreneurs—they appeal to real or perceived threats and injustices in order to mobilize support” (2003a: 12). The specific term used to describe these individuals is “biznesmen-patrioty” or “patriotic businessmen.” These were individuals who maintained lucrative patronage systems within Soviet economies, organized through personal connections and extended kin groups (2003a: 149). They also used their patronage positions to finance and develop the fledging institutions of post-Soviet states.

Unfortunately, these processes contributed to the amplification of ethnic conflict during and after the Soviet collapse (Koehler and Zurcher 2003a). Biznesmen increasingly used their influence and resources to support separatist movements and ethnonationalist militias (Koehler and Zurcher 2003:149; Zurcher 2007). In the Karabakh region, the exact nature of the biznes operated by patriotic businessmen is unclear. But the region’s status as a producer of desirable luxury goods (including valuable citrus fruit and brandy) during the Soviet period likely played a role. Thomas de Waal has also reported rumors of marijuana plantations operating in Karabakh (de Waal 2013: 153). In neighboring Georgia the 1980s were described as “a period of especially rapid growth in the shadow economy … since produce from the Abkhazian agricultural sector, including tea, tobacco, wine and citrus fruits, brought huge profits on the Soviet market” (Zurcher 2007: 121).

The geography of the southern Caucasus—consisting of high mountain passes that form a critical land bridge between Europe and Asia—also makes the entire region valuable as smuggling territory. Transit corridors in mountainous regions are limited, and any group that controlled a remote mountain pass would be able to collect revenues for guaranteeing safe passage for valuable cargo. These practices had a long history in the Caucasus. As one historian noted, “Until the late nineteenth century the borders separating the many different political entities in the Caucasus were often opportunities for extraction—collecting tolls for safe passage … The goal of any political power was to control the locus of extraction, such as a key bridge, port, mountain pass or fortress” (King 2008: 21).