Keywords

The 1994 peace accord was fragile, but the cessation of hostilities allowed civilians and demobilized soldiers to exit combat zones and find shelter in refugee camps and urban settlements. Preliminary efforts were made to assess the war damage, including the loss of lives and destruction of agriculture and industry. According to one estimate approximately 25,000 people were killed or missing in combat (Broers 2021: 38). Official tallies are misleading, however, because there was never a clear line between formal armies, informal militias and civilians (Zurcher 2007). While the overall number of conflict deaths in Karabakh was smaller than in the Bosnian or Chechen wars, the number of internally displaced persons (IDPs) was significantly higher (King 2008).

4.1 Rebordering and Forced Migration

The OSCE line of contact was established to demarcate the de facto Republic of Artsakh, which was formed after the 1994 conflict (see Fig. 3.1b). It consisted of NGK and the surrounding territory reaching to the borders of Iran in the south and Armenia in the west. This territorial configuration represents one potential iteration of “augmented Armenia,” the vision of ancestral territorial claims developed by some Armenian nationalists after the cease fire agreement in 1994 (Broers 2021). Augmented Armenia includes seven districts surrounding NGK that were previously part of Azerbaijan. As Broers described, these additional territories “comprised more than the original surface area of the NKAO’s 4,400 square kilometers” (Broers 2021: 98). This expanded cartography was incorporated into the Armenian body politic and many Azeri place names were changed to evoke Armenia’s “medieval geographies” (Broers 2021). Broers goes on to state that the idea of augmented Armenia is “problematic because it combines the legitimacy of self-determination with the illegitimacy of occupation and ethnic cleansing” (2021: 102).

Azerbaijan was more internally fragmented than Armenia after the Soviet collapse, and there was no immediate national consensus on the territorial claims surrounding the Karabakh conflict. But over time a competing vision of “wider Azerbaijan” emerged and its national vision absorbed all of present-day Armenia. As Broers described,

[Wide Azerbaijan] is a geopolitical vision that absorbs a modern Armenian territoriality in its entirety. Its implications are obvious: a historically deepened and horizontally elongated Azerbaijan edges Armenia out of the Caucasus … Whereas Armenian practices trace their palimpsest across large swathes of western Azerbaijan, Azerbaijan’s is more total in extending over all of Armenia. Contemporary Azerbaijani textbooks depict early nineteenth-century Azerbaijan as a wide, homogenous geo-body stretching from the Caspian to Igdir in the west. (2021: 118)

Azerbaijan’s ethnonationalism also led to mass expulsion of Armenian citizens from its body politic during the early phase of conflict. Over 500,000 ethnic Armenians lived in Baku before the war. By 1995 only about 10,000 remained (Goltz 1998: xxii). Due to the food and energy crisis in Armenia, an estimated 667,000 Armenians fled the country to live abroad, with slightly less than half coming from the city of Yerevan itself. Armenia lost 18% of its population to outmigration, and the capital city lost nearly 25% of its inhabitants (Dudwick 1997: 83). Over 80,000 Armenian refugees were still living in camps many years after the 1994 peace accord was signed, and “hundreds of thousands more were living in a vast archipelago of sanatoria, student hostels and makeshift accommodations” (de Waal 2013: 230).

Conflict-driven population movements have been undertheorized by social scientists. As Danilo Mandic has noted, “Unforced migrants … dominate the theoretical agenda” of migration studies (2022: 61). But recent work in political sociology has better framed forced population movements as part of the violent identity politics characteristic of New Wars. One key element of this updated social theory is the explicit delineation of one or more “force factors” displacing multitudes of people in a relatively compressed time span. Force factors include varieties of “violent social actors” including militias, organized crime groups, warlords, nation-state armies and revolutionary movements (Mandic 2022).

Several scholars have detailed how these violent expulsions have become common in New War conflicts (Broers 2021; Kaldor 2012; Malesevic 2010). Russia’s 2022 invasion of Ukraine, for instance, produced an unprecedented wave of forced depopulation intended to pave the way for Russian occupation. Over 7 million refugees exited the country within the first few months of fighting due to the extreme violence targeting civilians and civilian infrastructure (UNHCR.org/en/situationsukraine). Similarly destructive conflicts have also been waged in Syria, Iraq, Afghanistan and Yemen. In the Western hemisphere the Cartel zones in Mexico and Central America continue to displace an estimated 400,000 people per year due to “environmental challenges and chronic violence” (Cheatham and Roy 2022).

These forced population movements create massive vulnerabilities to infectious disease outbreaks, as IDPs abandon their homesteads and relocate to crowded refugee camps or improvised housing. When political space is contested for long periods of time public health surveillance and vector control efforts are disrupted or abandoned. Preventable diseases can re-emerge and circulate undetected in these spaces until order is re-established or afflicted populations migrate to areas that have operational health infrastructure and resources to detect outbreaks. When armed conflicts are centered in rural areas, population movements can have major impacts on agricultural production and lead to widespread abandonment of croplands. Abandoned croplands—especially those fed by irrigation canals—create ideal breeding grounds for anopheles mosquitoes. Outbreaks can also follow impoverished migrants fleeing conflict zones, and foreign mercenary fighters or peacekeepers coming into conflict zones (Katz 2016). These dynamics are all visible in Fig. 4.1, which details the spatial distribution of displaced persons, violence and malaria cases during the most intense phase of the Karabakh conflict.

Fig. 4.1
A map of West Asia with a focus on Armenia and Azerbaijan. I D Ps and U N H C R are concentrated on the southern border with Iran, eastern border with Baku, and western border with Georgia. Malaria cases decrease moving away from the borders.

Geographic overview of violence, population displacement and documented malaria cases (1991–1998) during the Karabakh conflict. The position, level and direction of IDP/refugee movement as well as returning soldier position are best estimates based on relevant literature

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4.2 Forced Migration and Population Health Crises

In addition to the forced expulsion of hundreds of thousands of Armenians and Azeris during the conflict, new populations of foreign soldiers were brought into the region. While both sides had foreign fighters, Azerbaijan seemed to recruit more of them, including an estimated 1500–2000 mujahideen from Afghanistan soon after Aliyev took power (Taarnby 2008; de Waal 2013; Goltz 1998). Documents and materials found on the battlefield support this, including notes on armory positions, tactics and instructions, photos and personal letters, all in Pashto (Sneider 1993). Captured soldiers and Armenian Ministry of Defense reports also suggest that the Azerbaijan government actively arranged recruiting, housing and training in Azerbaijan, with the help of Russian and US citizens (Taarnby 2008; Goltz 1998).

During the 1970s and 1980s Afghanistan had high rates of malaria and reported several hundred thousand cases annually (WHO 1999). It is estimated that millions of malaria cases occurred in Afghanistan in the early 1990s (WHO 1998). The ability of P. vivax to lay dormant in the human body for months increases the potential for introduction of malaria into conflict zones. Population dislocations amplified outbreaks of infectious disease throughout the conflict, especially in landlocked Armenia where it became almost impossible to import food and essential medical supplies. In 1992 inflation reached approximately 360% per year and food supplies were scarce. A December 1992 cable from the US Embassy in Yerevan noted the country had little to no supply of surgical anesthesia, infant formula or milk. Infant mortality was predicted to rise and “diseases associated with contaminated water and standing sewerage, and malnutrition are anticipated” (USAID 1992).

After the devastating earthquake in 1988, a team of international aid workers supported by USAID was permitted by the USSR to engage in humanitarian relief work in Armenia. Many of the medical professionals on this mission were specialists in reconstructive surgery and rehabilitation. But as living conditions worsened additional teams were sent to Armenia including epidemiologists and emergency medicine specialists. One visiting surgeon described his working conditions in the winter of 1993 as follows,

This quarter coincided with serious disruptions and worsening of overall conditions in Armenia. The winter was the worst in over thirty years. Economic problems were profound. Public transportation was virtually nonexistent much of the time. Prices for food and staples were increasing at double digit inflationary rates. Electricity throughout the country was reduced to 1-2 hours per day maximum with many people without electricity (and water) for days. All morbidity/mortality rates for all age groups rose dramatically. People starved to death and froze to death within hospitals in Yerevan. Most of the city of Yerevan hospitals and clinics closed, as did rural clinics and policlinics. (McIntyre 1993)

The black market price of gasoline was reported by the New York Times to be 7500 rubles for 5 gallons, twice the average monthly salary. Desperate for heat during the freezing winter months, Armenians cut down trees in Karabakh, as well as in urban and rural areas all over the country (New York Times, February 7, 1993). In December 1992 a State Department Cable described the growing crisis as follows,

A national emergency exists in Armenia. Armenia faces the prospect of disintegration, catastrophic hardship and starvation of the small, weak and infirm … The blockade has effectively ended any substantive importation of fuel and curtailed imports of food required by Armenians … Until the blockade is lifted, broken or modified to allow the importation of food and fuel, Armenia will require continual humanitarian assistance and support. All major industry is closed. There is no continuing supply of natural gas. Extended power blackouts are affecting all sections of Yerevan … By late December there will be no milk or baby formula in country … 597,000 elderly Armenian pensioners also require food supplements … The blockade has also left Armenia without medical reserves. (USAID 1992)

A team of epidemiologists from the Centers for Disease Control in Atlanta was dispatched to Armenia work with local public health professionals and rebuild disease surveillance capabilities (Balasanian and McNabb 2000; McNabb et al. 1994; Wuhib et al. 2002). These groups collaborated on a population health census that revealed alarming trends. Almost 90% of elderly residents were found to be experiencing severe poverty and hunger. Monthly rates of measles increased by 60% since the 1980s, diarrheal illness by 61%, viral hepatitis by 163% and tuberculosis by 75% (USAID 1992). Diphtheria was spreading in rural and urban areas. Based on the CDC assessments, US government agencies predicted up to 30,000 deaths from starvation unless additional food assistance was provided to Armenia. US State Department cables also described a total refugee population in Armenia of over 400,000 with approximately 100,000 people living in “sub-human conditions” (UNHCR telegram from Yerevan to Multiple US Agencies and Embassies, September 1992).

4.3 Resurgent Malaria and Environmental Change

The first cases of malaria recognized in Armenia during the Karabakh conflict were almost all imported, with one locally acquired or autochthonous case identified in 1994. Another 502 imported cases were recorded in 1995, with most in Masis district south of Yerevan (Avetisyan 2002; Davidyants et al. 2019). The epidemic peaked in 1998, with 1156 total cases reported, with 89% in the villages of the Masis district (Davidyants et al. 2019). This pattern suggested a local introduction which facilitated malaria re-emergence in this region of Armenia.

Returning soldiers and displaced persons would have been susceptible during fighting on the front lines as surveillance and control measures were disrupted. Conflicts were heavy in the areas east and south of NGK, especially in 1993, with thousands of displaced people and extensive land abandonment (Fig. 3.2). These areas are also significantly lower in elevation and possess extensive agriculture and irrigation, as compared to the mountainous NGK region. An outbreak of malaria also developed in Azerbaijan beginning soon afterward, predominantly in the central and southern river valleys (Mammadov et al. 2016).

The influx of foreign mercenaries from malaria-endemic regions such as Afghanistan most likely reintroduced P. vivax to the Caucasus, though it is difficult to be certain without more thorough epidemiological research.Footnote 1 The rapid concentration of displaced persons in improvised housing and refugee camps in lowland areas provided a large pool of vulnerable human hosts to fuel an expanding epidemic. During the conflict period, the Ministries of Health were unable to conduct routine mosquito surveillance and chemical abatement procedures as they had done previously (Wuhib et al. 2002). As a result, mosquito populations previously under control were largely untouched throughout the lowland agricultural areas of Armenia and Azerbaijan. Anopheles sacharovi, the most common vector for malaria in the region reappeared after the conflict (Boccolini et al. 2000; Romi et al. 2002; Severini et al. 2004). Cases of malaria peaked in 1996 and 1998, respectively (Fig. 4.2). Figure 4.2 shows the accumulated cases of malaria from 1994–1999 in the provinces of Armenia and Azerbaijan. In Armenia, cases began to appear in 1994 in the population centers south of Yerevan in the provinces of Ararat and Armavir, all within the agriculturally productive Araks River valley (CDC 1998; Avetisyan 2002; Davidvants et al. 2019).

Fig. 4.2
2 dot plots. a. Iran, Turkey, and Azerbaijan have low count till 1992, rise and fluctuate after, and vice-versa for Armenia. 2. Iraq and Tajikistan have a drastic rise post 1992. Pakistan fluctuates between 90 and 100 while Afghanistan peaks and dips between 1985 and 1991 and has no cases after.

(a) Malaria cases per 100K population of malaria from 1985 through 1997 in the Caucasus and neighboring countries (b) in other regional conflict zones. Cases of malaria are taken from the WHO World Epidemiological Reports. *peak of malaria during the conflict between Afghanistan and the Soviet Union. **peak of malaria after the first Iraq-US Persian Gulf war. ***increase in malaria cases in Tajikistan following the start of civil war

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At the beginning of the outbreak in 1994 and 1995, more than 90% of cases occurred in displaced persons and soldiers returning from the conflict areas around NK (CDC 1998; Avetisyan 2002). IDPs from the NGK region may have been more susceptible to malaria infection due to lack of immunity as NGK is more protected from malaria than other areas due to its elevation (Avetisyan 2002). Furthermore, their placement in makeshift camps in lowland regions highly susceptible to malaria would have put them at increased risk for exposure (see Fig. 3.2). While the numbers of cases of malaria in these UNHCR camps were not available they were located in heavily irrigated lowland areas, prone to malaria (Mammadov et al. 2016; Bruce-Chwatt 1959). Indeed, UNHCR reports suggest that malaria control measures were implemented in the late 1990s in many of these camps, including anti-malarial drugs, insecticidal spraying and bed net distribution (UNHCR Report 2009). The nature of the settlement camp infrastructure and condition in combination with its location likely increased the chances of malaria outbreaks.

Over 90% of Armenia’s locally acquired cases in 1996 were from three cities in the provinces south of Yerevan: Masis, Vedi and Artashat (Avetisyan 2002). This suggests that widespread transmission was only occurring in this area. In Azerbaijan, most malaria cases occurred in the provinces to the east of NGK in the lowlands of the Kura River valley and in provinces along the Araks River bordering Iran (Mammadov et al. 2016; Avetisyan 2002; CDC 1998; Temel 2007). These areas to the south of Yerevan and in the south and west of Azerbaijan are regions of high agricultural productivity. Regionally, there were also increases in malaria cases in Iran, Iraq and Turkey as well during the early 1990s, as detailed in Fig. 4.2. In Turkey, increases in malaria were largely due to construction of the Southeastern Anatolia Irrigation Project or GAP in the early 1990s (Askoy et al. 1995).

Armenia’s geographical location supports several distinct anopheles mosquito populations, including those from the southern and eastern Mediterranean, Middle East and Central Asia. Recent reports have also suggested that mosquito population dynamics and Plasmodium parasite biology have changed since the 1970s, including those found in Armenia (Romi et al. 2002; Kondrashin et al. 2018). Increases in the number of reactivated P. vivax cases or long-term cases of malaria have also been observed in many areas of Russia, Central Asia and the Caucasus (Kondrashin et al. 2018). These changes have the potential to facilitate the re-emergence of malaria in these regions, especially if conflict and political instability return.

There is no vaccine for P. vivax malaria, and (as detailed in Chap. 2) malaria eradication in the Caucasus during the twentieth century took decades of sustained authoritarian measures. P. vivax is especially challenging to control since it can remain dormant in the human body during winter months and re-emerge in the spring when mosquitoes begin to hatch. Furthermore, P. vivax can be asymptomatic in a host with some immunity and regular exposure but create devastating epidemics in immunologically naive populations. Successful control of malaria requires multiple interventions including modifications of the landscape to eliminate standing water or seasonal flooding, use of insecticides to reduce mosquito populations and regular dosing of susceptible human populations with anti-malarial drugs. Unfortunately, remote sensing research shows that even short periods of armed conflict can reshape the landscape in ways that facilitate expanded breeding sites for anopheles mosquitoes.