Keywords

Our primary goal in this collaborative work has been to combine qualitative historical and social science research with geospatial analysis to better understand the relationship between armed conflict, environmental change and population health crises in the Caucasus. As Mary Kaldor has described, New Wars like the Karabakh conflict are different from the nation-state warfare that defined the twentieth century (2012). New War armies are more likely to begin as informal militias, and violence against civilians is common.

A number of scholars in public health and global health have identified New War conflicts and “resource wars” as contributing to disease outbreaks, but the mechanisms driving these health transitions have not been fully established (Bausch and Schwarz 2014; Hotez 2020; Klare et al. 2011). Our extended case study explores the Karabakh conflict and its associated health crises through an expanded temporal and spatial lens that better contextualizes the population health crises that accompanied this conflict.

Our historical analysis, for instance, reveals that P. vivax was well established in northern latitudes prior to the Soviet eradication campaign. This suggests the malaria epidemic in the 1990s should not be viewed as an anomalous outbreak of a tropical disease in a temperate zone, but as the return of an ancestral pathogen with a long history of success in the region. Our geospatial analysis provides insight into the ways warfare changed the natural environment in the Caucasus to facilitate sustained transmission of malaria and other preventable infectious diseases.

One key process that contributed to the health crisis that emerged during the Karabakh conflict in the 1990s was the reconfiguration of political boundaries following the collapse of the USSR. These processes are not well theorized in political science or international relations (Mandic 2021). Both fields remain influenced by twentieth-century beliefs about the permanency of Westphalian states, and there is less consensus about the inverse processes of state fragmentation, collapse or territorial reconfiguration (Fituni 1995; Mandic 2021; Rich 1999; Zartman 1995). But many New War conflicts are driven by ethnic or other separatists that create “torn states” with uncertain territorial boundaries (Mandic 2021). In his detailed study of the Karabakh conflict, Laurence Broers referred to this process as “rebordering” (2021).

Rebordering signifies the reconfiguration of geopolitical boundaries through the creation of new semi-autonomous mini-statelets (like Karabakh in the early 1990s) as well as the violent incorporation of contested borderlands into existing nation-states.

Our research leads us to expand this concept by dividing it into phases. Rebordering is preceded by “debordering,” or the coercive extraction of territory from one nation-state prior to incorporation into another. This work is typically done by violent non-state actors, such as ethnic militias, organized crime groups or warlords who often go on to become political leaders in breakaway regions (Mandic 2021).

Debordering is inherently violent and creates tremendous human vulnerability, including vulnerability to infectious diseases. There are no formal rules of engagement governing warfare between non-state actors. Atrocities, human rights abuses and attacks on infrastructure (including hospitals and health care facilities) are common (Gall and De Waal 1997; Gilman et al. 2015; Trabulsi 2015). Insurgencies are often financed with activities in the informal economy and may include collaborations or transactions with international organized crime groups (Broers 2021; Glenny 2008; Mandic 2021; Zurcher 2007). Warlordism is a common feature of governance in breakaway regions (Bunker 2015; Chan 1999; Mandic 2021; Marten 2012; Rich 1999; Sullivan 2015).

In the early phases of the Karabakh conflict ethnic militias waged internal warfare that resulted in mass killing of civilians and expulsion of minority populations from contested regions. The surrounding nation-state—the USSR—then used violence against militias to try and re-establish control of breakaway territories. In the spring of 1991 the Soviet army launched “Operation Ring,” and encircled multiple Armenian villages. Electricity and communications were cut off and Armenians were forcibly removed for the crime of articulating an anti-Soviet national identity (Croissant 1998; de Waal 2013: 116). Atrocities were common, similar to the ones perpetrated by Soviet soldiers during their occupation of Afghanistan in the 1980s (Gall and De Waal 1997). After the Soviet Union collapsed in 1991, Armenia mounted a new offensive and reclaimed a good deal of territory that had been repopulated by Azeri settlers during Operation Ring. Ongoing military successes led to Armenia to claim an additional 7100 square kilometers around Karabakh that had previously been part of Azerbaijan during the Soviet era (Broers 2021: 269). Renewed hostilities in the winter of 2020 led to further revision of the region’s cartography and significant territory controlled by Armenia was returned to Azerbaijan as part of a peace deal.

During the early phase of conflict in the late 1980s and early 1990s, disease surveillance and vector control activities were interrupted due to the collapse of the USSR and the devastating 1988 earthquake. Population mobility accelerated due to forced migration of refugees. New groups entered the region, including foreign fighters from malaria prone areas of Afghanistan and Turkey. Once malaria was imported there were few obstacles to sustained transmission due to the collapse of government services and the crowding of vulnerable populations into improvised housing and refugee camps.

Sonia Shah has described how warfare generates “ecological insults” to the landscape that create environmental conditions favorable for mosquito breeding and malaria transmission. Some of these activities include digging trenches, destruction of dams and construction of new roads through uninhabited areas (2010: 86). In the Karabakh conflict, our remote sensing analysis identified multiple environmental insults that very likely contributed to the re-emergence and expansion of malaria in lowland areas surrounding the primary conflict zone. There were high rates of forest disturbance, for instance, as remote villages were cut off from fuel supplies and rural households harvested timber to heat their homes. Criminal groups allegedly took advantage of weak or absent governance to engage in illegal logging or natural resource extraction that further destabilized the natural environment (Conflict and Environment Observatory 2021; UNECE 2019).

Other environmental insults in the Caucasus included high rates of cropland abandonment and changes in surface water resulting from clogged irrigation canals. Abandoned farmland, especially when fed by open irrigation canals like in the Caucasus, provides an ideal habitat for anopheles mosquitos. This is one reason Soviet malaria control efforts in the 1920s and 1930s required an extensive workforce to monitor rural areas and waterways for signs of Anopheles mosquito activity (Johnson 1988). Despite this massive investment in public health and engineering work malaria remained endemic in the USSR until the widespread use of DDT in the 1950s.

A brief survey of other post-Cold War conflicts in the Caucasus reveals similar patterns of violent rebordering accompanied by forced migration and population health crises (Guha-Sapir and van Panhuis 2002; Levy and Sidel 2016; WHO 2019). Georgia suffered three civil wars in the 1990s that led to over 250,000 people being displaced from the Abkhazia region due to ethnic violence (Zurcher 2007). During that time multiple armed groups occupied different sections of the country, engaged in informal taxation and “combined ‘patriotic’ with purely profit seeking motivations” (Zurcher 2007: 146).

The conflict in Georgia also triggered outbreaks of malaria, with hundreds of cases recorded between the early 1990s and 2000s (Kandelaki et al. 2012). Reduced health budgets, collapse of infrastructure and interruption of malaria prevention measures were all identified as contributing factors in these outbreaks (Sabatinelli 2002). The majority of cases in Georgia were reported in the eastern portions of the country along the borders with Azerbaijan and Armenia. The consequences of the conflict in these countries, including large-scale population migrations likely exacerbated the expansion of malaria in Georgia.

Civil war also broke out in Tajikistan following the collapse of the Soviet Union, with malaria cases increasing from approximately 400 per year in 1992 to nearly 30,000 in 1998 (Matthys et al. 2008). Many factors have been implicated in the malaria re-emergence in Tajikistan (and other former Soviet Republics), including reduced pesticide spraying, planting of crops such as rice and cotton. The influx of refugees, including nearly 600,000 ethnic Tajiks from malaria prone regions of Afghanistan, also contributed to the expansion of epidemic malaria throughout the region (Kondrashin et al. 2017; Sabatinelli 2002). Malaria control measures were intensified in 1999 but it took nearly ten years of sustained public health work to achieve full elimination (Kondrashin et al. 2017).

In Chechnya, years of irregular conflict and unresolved attempts at rebordering in the 1990s resulted in the complete destruction of urban infrastructure and rapid breakdown of the social order. According to Valery Tishkov, “civilian casualties in the Chechen war have exceeded those of both Russia’s army and the insurgents’ battalions and guerrillas” (2004: xiii). Approximately 400,000 people—one-third of the population—became displaced by conflict in Chechnya and 35,000 were killed (2004: xiii). Kidnappings and homicides—including indiscriminate killing of foreign aid workers and journalists—were common. Enterprising warlords and other biznesmen-patrioty seized control of agricultural areas and engaged in massive deforestation for poppy cultivation (2004: 188). The prolonged conflict in Chechnya reduced industrial production in the region to levels representing only about 5% of prewar production (2004: 188). Schools and health facilities closed and the homicide rate increased 700% (2004: 66). Journalists Carlotta Gall and Thomas de Waal described Chechnya in 1994 as “a Shakespearean kingdom with armed groups roaming the countryside at will… [with] no fixed borders or front lines” (1997: 137).

Valery Tishkov detailed how the conflict in Chechnya created “pre-modern” social conditions due to the rapid exodus of educated professionals from the region (2004). Tishkov observed that the exodus of educated professionals from conflict zones makes “the agenda of modern life” impossible to maintain (2004: 14). The result is a return to a pre-modern social order: kin-based social organization reinforced by ethnic and religious homogeneity. The state’s monopoly on violence disappears and clan-based communal violence expands to regulate social and economic life. Populations became desensitized as “accepted limitations on violence are abandoned and society increasingly lapses into anarchy and chaos” (2004: 127). Tishkov describes these institutional changes as combining to create a process he terms “demodernization” (2004: 13).

Our research suggests that New Wars, in addition to demodernizing social institutions, can also generate demodernization of health and mortality patterns. To elaborate, a “modern” mortality profile is one where the majority of deaths in a population are from non-infectious diseases of older age groups like heart disease and cancer (Barrett and Armelagos 2014; Schneider 2014). Modern health indicators are achieved by a combination of public health interventions (such as clean water and sanitation systems) combined with improved nutrition, lower fertility rates and consistent childhood immunizations (Barrett and Armelagos 2014). A “pre-modern” health and mortality pattern, on the other hand, is one with high death rates from acute infectious diseases—especially childhood diseases like measles, diphtheria and typhoid. During the late Soviet period all the Caucasus countries reported relatively modern health and mortality patterns (Cockerham 1999). But multiple New War conflicts in the 1990s led to extensive outbreaks of “pre-modern” diseases—including malaria—in these “modern” societies.

During the twentieth century most public health professionals regarded modernization of health as a one-way process (Barrett and Armelagos 2014; Omran 1971). Once a society has successfully controlled preventable infectious diseases, those successes were assumed to be more or less permanent. These beliefs were formalized in “demographic transition theory,” which still appears as a regular feature in some public health textbooks and teaching materials (Barrett and Armelagos 2014; Schneider 2014). While many public health scholars have recognized the growing risks of emerging infectious diseases and new pandemics (Hotez 2020; Shah 2016) there has not yet been a formal revision of mortality transition theory to include reverse transitions that temporarily or permanently return a population to pre-modern health and mortality patterns.

Our research suggests that New War conflicts, especially those with multiple cycles of debordering and rebordering, have this potential. Debordering creates rapid environmental changes from armed conflict and the expansion of “ungoverned spaces,” devoid of essential public services. Incomplete rebordering can lead to prolonged depopulation of regions and parallel expansion of crowded refugee settlements and improvised housing in neighboring areas. Ethnic minorities are likely to be expelled from homes and farmsteads, leaving behind abandoned land. If new settlers move into the region, they become vulnerable to retaliatory violence if the conflict reignites or expands. In Karabakh some villages experienced repeated waves of forced migration, violence and resettlement during the most intense years of conflict between 1988–1994. All these trends create conditions of demodernization, with a return to informal kin-based systems of governance and exchange. Demodernization of the social world also sets the stage for demodernization of health and mortality patterns, as the infrastructure of infectious disease control contracts or collapses in contested territories.

Even without sustained conflict re-emerging in the Caucasus, the population impacts of climate change are likely to create similar health crises in vulnerable regions. Rising sea levels and ocean temperatures are increasing extreme weather events around the world (IPCC AR5 2014). Outbreaks of vector-borne diseases, including malaria, dengue and tickborne diseases, are increasingly common outside of their established twentieth-century risk zones (Smith et al. 2014). Waterborne diseases such as cholera are common in flood-stricken areas with limited infrastructure (Smith et al. 2014: 726). Repeated extreme events in the same location may create prolonged cycles of economic and social instability, including violent resource competition that occasionally flares into a New War. These changes will increase population movements and outbreaks of preventable infectious diseases, including “tropical” diseases like malaria in temperate zones (Hotez 2016, 2020).

The conflict in Karabakh reignited in December 2020 and some of the areas claimed by Armenia in 1994 were returned to Azerbaijan as part of a peace deal brokered by Russia. There is still no formal consensus about the geographic revisions, and low intensity violence continues to erupt in contested areas (Hernandez 2022). The southern Caucasus may not yet be done with rebordering and the possibility of new conflict and associated health and environmental crises remains high.