Meeting the Health and Psychosocial Needs and Ensuring the Human Rights of Refugees From Nagorno-Karabakh

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Abstract

Wars of all types are harmful to health, but wars aiming to remove entire populations are particularly threatening. While the term “ethnic cleansing” has garnered varied definitions over the years, the United Nations describes it as a purposeful policy designed by one ethnic or religious group to remove, through violent and terror-inspiring means, the civilian population of another ethnic or religious group from a certain geographic area. The Armenians of Nagorno-Karabakh, in the mountains of the South Caucasus, are in need of a coordinated set of interdisciplinary approaches to address their health and psychosocial needs. The public health community calls on political powers at all levels to protect health and save lives by providing security and protection, human rights monitoring, humanitarian aid, refugee support, medical assistance, psychosocial support, education, peace mediation, amnesty and legal support, sanctions and diplomacy, reconstruction and economic support, accountability, and regional cooperation.

Relationship to Existing APHA Policy Statements

APHA has repeatedly adopted action statements that affirm the importance of social, political, economic, and health justice and has opposed the blockade of ports. The blockade of entry to the Nagorno-Karabakh territory was the precursor to armed invasion and occupation of the area, which has resulted in a humanitarian catastrophe and a health emergency. APHA similarly opposed the blockade of Yemen’s ports in 2020. These vital passageways are required to permit the unimpeded flow of food, medicine, and other humanitarian goods.

Previous statements adopted by APHA related to war and health include the following:

• APHA Policy Statement 201910: A Call to End Violent Attacks on Health Workers and Health Facilities in War and Armed Conflict
• APHA Policy Statement 201810: International Food Security and Public Health: Supporting Initiatives and Actions
• APHA Policy Statement 20158: Preventing Occupational Transmission of Globally Emerging Infectious Disease Threats
• APHA Policy Statement 20095: The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War
• APHA Policy Statement 20089: Strengthening Health Systems in Developing Countries
• APHA Policy Statement 200718: Opposition to U.S. Attack on Iran
• APHA Policy Statement 200617: Opposition to the Continuation of the War in Iraq
• APHA Policy Statement 200211: Opposing War in Central Asia and the Persian Gulf
• APHA Policy Statement 20208: A Call to End the Bombing of Yemen and the Blockade on Its Ports

The statements below are to be archived but represent historical APHA positions in this field:

• APHA Policy Statement 200030: Preventing Genocide
• APHA Policy Statement 9923: Opposing War in the Middle East
• APHA Policy Statement 9817: Arms Trade Code of Conduct
• APHA Policy Statement 9715: Impact of Economic Embargoes on Populations Health and Wellbeing
• APHA Policy Statement 8926: Foreign Assistance Act
• APHA Policy Statement 8531(PP): The Health Effects of Militarism
• APHA Policy Statement 7913: World Peace and the Military Budget
• APHA Policy Statement 7632(PP): Policy Statement on International Health
• APHA Policy Statement 6716(PP): International Health
• APHA Policy Statement 20188: Advancing the Health of Refugees and Displaced Persons

Problem Statement

Armenia’s history is scarred by a legacy of oppression and coerced displacement, most notably by the tragic occurrence of the world’s first genocide during the onset of World War I under the Ottoman Empire. This genocide saw the mass murder of more than a million Armenians, carried out through harrowing death marches into the Syrian Desert. Although scholars and historians have consistently labeled these events as a genocide, not until 2019 did the United States government officially recognize these massacres as such.[1] Escaping the carnage, approximately 80,000 Armenians migrated to the United States at the end of World War I.[2,3] The United States actively organized assistance to Armenians by providing aid to survivors under the Woodrow Wilson administration.[4] Today, one of the largest Armenian populations living outside of Armenia resides in California, with more than 200,000 Armenians living in Los Angeles County alone. There are also large Armenian Diaspora communities in Massachusetts, New York, New Jersey, Michigan, and Florida totaling approximately 2 million in the United States, almost as many as in Armenia itself. For more than a century, the United States has been home to Armenians who have contributed to its economic growth, ethnic diversity, and cultural richness.

In 1923, the Soviet Union established the Nagorno-Karabakh Autonomous Oblast (“Artsakh” to Armenians)—home to a 95% ethnically Armenian population—within the Azerbaijan Soviet Socialist Republic.[5] Nagorno-Karabakh’s regional legislature passed a resolution in 1988 declaring its intention to join the Republic of Armenia, despite its official location within Azerbaijan. Armed fighting between the two republics, which have a long history of ethnic tension, was kept under relative control during Soviet rule. As the Soviet Union began to unravel, so did peace in the region. Amid Soviet dissolution in 1991, just as Armenia and Azerbaijan achieved statehood, Nagorno-Karabakh officially declared independence. War erupted between Armenia and Azerbaijan, resulting in roughly 30,000 casualties and creating hundreds of thousands of refugees.[6,7] By 1993, Armenia had gained control of Nagorno-Karabakh and occupied 20% of Azerbaijan’s geographic area. In 1994, Russia brokered a ceasefire known as the Bishkek Protocol, leaving Nagorno-Karabakh de facto independent, with a self-claimed democratically elected government based in Stepanakert, but still heavily reliant on close economic, political, and military ties with Armenia.[8]

Geopolitical history shaping the health and well-being of Armenian people: In 2020, Azerbaijan initiated a large-scale war against Nagorno-Karabakh with the open military and political support of Turkey. Ballistic missiles, drones, and other heavy artillery have been used, resulting in multiple civilian deaths and injuries. Hospitals, churches, kindergartens, and schools were hit during the bombardment and missile attacks, which included the use of internationally banned cluster bombs. As a result of the intensive bombardment of Nagorno-Karabakh in 2020 by the Azerbaijani armed forces, it was reported that half of Nagorno-Karabakh’s residents, mainly women, children, and the elderly, were displaced.[9]

The history of Nagorno-Karabakh is marked by centuries of cultural, ethnic, and political complexity. Despite having a historically Armenian majority, the Soviet Union under Stalin incorporated Nagorno-Karabakh into Soviet Azerbaijan (rather than Soviet Armenia) in the 1920s, making it an autonomous oblast. Repeated efforts by the Armenians to free themselves of Azeri domination were denied by both the Soviets and the Azeris. The failure to obtain freedom, despite the promise of Glasnost in the late 1980s, sparked a full-scale war in 1992. A 1994 ceasefire failed to lead to lasting peace. Nagorno-Karabakh subsequently functioned as a de facto independent state, albeit unrecognized by the international community, for nearly three decades. In September 2020, hostilities flared again, resulting in about a 30% loss of territory to the Nagorno-Karabakh enclave. In an effort to finally regain total control of the region, Azerbaijan instituted a blockade of the only road connecting Nagorno-Karabakh to Armenia (the Lachin Corridor) on December 12, 2022. For 10 months the international community decried the blockade but was unable to force Azerbaijan to lift it. Then, on September 19, 2023, Azerbaijan attacked Nagorno-Karabakh, forcing the weakened population into a full surrender. Within a few days, nearly the entire population of indigenous Armenians fled to Armenia through the now open Lachin Corridor. In a span of one week, the nation of Armenia increased its population by more than 3%, creating a humanitarian crisis.[10]

Humanitarian conditions in Nagorno-Karabakh were already poor when Azerbaijan’s 2023 invasion was launched, after Azerbaijan’s months-long punitive blockade on food, medicine, and other essential goods. The Lachin Corridor “Road of Life” became the only route connecting the estimated 120,000 ethnic Armenians living in the Azerbaijan-controlled Nagorno-Karabakh region with the Republic of Armenia after the 2020 war.[11]

Three years after the 44-day war of 2020, without brokering a peace treaty, Azerbaijan instituted a blockade of the Lachin Corridor—the vital lifeline that connected the Armenian people of Nagorno-Karabakh with the Republic of Armenia—on December 12, 2022, under the guise of an environmental protest. Subsequently, severe shortages of food, medical supplies, drinking water, and other essentials created a dire humanitarian crisis for the 120,000 people living in Nagorno-Karabakh. Azerbaijan also sabotaged important civilian infrastructure such as power transmission lines and fixed-line Internet. The blocking of access to essential goods such as food, water, and heat by the Azerbaijani government was unconscionable.[12]

Azerbaijan emerged from the 2020 conflict reclaiming all of the territory it had lost to the Armenians in the early 1990s, in addition to one third of the territory of Nagorno-Karabakh that it included under the Soviet Union.[13] During the nearly yearlong blockade, the United States unsuccessfully called for the lifting of the blockade and worked to allow humanitarian assistance to reach the population of Nagorno-Karabakh. Furthermore, the United States urged officials from Baku (the capital of Azerbaijan) and representatives from Stepanakert (Nagorno-Karabakh’s primary city) to convene without delay to agree on the means of transporting critical provisions to the men, women, and children of Nagorno-Karabakh—including additional supply routes—and resume discussions on all outstanding issues. U.S. spokespersons stated that basic humanitarian assistance should never be held hostage to political disagreements.[14]

A Los Angeles Times editorial described Azerbaijan as using the blockade to make living conditions so unbearable that Armenians would be forced to leave the region.[15]

Within 24 hours of the Azeri assault on September 19, 2023, the Nagorno-Karabakh authorities surrendered. When Azerbaijan lifted the Lachin blockade a few days later, an exodus of 90% of Armenians indigenous to this land fled in a massive displacement to Armenia. Others were killed, kidnapped, or arrested. At the tail end of the exodus, in the first week of October, a United Nations mission arrived in Nagorno-Karabakh for the first time in three decades to assess the situation.[16] Registration intake centers in the Republic of Armenia became overwhelmed with huge numbers of exhausted and traumatized refugees, a third of whom were children. The United States, Armenia, and others have accused Azerbaijan of ethnic cleansing. Armenia’s European Union envoy has urged Western nations to sanction Azerbaijan, including its lucrative oil and gas industry, and requested military aid for Armenia.[17]

On September 26, 2023, ethnic Armenians were queueing at overwhelmed petrol stations, desperate to leave the territory after it surrendered to Azerbaijan, and an explosion at a crowded gas station in Nagorno-Karabakh region left at least 170 people dead and 290 injured.[18] Hospitals were already short on supplies because of the blockade, impeding their ability to care for those in the explosion or those attempting to flee. Some of the injured were evacuated by Armenian helicopters to hospitals in Yerevan, Armenia’s capital. The United Nations Security Council held an emergency meeting to discuss the worsening humanitarian situation in mid-August 2023.[19] The International Committee of the Red Cross (ICRC) alerted the humanitarian world that its aid had been blocked, rendering the relief organization unable to take supplies of food and medicine in or out.[20] Tatiana Oganesyan, doctor and head of a foundation of health professionals that is now helping refugees in Goris, told the BBC that people who came to the doctors were exhausted, malnourished and psychologically crushed. Her report also warned that those who stayed could face ethnic cleansing.[21]

External parties have benefited from Azerbaijan’s military victories, and these alliances stand in the way of lasting peace. For example, Turkey stands to gain from the erasure of Armenians from Nagorno-Karabakh. Turkey seeks to complete the “Zangezur land corridor” to give Baku (Azerbaijan’s capital) unimpeded access to the Nakhchivan territory (previously captured from Armenia in the 2020 conflict). Azerbaijani president Ilham Aliyev hosted talks with Turkish president Tayyip Erdogan in late September 2023, expressing his interest in creating a land corridor between Turkey and Azerbaijan via Armenia that would cut off Armenia from its southern and only border with Iran.[22] Armenia’s decoupling from Russia, Russia’s growing alliance with Azerbaijan, and the attempt of the Russo-Azerbaijani axis to keep the United States and the West out of the region have led to Russia’s tacit support in obstructing and discrediting the Western-led peace process to control regional instability and obstructing Armenia’s democratization, its escape from Russia’s orbit, and Armenia’s Western pivot. Furthermore, Russian peacekeeping forces have facilitated the Lachin blockade and the subsequent humanitarian crisis that preceded the Azeri bombardment campaign. In the wake of the operation, Armenian lawmakers approved a key step in joining another international court based in The Hague: the International Criminal Court (ICC).[23] This infuriated Armenia’s traditional ally Russia because the ICC has issued an arrest warrant for Kremlin chief Vladimir Putin on allegations of abducting Ukrainian children during Moscow’s invasion.

As well, one of Azerbaijan’s most powerful allies, Israel, is entangled in this conflict, primarily because of its interests in the geopolitical power axis vis-à-vis Iran.[24] After the dissolution of the Soviet Union, Israel was one of the first states to recognize the newly independent Republic of Azerbaijan on December 25, 1991, and has been the source of weapons to fight Armenians. Israel sought to increase its legitimacy in the Muslim world with newfound post-Soviet majority-Muslim republics, reduce Arab influence, gain additional United Nations votes, and garner the new states’ cooperation in facilitating Jewish immigration to Israel.[25]

Health status assessment: Hybrid warfare strategies in the Nagorno-Karabakh setting include weaponization of health care, use of nonconventional weapons, and strategic displacement of civilian populations via direct targeting, sexual violence, disinformation campaigns, and disruption of essential services such as water, food, gas, and access to health care.[26] The 2020 second Nagorno-Karabakh war between Azerbaijan and Armenia harmed public health by displacing, wounding, disabling, and/or killing ethnic Armenians; the subsequent blockade of the Lachin Corridor compounded health risks. The large-scale attack by Azerbaijani forces in September 2023 escalated that campaign, weakening the ability for resistance by people who had been subjected to a punitive blockade since December of the previous year.[27]

With limited evidence provided by authorities, media outlets, and human rights organizations, little is known about the death toll caused by the 44-day conflict in and around Nagorno-Karabakh in 2020. In one study, age-sex vital registration data from Armenia, Azerbaijan, and the de facto Republic of Nagorno-Karabakh were used to assess differences in 2020 observed mortality values from expected deaths based on trends in mortality between 2015 and 2019 and offer estimates of excess mortality resulting from the conflict. The war was found to have produced almost 6,500 excess deaths among people 15 to 49 years of age. Nearly 2,800 excess losses occurred in Armenia, 3,400 in Azerbaijan, and 310 in de facto Nagorno-Karabakh. Deaths were highly concentrated among late adolescent and young adult males, suggesting that most excess mortality was directly related to combat rather than COVID-19. Beyond the human tragedy, for small countries such as Armenia and Azerbaijan, the loss of a generation of young men represents a considerable long-term cost in terms of future demographic, economic, and social development.[28]

The war led to a significant mental health burden of disease among this population, including depression, anxiety, and stress-related psychosomatic illnesses such as dissociative disorder. However, access to medical and psychological services is limited.[29] A study of combat-exposed military service members in Nagorno-Karabakh revealed more than half (54.3%) of service members admitted to an inpatient residential treatment program for evaluation of fitness to serve and treatment of trauma-related conditions met the provisional posttraumatic stress disorder diagnosis. The most common symptoms rated moderately or higher included sleep troubles, disturbing memories and dreams, avoidance of memories, and negative feelings.[30]

During the 2020 Nagorno-Karabakh war, 93 Armenian soldiers with severe burns were transferred to the National Burn Center in Yerevan, Armenia. Among these soldiers, 87 had their cases assessed by a team of surgeons from Assistance Publique–Hôpitaux de Paris. Their average age was 24 years, and the average affected total body surface area was 14%. An array of unusual injuries and/or clinical evolutions were noted in this cohort. The 16 surviving patients managed in intensive care were examined under ultraviolet light, and all had fluorescence either in their external ear canals and/or on the burn lesions. Cavitary lesions associated with acute hypocalcemia were highly in favor of white phosphorus burns.[31]

Prisoners of war: After this most recent blitz (September 19, 2023), the Azeris began arresting heads of the Nagorno-Karabakh government, including Ruben Vardanyan, philanthropist cofounder of the Aurora Humanitarian Initiative, who headed Nagorno-Karabakh’s government between November 2022 and February 2023. According to the ceasefire agreement of 2020, Armenian prisoners of war (POWs) taken during the war of 2020 should have already been released (but many have not), and no accounting has been made of either civilians or military missing in action. While Armenia had allowed the ICRC access to its Azeri prisoners (and has now released them all), the ICRC has not been allowed to visit imprisoned Armenians.[32]

The Lancet has reported evidence of increased death rates in the early years after severe POW captivity experiences from accidents and infection. Relative to their combat counterparts, POWs are also at increased risk of somatic complaints, musculoskeletal disorders, gastrointestinal disorders, and peripheral neuropathies.[33]

Evidence-Based Strategies to Address the Problem

A just resolution of the armed conflict is required to achieve peace and improve health. The United States, working with the international community, supports an internationally implemented peace agreement that protects the territorial integrity of Armenia and the long-term security needs of Armenians in the region.[34]

For those who have endured war trauma, researchers recommend organizing programs such as support groups to share wartime experiences. Resilience promotion, psychosocial support for health care providers, integral COVID-19 management, and education support are recommended to enhance the condition of displaced Armenian populations.

Opposing Arguments/Evidence

The politics of the blockade, invasion, and wholesale population displacement in Nagorno-Karabakh attract multiple viewpoints. It must be acknowledged that, although it is a disputed territory, Nagorno-Karabakh is recognized by the United Nations Security Council as a territory of Azerbaijan,[35] regardless of the ethnic identity or political preferences of its inhabitants. Since the conflict’s beginning in the late 1980s, ethnic Azerbaijanis, too, have felt compelled to flee their homes. Despite nearly 30 years of negotiations involving international intermediaries, a peace agreement has not been achieved.[36]

Alternative Strategies

Recent military events in Nagorno-Karabakh have resulted in a resolution of the conflict, although this resolution is unsustainable without justice. After Azerbaijan’s seizure of the region in September, more than 100,000 ethnic Armenians fled Nagorno-Karabakh. Armenia’s government has stated that it will accommodate the refugees as “equal citizens” as best as possible with limited resources.[37]

It is antithetical to APHA principles to rely on military resolution of conflicts over land and sovereignty. War crimes should be prosecuted in courts with international legitimacy. Failure to ensure accountability for war crimes will undoubtedly result in this scenario being played out with greater frequency globally, erasing the public health wins of the previous century.

Action Steps

1. APHA is committed to justice and peace as social, political, and economic determinants of health. As a means of reaching this commitment, APHA recommends the following action steps.
2. Security and protection: We urge Azerbaijan to take concrete measures to respect the rights and security of any ethnic Armenians remaining in Nagorno-Karabakh, including ensuring unimpeded humanitarian access to the civilian population in need. Going forward, civilians and humanitarian organizations must have unimpeded access via the Lachin Corridor. As is the right of all refugee populations, Azerbaijan should ensure the right of expelled Armenians to return to Nagorno-Karabakh.
3. Human rights monitoring: We urge the U.S. Congress to condemn Azerbaijan’s blockade of the Nagorno-Karabakh territory and call for continued monitoring of ongoing human rights violations.
4. Humanitarian aid: We urge Azerbaijan to refrain from further hostilities toward Armenians either remaining in or fleeing from Nagorno-Karabakh and provide unhindered humanitarian access to support Armenian health and social needs, including allowing the International Committee of the Red Cross unfettered access to Armenian prisoners to ensure just and humane treatment and to Nagorno-Karabakh.
5. Refugee support: We urge relief agencies and bilateral donors to support Armenia’s efforts to accommodate displaced persons and refugees, including providing funding to support the full integration of the refugees into Armenia’s health system and strengthening that system with improved primary health care, better quality of care, and universal coverage, all of which are aligned with the priorities of the Armenian Ministry of Health. Also, the United Nations should be able to conduct an international observer mission into Nagorno-Karabakh to ensure that any remaining Armenians are safely allowed to leave if they so choose or to remain in their homes safely.
6. Medical assistance: We urge international organizations to finance medical teams in providing equipment and supplies to address the health care needs of those affected by the crisis, including treatment for injuries and trauma. Also, these organizations should ensure that health care providers are trained in trauma-centered care and that they, too, have access to mental health services.
7. Psychosocial support: We urge the United Nations to adopt and support policies, health care services, information systems, and social initiatives promoting social integration and improving the health of Armenian refugees.
8. Education: We urge that children displaced by the crisis continue to have uninterrupted access to their educational needs, especially as schools are important centers of support and service delivery. Also, it is important that sufficient numbers of teachers are available and trained in trauma-centered approaches and that teachers have access to mental health support as well.
9. Sanctions: We urge the U.S. federal government to enforce U.S. law (Section 907 of the 1992 FREEDOM Support Act) that generally prohibits assistance other than specified support for nonproliferation and disarmament to the government of Azerbaijan.
10. Reconstruction and economic support: We urge global agencies to ensure economic assistance to stabilize Armenian communities absorbing thousands of new refugees, stimulate economic recovery, and create sustainable livelihoods. Also, there should be assistance for postcrisis reconstruction efforts, including rebuilding infrastructure and essential services, and long-term development programs to support resettled refugees in making new lives.
11. Accountability: We urge the United Nations to hold perpetrators of human rights abuses and violations to account, including third-party countries that aided the blockade and subsequent invasion.

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