by Carolann S. Najarian, MD
Dr. Najarian is an internist and a member of the staff of St. Elizabeth's Medical Center, Boston, MA. As President of the Armenian Health Alliance, she has made over 20 trips to Karabakh since 1992.
Early in 1995, one year after the cease-fire had gone into effect, I accompanied the chief doctor of Shushi to the village of Karintak, a twenty-minute ride from the city, to examine patients. We reached the village after negotiating a series of hairpin turns around the side of the mountain, leading deep into the valley "under the rock," on which Shushi itself is built, giving the village its name, karin-tak. The villagers here are known for their heroism during the war and will point to the burned out house on the edge of the village where a husband and wife successfully held off the Azeris. Unable to enter the village, the Azeris then bombarded them from the rocks above with gasoline soaked tires, flaming through the sky night after night. Resolved to never leave their village, these villagers lived out the war in dugouts under their homes.
The village's nurse practitioner, the feldsher, had seen the doctor's car approaching and was at the medical post to greet us. The medical post itself was one room, the floor and walls were built of wood planks without any insulation. At one end was a rusted metal bed of sorts, with a thin mattress laid over the springs. A sheet hung by a wire overhead provided some privacy. On the far wall, several white plastic bottles were lined up on a shelf. These medicine bottles were similar to ones I had seen in other medical posts distributed by the international relief organization, Médecins Sans Frontières (MSF). For several years, MSF had been working with the Ministry of Health to help organize its warehouse and to distribute humanitarian assistance to the villages, a job now carried out by the International Red Cross. The bottles were labeled with distinctive black letters. There were two kinds of antibiotics, one type of blood pressure medication, a medicine for treating intestinal worms, aspirin and acetaminophen (Tylenol), a bottle of alcohol, a roll of gauze, and a few cotton swabs. On the feldsher's writing table was a very old blood pressure cuff, a type that I had never seen before; a stethoscope hung on the wall. Everything from the floor to the ceiling was clean.
All of the medical posts I saw in Karabakh's Armenian villages during those years looked the same. They were small shabby buildings set on the edge of a village, without water and without sufficient medical supplies or basic equipment such as an otoscope for looking into a child's painful ear or an electrocardiograph for evaluating chest pain. Although few medical posts in the former Soviet Union would have had these supplies and equipment, Karabakh had even less than its share under the Azeris.
I visited Karintak again in the spring of 1997 expecting to find the feldsher tired and depressed, and complaining about his problems. To my surprise, he greeted us with a big smile and took us to the medical post, the new medical post, one made of bricks and brightly painted plaster walls. He showed us through the rooms: a waiting room, an examining room, a room for patients with infectious diseases, one for performing simple procedures such as draining an abscess, and a room in which to store medicines. Next to the medicine cabinet was an old microscope and a textbook, both carefully placed on a table. In each of the examining rooms there was a bed, similar to the one in the old medical post, now painted and covered with a clean white sheet. Curtains covered the windows. The feldsher could hardly speak through his broad smile. What had been accomplished by these villagers was not extravagant, not yet on a level with Western medicine; they still did not have an otoscope or an electrocardiograph, but it was far better than anything they had ever had. It was a new beginning.
In Nagorno Karabakh the health care system had always been in the hands of Armenian physicians, but they depended on their Baku overlords for funds, equipment, and medical supplies. Karabakh's hospitals and clinics, vintage 1940, were deprived of the needed funds for repairs and renovations. The Armenians had to find ways of keeping roofs from leaking, and making sure the plumbing worked, but they were unable to undertake any major construction. When it came to equipment and medication, however, they fared somewhat better, receiving close to their just share. Some think that it was because 70% of the patients in these Armenian-run facilities were Azeri.
Armenian physicians were sought out and revered as much by the Azeris as by the Armenians because care was delivered without discrimination. Dr. Brina Marutian, Karabakh's chief obstetrician until her recent retirement, tells how she was often called to attend Azeri women giving birth, especially when the delivery was expected to be difficult. She would be taken from her house at night to the city of Agdam or to a distant Azeri village to attend the patient. Refusing to go was not an option open to her. At times she would be gone for several days. Although she had concern about what might happen to her if a boy baby or the mother died, she says that she was never really afraid.
That was in the time before the massacres of Armenians by Azeris in the city of Sumgait. After that, bars were installed over the windows of the Maternity Hospital to prevent the Azeris from stealing Armenian babies. During the years of aerial bombardment of Stepanakert, the Maternity Hospital was hit sixteen times by GRAD missiles. Dr. Marutian tells how, in the middle of the night, while getting ready to deliver a baby by caesarean section in the hospital's third floor delivery room, a missile hit close by. The staff timed the next missile; it hit sixteen minutes later, just enough time to get the baby out and suture the patient's abdomen. Working frantically by candlelight they did just that. Then with the help of the patient's husband, they carried the mother and the newborn down the stairs in the dark, reaching the first floor when the next missile hit, destroying the delivery room they had just been in. After that the doctors were forced to deliver babies in underground makeshift hospitals that they moved from building to building.
Now, with the war at a standstill, the Karabakh Armenians face the formidable task of rebuilding their shattered healthcare system. To get through these hard times, humanitarian aid from international organizations and from the Armenian Diaspora have been extremely helpful, trucking in shipments of medicines and medical supplies over the mountainous land routes from Armenia, Karabakh's lifeline. They have also assisted with critically needed building projects: a rehabilitation center (organized by Lady Caroline Cox); a pediatric dental unit (The Howard Karagheusian Commemorative Committee); a pediatric intensive care unit and the renovation project of Shushi's general hospital (Armenian Health Alliance); a tuberculosis hospital and dispensary (MSF); and an eye care center (Dr. Roger Ohanesian and Mr. George Leylegian). With shared responsibility for these projects, builders from the Ministry of Health have demonstrated an extremely high quality of workmanship and meticulous attention to detail.
Wanting to make optimum use of these offers of assistance and of their scarce resources, Dr. Zoya Lazarian, the Minister of Health and her deputy, Dr. Slavik Aghabalyan, asked Dr. Harutiun Armenian, president of the American University of Armenia and director of the School of Public Health, to help in developing an overall health care policy for Karabakh. He enlisted Ms. Alina Dorian to carry out the project (funded by the International Red Cross and the Armenian Relief Society). Their report, based in part on a population-wide survey of attitudes and practices regarding health care within Karabakh, outlines priorities and projects for Karabakh's basic health care problems.
For example, in the area of maternal and child care they found that only 33% of new mothers surveyed initiated breastfeeding within the first 24 hours after delivery, a startling low percentage. Although the number of women who eventually try to breastfeed is much higher (97%), few continue through the internationally recommended period of six months. The report goes on to warn against supplying these mothers with infant formula because it has the effect of lowering breastfeeding rates; rather it urges the implementation of training programs for healthcare personnel to help new mothers successfully breastfeed.
In the midst of reorganizing and rebuilding, the Ministry of Health must meet the ongoing medical needs of the population. It employs 260 doctors and 1200 nurses to work in Karabakh's hospitals, polyclinics, dispensaries, and village medical posts. Theirs is a difficult job due to shortages of medicines and the rising rates of some diseases: respiratory and diarrheal diseases among children; and hypertension, diabetes, and coronary heart disease among adults. Before the war, the coronary care unit in Stepanakert's general medical hospital averaged two or three patients per month. Now, the unit admits more than 15 patients per month, many of them men in their 30's and even some young women. While visiting one of the regional hospitals I was asked to see a 32-year- old woman, a war widow with four children. She had suffered a massive heart attack three years earlier, presumed to have been caused by stress and not by any underlying disease like lupus or myocarditis. Her cardiograms confirmed the diagnosis. Suffering from severe congestive heart failure as a result, she and her doctors faced the problem of obtaining the necessary medicine to keep her alive, namely ACE inhibitors.
Surgeons also have their problems in treating their patients. They are able to perform elective and emergency procedures in clean operating rooms, under sterile conditions, but shortages of surgical supplies, intravenous medicines, and monitoring equipment are a never ending source of frustration that forces them to take risks unthinkable by Western standards. These are everyday occurrences for them, handled especially well by those who learned their craft in field hospitals during the war.
As if all of this is not enough for a fledgling healthcare system, there are the problems of infectious diseases such as tuberculosis and diphtheria. Armenia's Ministry of Health has helped with vaccination programs for children and adults, but as of this writing, these programs are funded only to the end of 1997. Recently when four cases of diphtheria, including two deaths, occurred among members of one household who had refused vaccination the Ministry of Health prevented the spread of the disease by moving with great speed to put the region under quarantine. They closed all schools and sent nurses to vaccinate anyone who could not prove recent vaccination. Public health announcements were made over radio and television, and in the newspapers, contrary to the old Soviet style of covering everything up.
Care must be provided too for thousands of disabled men, women, and children who are casualties of the war. Skirmishes along the borders and the nearly 100,000 land mines laid during the war continue to maim and kill soldiers and civilians alike. (British experts have helped to remove thousands of them.) During the war, the Azeris also dropped special bombs that did not explode, but spewed out colorful balls designed to attract children and explode when picked up, even years later. The Children's Hospital in Stepanakert has a poster showing the different kinds of explosive objects with which children might come in contact, but despite the warnings, the injuries continue. In a village in southern Martuni, I saw one of the more fortunate victims of these "toys," a six-year-old boy named Andranik.
Andranik stood in the center of the small medical post, his smile almost bigger than his face, while his family answered my questions about his stomach complaints. I asked a series of questions, running through my list of possible diagnoses that might cause a little boy to have stomach pain, but none of the answers seemed to fit together. It never occurred to me to ask if one of these colorful balls had exploded nearby him, filling him with shrapnel. I asked the little boy to lift his shirt so that I could start to examine him, and there was the diagnosis. His abdomen was a road map of scars from the many operations he had undergone in the effort to put his insides back together. The family was coping with the reality of what had happened to their little boy by denying it, never mentioning the catastrophic event to me. They were trying to approach his stomach pain as if he were just like any other child. It was hard for me too, not to go along with the charade.
The exact number of casualties caused by these devices since the war began is not known, but in the last three years alone more than one hundred civilians, including children, have been killed or maimed by them. The news of these explosions rips through the entire population of Karabakh, passing from village to village, from mouth to mouth, each new injury recalling all of those from the past, and in some ways, producing casualties that are harder to accept than those from the war itself.
I was at Shushi's Regional Hospital, getting ready to return to Stepanakert, when a young woman arrived with a sick infant. The Chief Doctor and I listened to her story. The three-week-old baby had been well, when suddenly a small red blotch developed on the baby's left leg. It had become worse and the baby had stopped eating. We unwrapped the infant and saw that the entire lower half of his body was an angry bright red, indicating a rapidly advancing infection of the skin, a pyoderma, that could take the baby's life in 24 hours. There was no time to lose. We drove the mother and baby to Stepanakert Pediatric Hospital where the doctor on call immediately recognized the life-threatening situation, performed the proper diagnostic tests, inserted an intravenous line, and started the proper combination of antibiotics, just as it would have been done in a Boston hospital, to my amazement and great relief. The next day when I visited, the mother had a big smile, unwrapped her baby and proudly showed me how the redness had begun to recede.
Questions nag at me when I think about these patients. What would have happened if we had left before that mother had gotten to the hospital? What would have happened to that young woman if her heart medicine had run out? What if the vaccine program is not renewed at the end of '97? For the Karabakh Armenians these are routine problems that they face with undaunting courage and will no doubt solve with their usual ingenuity and self-reliance, like the villagers of Karintak who refused to leave their village and the doctors who delivered the baby despite being under fire.
As one doctor summed it up, "If you bring bandages, we'll be grateful; if not, we'll improvise, using our bed sheets. If you can bring surgical instruments, we'll be grateful; if not, we'll sharpen and use our old ones. If you bring new medicines, we'll learn how to use them; if not, we'll manage with whatever we have." Then, after going through a long list of other things that I knew were badly needed, she said, "And if you cannot bring any of these things, we will manage, as long as 'you' still come. For us that is the most important thing. We need to know that you are out there, that Armenians around the world are standing with us. We will do the rest!"
