There is no apparent shortage of doctors, nurses and hospital beds in Nagorno Karabakh, but healthcare needs medical supplies and equipment without which even the best specialists are often unable to treat the sick and wounded.
Dr. Ira Ghoukassian, an ophthalmologist, has not done a routine cataract operation in years and sends her patients to Armenia. Other doctors say they have to improvise on a case by case basis with the limited supplies at their disposal.
"It's like having the best mechanics in the world but no spare parts to repair the cars that are brought to their garage. We have no problem diagnosing illnesses or prescribing treatments, but we don't have the tools to fix things," she said after examining a young patient.
"He needs a couple of stitches on his eyelid. This is simple, but what if he had a damaged retina. We don't have the surgical instruments to deal with cases which are a little more than routine," she said.
Dr. Ghoukassian's problem is not unique to her department at the Republican Hospital, the main medical facility in Stepanakert. The same is true in hospitals and clinics across this country of 150,000 people.
The Republican Hospital has 220 beds, 27 full-time doctors and surgeons, and 150 nurses. Its medical departments include general surgery, urology, neurology, infectious diseases, ophthalmology and other specialties. Treatment is free of charge, and so are the medications-if available.
The Republican Hospital, like the eleven others in Nagorno Karabakh along with five out-patient facilities and thirteen family clinics, are struggling to stay open despite all odds.
In the civilian sector, where 1,400 various medical and support personnel are employed by the Ministry of Health, the average salary of the medical and nursing staff is between 15 and 25 dollars per month while their 800 counterparts in the military hospitals are paid as much as 80 dollars per month.
"What keeps these doctors and nurses here is not the money," said Dr. Robert Ghazarian, the head administrator of the Republican Hospital. "For them staying in Karabakh and helping the people is part of their national duty, the right thing to do under these difficult circumstances."
Surgeons and internists often work with less than the minimum of equipment and supplies. Bandages and sutures, along with antibiotics and various pain killers are rationed to the most needy.
Hygiene is a problem and so is emergency aid, especially in the remote corners of this mountainous region where most roads are nothing more than unpaved dirt tracks.
"Thank God our people have a strong immune system because under these conditions, many from elsewhere in the world would die," Dr. Ghazarian said.
His remarks were brought home after a tour of the Republican Hospital, where rooms were poorly furnished, beds dilapidated and outdated and often broken down medical equipment added an element of despair to an already gloomy setting.
The intensive care unit, where patients are taken after surgery, was in shambles. There were no cardiac monitors or defibrillators, putting the lives of patients at risk despite the diligence of the nursing staff. Conditions in the hospital's operating rooms were worse.
In one operating room where an elderly man was undergoing prostate surgery, the doctors were busy suturing the incision using the only source of light- a nearby window.
"The medical staff has to compensate for the lack of equipment by whatever means they can. They have to improvise, and this is not easy. We have to work a lot harder to keep these people alive and infection-free without the help of simple devices which are available in hospitals around the world," a staff nurse said.
Thanks to financial aid from the Armenia Fund, conditions at Stepanakert's Pediatric Hospital are relatively better than most of the other facilities in the country.
The 70-bed unit is functioning at 50 percent capacity, but here too there is a shortage of medical supplies and equipment. Mothers are allowed to stay with their new born infants as an added element of security against infection and help to the medical staff.
While the civilian sector struggles to meet the needs of the population, the military hospitals face a more serious task - the prospect of renewed fighting and war casualties.
From Stepanakert's main military hospital, Dr. Samvel Gevorkian supervises a chain of several medical field facilities and mobile units and a medical staff of 87 full-time doctors and surgeons along with more than 700 support personnel.
"I need more doctors, and because the majority of the medical people in Karabakh are women, finding people to work in the military hospitals is not easy," he said during a tour of one of the military facilities.
Dr. Gevorkian, a Russian-trained surgeon, headed a small unit of volunteers in the early years of the war with Azerbaijan which was later integrated into the armed forces after the establishment of the Nagorno Karabakh army in 1993.
Today, the military has several well trained and highly disciplined medical units which can be moved from one part of the country to the other at a moment's notice.
"We are on a state of high alert and the doctors who work in our hospitals are all military men. Many come for a year or two but nearly all stay on much longer. No one is forced to stay, but they do just the same," Dr. Gevorkian said.
During a recent tour of one of the military hospitals, this reporter was taken to a room to visit an Azeri prisoner of war, a 22-year-old soldier who was wounded and captured by the Nagorno Karabakh army early during the summer of 1997.
"He had several bullet wounds which have healed nicely. He is regularly visited by a representative of the International Committee of the Red Cross and we hope to release him once we reach an agreement on a new prisoner exchange with the other side," Dr. Gevorkian said.
The Azeri prisoner's room, one of the best in the hospital, was under constant guard.
"As far as I am concerned this young man is our patient. As a doctor, I cannot deprive him of the best medical care available," Dr. Gevorkian said.
"He is getting exactly the same treatment as any of my soldiers," he said.
