HUMANITARIAN NEEDS EVALUATION FOR VICTIMS OF THE
NAGORNO-KARABAKH CONFLICT
JANUARY 18 – 30, 1998
Kirsti Lattu
David Garner
Dennis Culkin
Prepared under contract to the United States
Agency for International Development, Bureau of Europe and New Independent
States
EXECUTIVE SUMMARY
Across the southern Caucasus region
encompassing Armenia and Azerbaijan (including the territory of
Nagorno-Karabakh), there is no acute and widespread humanitarian crisis
affecting the victims of the Nagorno-Karabakh conflict. The situation of those affected by the
conflict has generally stabilized with respect to food security, shelter, and
medical services. While problem areas
clearly remain and some groups are in need of continuing relief assistance, the
general situation is evolving such that improving shelters and generating
income producing activities may be the most useful areas for intervention.
ARMENIA
There is no acute humanitarian
crisis in Armenia among victims of the Nagorno-Karabakh conflict. Conflict victims are affected by the same impoverishment
suffered by the majority of the general population, although in many cases they
endure inferior shelter conditions. A
significant number of refugees of urban origin face challenges in the rural
settings where they have been relocated.
Conflict victims, whether classified as refugees or Nagorno-Karabakh Armenians, suffer legal
status problems. Non-displaced
Armenians residing in the districts along the northern border with Azerbaijan
continue to be directly affected by the conflict, as cross-border hostilities
have reportedly compounded the challenges posed by inherently limited economic
opportunities and lack of central government assistance. Somewhere between 2-5,000 families from
Nagorno-Karabakh remain in Armenia, awaiting the rehabilitation of suitable
shelter which would allow them to return home.
Recommendations
1)
Review conditions in the northern border districts to determine whether
additional humanitarian assistance is called for.
2)
Review shelter conditions and assistance for refugees to determine
whether adequate resources are available for critical needs.
NAGORNO-KARABAKH
There is no acute humanitarian
crisis in Nagorno-Karabakh. The region’s
small population (estimated to be near 130,000) includes limited numbers of
potentially vulnerable people (+/- 5,000), principally those in the most
seriously damaged conflict areas, some elderly without family, and large
families without a breadwinner. The
least well-off unemployed in urban areas are another potentially vulnerable
group, although no evidence of systematic need has been found. There is a strong local administration which
appears to well connected to the needs of the community.
Recommendations
Humanitarian
assistance effort to Nagorno-Karabakh should:
1)
Focus on rehabilitation of
damaged shelter to allow return of displaced persons.
2)
Assess the existing immunization program, logistics and long-term
vaccination supply.
3)
Increase health awareness especially around Maternal Child Health (MCH)
issues and make health education and medical resource materials available at
different levels within the health system.
4)
Support ICRC initiatives to train medical personnel in appropriate
strategies for long-term home care.
5)
Support efforts to re-train warehouse managers in pharmaceutical
distribution, storage and pro-active planning to meet seasonal changes in
demand.
6)
Support ICRC's medical assessment of the current health status for the
whole population, and train health care
workers in use of medicines and implementation of protocols.
7)
Support the establishment of a comprehensive system of psycho-social or
psychiatric care, capacity-building among local practitioners, and introduction
of "new" out-patient or community-based methods such as work therapy.
8)
Support small-scale enterprise and agricultural production activities to
improve the economic condition of those most affected by the conflict.
AZERBAIJAN
There
is no acute humanitarian crisis in Azerbaijan among victims of the
Nagorno-Karabakh conflict. Conflict
victims are affected by the same impoverishment suffered by the majority of the
general population, although in most cases they endure inferior shelter
conditions. Azeris residing in the
districts along the northern border with Armenia continue to be directly
affected by the conflict, as cross-border hostilities have reportedly
compounded the challenges posed by inherently limited economic opportunities
and lack of central government assistance.
Some 600,000 internally displaced persons (IDPs), in varying conditions
and with varying capacities to provide for themselves, remain a serious economic
and political burden on a country struggling with post-Soviet economic
deterioration.
Recommendations
1) Review conditions in the northern border
districts to determine whether additional humanitarian assistance is called for
to the most vulnerable in those areas.
2)
Give priority to improving shelter conditions for IDPs.
3) Continue support for pilot
income-generating activities that enable families, inter alia, to pay
for health care services.
4) Support wider dissemination of
health educational and medical resource materials such as MSF standard medical
protocols in Russian, IRC's Azeri translation of "Where There is No
Doctor" and other USAID supported publications on MCH including breast
feeding, immunization and safe motherhood.
5)
Increase support from the international community to implement WHO
protocols for communicable diseases such as TB and malaria.
CONTENTS
Page
i. Executive Summary i.
ii. Matrix iv.
iii. Maps vii.
-----------------------------
I. Introduction 1
II. Armenia 3
Conclusions and
Recommendations
Findings
III. Nagorno-Karabakh 6
Conclusions and
Recommendations
Findings
V. Azerbaijan 15
Conclusions and
Recommendations
Findings
IV. Potential
Program Opportunities 22
V. Annexes
A. Field Notes, Nagorno Karabakh 25
B. Notes, Public Health 33
C. Contacts 41
D. Scope of Work 45
Links to Tables and
Graphics: Click on the buttons below:
HUMANITARIAN NEEDS EVALUATION FOR
VICTIMS OF THE NAGORNO-KARABAKH CONFLICT COMPARATIVE MATRIX
NAGORNO-KARABAKH MAP
ARMENIA AND AZERBAIJAN MAP
ABBREVIATIONS
N-K Nagorno-Karabakh
ICRC International Committee of the Red
Cross
NGO Non-Governmental Organization
IDP Internally Displaced Person
EPI Expanded Programme of
Immunization
INTRODUCTION
A three person team of independent consultants spent two weeks in the Caucasus, traveling to Armenia, the Nagorno-Karabakh region, henceforth referred to only as "Nagorno Karabakh", and the rest of Azerbaijan. The team consisted of a public health specialist, a regional specialist, and a development planner.[1] Following
briefings from USAID and State
Department officials, the team departed Washington on the 16th of January,
arriving in Yerevan on the evening of the 17th. The team returned to the United States on the 31st of
January.
The two weeks spent in the Caucasus
were allocated as follows:
January 17th to the 20th in Yerevan,
Armenia;
January 21 to 26 in Nagorno-Karabakh
;
January 26 to 31 in Azerbaijan.
The team’s mission was to carry out
an evaluation of the humanitarian assistance needs for refugees, displaced
persons, and needy civilians affected by the Nagorno-Karabakh conflict. A full copy of the team’s Scope of Work is
attached in an Annex.
A major focus of the team’s work was
to assess vulnerable populations among victims of the Nagorno-Karabakh
conflict. For purposes of this
evaluation, a working definition of ‘vulnerable’ was determined to be
populations at risk due to one or more of the following conditions: food insecurity; inadequate shelter, water,
or sanitation; lack of access to health care; and/or exposure to land mines or
unexploded ordnance.
The major focus of this evaluation
was Nagorno-Karabakh and the rest of Azerbaijan. Time spent in Armenia and contacts with humanitarian agencies
were limited at the request of US Embassy/Yerevan. Much of the work of the team
in Armenia was devoted to internal discussions with USAID and Embassy
personnel, with logistical arrangements to allow the team to proceed to
Nagorno-Karabakh, and meetings with a few organizations already active in
assistance to Nagorno-Karabakh. For
these reasons, this report says relatively little about the situation of
conflict victims inside Armenia proper.
The assessment methodology followed
by the team involved field visits and interviews with various levels of
officials, international and bilateral donor agency staff, non-governmental
organization (NGO) staff and local people.
Typically the team began in the capital city, worked out to local
leaders, and then visited a limited number of selected villages, internally displaced person (IDP) camps,
and/or medical facilities. The team
made periodic unannounced visits and stops along the way, to get as realistic a
picture of the overall situation as possible.
The authorities in Nagorno-Karabakh
and the staff of various international agencies and NGOs working in all three
areas visited went out of their way to help the team understand the magnitude
and complexities of the problems confronting the victims of the
Nagorno-Karabakh conflict.
ARMENIA
Conclusions
There is no acute humanitarian
crisis in Armenia among victims of the Nagorno-Karabakh conflict. Conflict victims are affected by the same
impoverishment suffered by the majority of the general population, although in
many cases they endure inferior shelter conditions. A significant number of refugees of urban origin face challenges
in the rural settings where they have been relocated. Conflict victims, whether classified as refugees or Nagorno-Karabakh Armenians, suffer legal
status problems. Non-displaced
Armenians residing in the districts along the northern border with Azerbaijan
continue to be directly affected by the conflict, as cross-border hostilities
have reportedly compounded the challenges posed by inherently limited economic
opportunities and lack of central government assistance. Somewhere between 2-5,000 families from
Nagorno-Karabakh remain in Armenia, awaiting the rehabilitation of suitable
shelter which would allow them to return home.
Recommendations
1)
Conditions in the northern border districts should be reviewed to
determine whether additional humanitarian assistance is called for. Specific concern has been raised about water
and sanitation issues for Novembrian, Idjevan, and Taush.
2)
Shelter conditions for refugees should be reviewed to determine whether
adequate resources are available for critical needs.
3)
Support should be given to UNICEF in addressing the psyco-social needs
of children in the border areas through training teachers in psycho-social
support for
children exhibiting
signs of stress.
4)
Appropriate steps should be taken to encourage the Government of Armenia
to extend to refugees in Armenia the
benefits of citizenship status legislation already adopted.
Findings
Vulnerable Groups
Economic crisis since the collapse of the Soviet Union has
driven the vast majority of Armenians into difficult and sometimes extremely
difficult circumstances. In this sense,
many Armenians in various categories (single elderly, those in social
institutions, earthquake victims, and others) could be said to be
vulnerable. This evaluation, however,
is focused on the victims of the Nagorno-Karabakh conflict, and all figures on
vulnerable populations are limited to this group. Other than to note the more widespread problem, no effort is made
here to make specific comparisons between the situation of conflict victims and
the socially vulnerable population.
In Armenia, the vulnerable population of Nagorno-Karabakh
conflict victims must be considered primarily as some subset of refugees. Of a total registered refugee population of
225,000 in Armenia, UNHCR estimates that 160,000 remain in the country (most of
the rest are abroad for employment opportunities). Of these, 15,000 families or some 60,000 people are said to live
in very bad shelter conditions. Apart
from shelter conditions, location in rural settings --- away from the greater
access and economic opportunities of
the urban areas --- seems to be the major factor making particular
refugees more vulnerable. Approximately
70% of refugees live in rural areas, but no figures are available for
identifying those within that percentage who might be more vulnerable due to
either shelter conditions or individual economic situations.
Given available information, and also that shelter is the most
readily verifiable factor directly affecting the health and welfare of
refugees, the 60,000 refugees living in bad shelter may be considered the most
vulnerable population among conflict victims.
This is approximately 2% of Armenia’s population.
In addition to this group, an unknown number of Armenians
residing in the northeast border districts, which continue to be affected by
the conflict, could be considered part of the vulnerable population.
Public Health
There appears to be a reasonable level of national cooperation
between the Ministry of Health, international NGOs and UN agencies to ensure
best efforts to improve maternal child health, access to care, and even
psychological programs for children.
However, unstable border regions are a concern. Interestingly, Yerevan hospitals act as
reference hospitals for Nagorno-Karabakh.
The Armenian Ministry of Health occasionally provides vaccines and
medicines to cover shortages in Nagorno-Karabakh. Thus there appears to be an informal institutional link between
the two health authorities.
Food Security
Food security does not appear to be an acute or widespread
problem among N-K conflict victims residing in Armenia. However, UNHCR provided anecdotal assessment
that some rural refugee children showed signs of malnutrition. UNHCR also stated that the PAROS system, an
income-estimation system used to target all humanitarian assistance in Armenia,
understated the food aid needs of certain refugee families. UNHCR may seek to have World Food Program
(WFP) support to refugees expanded to cover these perceived gaps.
Given the lack of quantitative information on the reported food
aid gaps for certain refugee families, it is not possible to make any precise
judgement on the subject. It should be
noted that chronic malnutrition (prolonged insufficiency of dietary intake), as
evidenced by stunting among children, has been observed in Armenia for several
years by nutritional surveillance activities covering the general
population.
Shelter
The team was constrained by time in Armenia, and did not
evaluate the current housing stock for IDPs or refugees. Briefings indicated that perhaps as many as
5,000 families from Nagorno-Karabakh currently are living in Armenia, and would
like to return to their place of origin, provided suitable shelter were
available.
Water and
Sanitation
The team made no visits outside of Yerevan, and was not able to
directly investigate water and sanitation issues in Armenia. However from general conversations, the team
believes that water and sanitation conditions in Armenia are roughly comparable
to the situation in Nagorno-Karabakh and Azerbaijan, which are described below.
NAGORNO-KARABAKH
Conclusions
There is no acute humanitarian
crisis in Nagorno-Karabakh. The
region’s small population (estimated to be near 130,000) includes limited numbers
of potentially vulnerable conflict victims, (+/- 4,000), principally those in
the most seriously damaged conflict areas, together with invalids from the war,
plus some elderly without family, and large families without a breadwinner. The least well-off unemployed in urban areas
are another potentially vulnerable group, although no evidence of systematic
need has been found. The team’s main
conclusions:
1)
There is a strong local administration in place, which is closely in
touch with local needs.
2)
Food security is generally assured, in large part due to the
self-sufficient agricultural activity in the rural areas, although chronic
malnutrition and some stunting among children (typical of the south Caucasus
region) are likely to be found.
3)
A well-identified and relatively limited number of private dwellings
(perhaps 3-5,000) require rehabilitation to allow return of displaced persons
and refugees; scattered vulnerable individuals, particularly elderly, are in
need of improved shelter. An estimated
overall need for shelter is +/- 5,000 units.
4)
In Nagorno-Karabakh the public health system suffers familiar
post-Soviet
ills such as: lack
of prevention; health education; outdated protocols; medical under treatment
contributing to drug resistance; deteriorating infrastructure and poor
distribution or lack of medicines. No
current epidemics of serious infectious diseases have been seen. Non-civilian medicine remains the stated
N-K authority's priority for medical equipment, trained personnel and financial
resources.
5)
Children, who comprise more than 20% of the population, [+/- 39,000] are
moderately vulnerable due to suspect immunization coverage. Their risk is compounded by the absence of a
health system infrastructure that enables early detection or prevention
activities beyond immunization.
6)
The home-bound war-wounded, including paraplegics, disabled, amputees
and paralyzed are a small but potentially vulnerable population.
7)
Provision of medicines beyond those aimed at insuring childhood
immunizations supply will not be effective assistance at this time due to
distribution problems and uncertainties.
Private foreign donations of medicines might alleviate drug shortages if
management of distribution can be improved.
8)
It would be beneficial to explore post-traumatic stress disorder (PTSD),
psycho-social or neurological incidence, and to foster establishment of an
early detection and referral system.
9)
Water and sanitation conditions vary, but appear sufficient to prevent
serious outbreaks of enteric illnesses.
The few urban water systems are most likely in need of rehabilitation,
but reliance on artesian and other good natural sources in most rural areas is
an advantage. The authorities expressed
no interest in assistance to reconstruct urban water facilities.
10)
Fatalities and injuries by land mines and unexploded ordnance continue,
but in most locations residents know and avoid hazardous areas, and an internal
de-mining capacity (operated by the military is available for a fee in
non-strategic areas) exists. The number
of victims has declined dramatically in the past 6-12 months, now averaging
perhaps a few a month. Significant
hectarage of valuable land remains out of production as a consequence of mines
and unexploded ordnance, as well as the unsettled condition along the military
front. The impact of mines on N-K’s
dwindling supply of agricultural equipment is significant. Cattle are substantially at risk from mines,
with economic consequences.
11)
As unemployment spirals and the economy stagnates, small scale
income-generation activities and assistance to agricultural production could
contribute to addressing the humanitarian needs of the region.
12)
Few non-governmental or international organizations are active in
providing relief to N-K. Nonetheless,
the small population can probably be substantially addressed through these
organizations, perhaps augmented by one or two NGOs. This may be particularly true if unknown but presumably substantial
Diaspora donations are channeled efficiently to meet priority humanitarian
requirements.
13)
The villages most affected by the conflict, although suffering some
substantial destruction, are relatively cohesive, and their populations are
taking active constructive steps to rebuild their lives and reestablish rural
economic productivity, within existing constraints.
Recommendations
Humanitarian
assistance effort to Nagorno-Karabakh should:
1)
Focus on rehabilitation of
damaged shelters to allow return of displaced persons.
2)
Support an assessment of the existing immunization program, logistics
and long-term vaccination supply.
3)
Increase health awareness especially around Maternal Child Health (MCH)
issues and understanding standard medical protocols and make health education
and medical resource materials available at different levels within the health
system.
4)
Support ICRC initiatives to train medical personnel in appropriate
strategies for long-term home care of war-wounded and home-bound.
5)
Support re-training of warehouse managers in pharmaceutical
distribution, storage and pro-active planning to meet seasonal changes in
demand.
6)
Support ICRC's proposed medical assessment of the current health status
for the whole population, and train health care workers in use of medicines and
implementation of protocols.
7)
Support the establishment of a comprehensive system of psycho-social or
psychiatric care, capacity-building among local practitioners, and introduction
of "new" out-patient or alternative methods such as work therapy.
8)
Support small-scale enterprise and agricultural production activities
that directly improve the economic condition of those most affected by the
conflict.
Findings
Vulnerable Groups
As in the rest of the region, economic conditions within N-K are
difficult, and much of the population is vulnerable from an economic and social
perspective. For purposes of this
evaluation, however, those most directly affected by the conflict were the primary
focus. In general, this group is the
population of villages damaged during the period of armed conflict, any
displaced persons who are within N-K but have yet to return to their pre-war
residences, and possibly large families whose primary breadwinner has been
killed in the hostilities.
The ICRC identified 43 villages as the most severely affected by
the conflict when it began relief operations in N-K. The total population of these villages was approximately 16,600. As of now, the ICRC has decided to phase out
relief assistance to 14 of these villages, to restrict and target relief to the
most vulnerable 15% of the population within 17 “phase down” villages, and to
continue general relief distribution to 12 “worst off” villages. Assuming an average population of 300
persons per village, adding 15% of the population in the “phase down” villages
to the total populations of the 12 “worst off” villages yields a total
vulnerable group of about 4,400 persons.
Using a total regional population of 130,000, this is slightly more than
3% of the total population.
The two largest “green” areas (inhabited by predominantly ethnic
Azeri populations prior to the conflict) in N-K, Shushi/Shushay and Umuglu, may
contain an additional but unknown number of vulnerable conflict victims. Umuglu is not a problem area, according to
N-K authorities, who note that it was essentially undamaged during the war, and
lies in an agriculturally rich area.
There seems to be little agreement among various observers about either
the number of people living in Shushi/Shushay, their conditions, or any
critical humanitarian needs that might exist there. The authorities made a wheat flour distribution there in December
1997, but when repeatedly pressed for details on any critical needs, the
"Minister of Social Welfare"
made only general references to employment problems, the lack of access to
garden plots, and difficulties with the water supply. It is thus not possible for the team to make any quantitative or
qualitative evaluation of humanitarian aid needs in Shushi/Shushay, although
the
N-K authorities’ refusal to place any
emphasis on such needs is suggestive.
A group of conflict victims which might be considered more
vulnerable is that of large families whose primary breadwinner was killed
during the hostilities (or during the border skirmishes that reportedly
continue). There are no precise figures
for this group. However, there is
reason to believe that this group has been and continues to be the recipient of
focused aid from the local administration and diaspora groups, which may in
effect reduce their actual vulnerability.
For example, the Hadrut region has established an in-kind assistance
arrangement benefiting families who have lost their breadwinners. The central authority reportedly pays a
small pension to children of those killed in the conflict until they reach 18
years of age. In addition, a
significant number of private and diaspora organizations whose assistance to
Nagorno-Karabakh is listed in USAID/Caucasus documents are described as
focusing on aid to families whose members were killed in the conflict.
While social vulnerability is not the focus of this evaluation,
the small size of the N-K population allows more detailed comment on the
subject. The "Minister of Social
Welfare" noted that there are approximately 700 elderly pensioners without
family in N-K or elsewhere. Of these,
25 will be accommodated in a purpose-built residential facility operated by the
"Ministry". Another facility
to house 100 elderly is planned. The
" Minister" stated that untargeted external humanitarian assistance
is allocated to single elderly as a priority.
Thus the primary social vulnerability issue confronting the N-K
authorities seems to be approximately 575 elderly pensioners without
family ---- a comparatively limited
burden by regional standards, and even in terms of the region’s small
population.
Public Health
N-K statistics reflect levels of overall immunization coverage
ranging from 96%-98%. "MOH" immunization strategy was designed to
follow WHO/UNICEF guidelines which are reported to have been adopted as early
as 1993. The "MOH" conducts 2
vaccine campaigns a year. Immunization
related activities appear on the surface to be well organized and functioning. An estimated 3% of children have not
received vaccinations. However, in
direct contradiction to "MOH" statistics, an independent study
estimated measles coverage at 37.8%.
Hidden problems of vaccine supply, cold chain or drug effectiveness are
reflected in disease incidence. For
example, there were 191 cases of measles and 2 cases of polio during 1997 as
well as a diphtheria outbreak in 1996.
Spread of TB is a quiet time bomb in the region due to 1)
improper treatment of the disease 2) high drop-out from treatment programs
before being cured and 3) failure to implement WHO protocols. All three have contributed to increasing
drug resistance. However, in Armenia,
Azerbaijan and N-K, international organizations are actively involved in
encouraging adoption of WHO treatment protocols.
The homebound war-wounded are a small but forgotten population
estimated between 50 to several hundred individuals. They present a costly drain on family finances and an emotionally
difficult burden. The N-K
"MOH" might be prepared to minimally cope with their in/out patient
care, but lacks capacity to provide appropriate lifecare to permanently
handicapped.
It has been reported that as much as 80% of drug supply and equipment are stored in the N-K authority controlled central Humanitarian Warehouse. However, medicines are short throughout N-K and available medications are expensive. Three possible explanations for the warehouse bottleneck are[2]: 1) the stock is
kept
centralized in case of war, 2) warehouse managers justify their positions and
employment by hoarding the stockpile or 3) there is no political willingness to
distribute the drugs.
Diseases causing morbidity and mortality, (with the exception of the high prevalence of TB,) [3] appear to
reflect
the local diet, lifestyle and climate, and are not significantly different from
those found in the region. In adults
these include hypertension, heart disease, cancers, diabetes, etc. In children and adults respiratory
infections, colds, and skin diseases are most commonly cited by the medical
community.
Medical personnel report all diseases are exacerbated by the
stress of war. Drug abuse exists, but
at an unknown rate. Parents frequently
mention that they and their children spent part of the war fleeing, or living
hidden in crowded basements for a year or more. There is no comprehensive system of referral, knowledge of
updated methods or adequate care available for psycho-social or psychiatric
problems. The current psychiatric
hospital is a half heated building with a capacity of in-patient beds that
allows institutionalization of severe cases.
Both in-patient and out-patient services follow unclear diagnostics or
treatment regimes. Counseling as it is
known in the west is non-existent.
Food Security
The team found no evidence of acute malnutrition, nor any
superficial indications of chronic malnutrition or other serious and systematic
nutritional problems. Chronic
malnutrition, evidenced by stunting in children, has been documented in both
Armenia and the rest of Azerbaijan, and it is likely that such problems also
affect at least a portion of the population of N-K. Lack of diversity in the diet is very likely among the urban less
well-off, with consequent micronutrient deficiencies. But availability and access to food do not appear to be serious
problems for a significant part of the population. Every individual, official or private, local or foreign, with
whom the team came in contact was queried about food security issues. No one provided specific negative
information or indicated any strong concerns regarding food security.
Local conditions support the conclusion that food is not a major
problem. N-K, previously a prosperous
agricultural area, may still be a cereals-surplus region. According to N-K authorities, the region
exported 15,000 metric tons of wheat to Armenia in 1997, and a lesser amount
the year before. This cereals surplus
comes despite the fact that large amounts of the best grain-growing land in the
north are not cultivated due to their location in zones of military
activity. The availability of cereals,
combined with the ready access to gardens and often livestock by those outside
the regional capital, would indicate no food security problems for the bulk of
the population, who live in the rural areas.
The potentially more vulnerable urban population (single
elderly, unemployed) would benefit from the general availability of food in the
region, and presumably from family or other informal networks linking rural and
urban populations. In the Hadrut
region, the local “safety net” arranged by de-facto regional administration
involves provision of wheat and other agricultural products by relatively prosperous
families (including some involved in commerce and not agriculture) to families
of men killed in the conflict. This
relatively formal system supplements whatever informal networks exist, although
it is not known if the Hadrut system has any counterparts elsewhere in N-K.
Shelter
The authorities informed us that they had successfully
rehabilitated approximately 8,000 single-family dwellings, repairing one or
more rooms to permit families to return to their homes. In addition a further 1,500 apartment units
have been rehabilitated sufficiently to allow families to return and occupy the
space. It appears that an additional
5,000 dwellings and/or apartments remain to be rehabilitated, (or approximately
33% of the damaged housing stock.) Some
sources suggest that as many as 3,000 of the 5,000 refugee families who have
(or had) been living in Armenia have already returned to N-K, and are living
with relatives, or have doubled up with other families in temporary quarters. The potential need for a shelter program for
N-K is manifest. It can help generate
employment through direct reconstruction, allow people to return to their
homes, improve their health, and permit families to resume normal lives, and
undertake normal commercial and economic activities.
Water and
Sanitation
The team visited three urban centers and three relatively
representative villages in N-K. The
towns included Stepanakert (or Khankandi) the provisional capital city, plus
Mardakert/Agdara, a region capital in the north, and Hadrut, a region capital
in the south. In Mardakert/Khankandi
the team visited two villages, Gulatagh and Janatagh. In the southern part of N-K, the team visited the village of
Kochbeck. (Short profiles of each of
these regions and villages are given in an Annex.) From what the team was able to determine from interviews and
conversations in urban centers and from these short visits, the provision and
adequacy of water (and/or sanitation) did not seem to be an urgent
priority. The authorities were explicit
in indicating that they did NOT seek assistance in repairing the larger urban
potable water systems. The villages
have traditional watering points, many of which come from artesian
sources. These sources generally seemed
to be relatively potable. When we
queried staff from international donor agencies working in NK about their
experience with the local water, they advised us that they routinely drank the
water, and did not become sick. As the
area moves towards systematic reconstruction, there could be economic
advantages in terms of the use of people’s time if community water and
distribution systems are repaired and put back into service, but it does not
seem to be an immediate priority. For
the time being, sanitation issues do not seem to be a significant public health
problem.
Other issues
The apparent strength, focus, and engagement of the de-facto
local administration in N-K was striking.
In each location the team visited, the local authorities demonstrated a
detailed familiarity with the specific problems of the community. It appeared that urgent local needs were
factored into the authorities’ priorities and actions. The sense of a close connection to specific
community conditions was also present at Stepanakert/Khankandi. The team found this to be a key factor in
helping the community cope, with apparent success, with the challenges of the
situation.
Land mines and unexploded ordnance continue to pose a hazard to
humans, livestock, and farm equipment in N- K.
No reliable figures seem available, but the consensus among local
authorities and the ICRC indicates that just a few cases of mines/ordnance-related
injuries occur every month. Fatalities
occur infrequently, and local authorities indicated repeatedly that mines and
ordnance are no longer a critical humanitarian problem. The ICRC confirms this view. According to all sources, local populations
are generally familiar with the most dangerous areas of their villages and
regions, and avoid them. In addition,
the internal mine-clearance capacity of local military authorities, a result of
training by the British NGO Halo Trust, is now used to clear high-priority
land. According to local authorities,
for a cost of $200/hectare, this authority will clear agricultural land for
local farms.
According to local N-K authorities, the mine/ordnance problem is
under control, but it still exists. In
addition to any human injuries or deaths still caused in such incidents, the
economic toll of the problem is important.
Livestock are regularly lost to mines, and the destruction of the
region’s dwindling stock of farm equipment such as tractors and combines is
weakening the agricultural sector.
AZERBAIJAN
Conclusions
There is no acute humanitarian
crisis in Azerbaijan among victims of the Nagorno-Karabakh conflict. Conflict victims are affected by the same
impoverishment suffered by the majority of the general population, although in
most cases they endure inferior shelter conditions. Azeris residing in the districts along the northern border with
Armenia continue to be directly affected by the conflict, as cross-border
hostilities have reportedly compounded the challenges posed by inherently
limited economic opportunities and lack of central government assistance. Some 600,000 internally displaced persons
(IDPs), in varying conditions and with varying capacities to provide for
themselves, remain a serious economic and political burden on a country
struggling with post-Soviet economic deterioration. Little is known about the
status of 200,000 refugees, who are also victims of the conflict over N-K.
1)
With the deteriorating economic conditions across rural Azerbaijan, the
IDPs and refugees no longer constitute
a uniquely vulnerable population. It’s
important to look at the overall situation for the whole population, and view
the IDP and refugees in context. As the
economy contracts, the resident or Azeri ‘middle class’ is being squeezed or
eliminated, and the whole society is becoming more sharply stratified. While the IDPs represent 8% of the national
population, the incomes and quality of life for an additional 20% of the
population is also deteriorating significantly.
2)
Agricultural production is declining dramatically, (some say
collapsing), and land reform actions may lead to increased pressures on the
IDPs, as well as on local populations.
Some estimates of overall unemployment across Azerbaijan run as high as
80%. Whatever the figure might be for
the local population, it appears that unemployment for the IDP population is
probably higher.
3)
Of the estimated 600,000 IDPs, perhaps the bottom 25% or 150,000 people
are characterized as particularly vulnerable, based on their incomes and
shelter conditions.. Other indications
suggest that as many as 90,000 families (or more than 300,000 people) could
be living in sub-standard conditions.
4)
Some degree of friction is developing between the IDPs and the local
population, because the IDPs have a minimal social safety net in terms of food
supplements and access to medicines, unlike the local population.
5)
An adversarial relationship exists between the government and the
international assistance community, and some knowledgeable agencies believe
this condition is becoming more marked.
Recommendations
A humanitarian
assistance program for Azerbaijan should:
1)
Review conditions in the northern border districts to determine whether
additional humanitarian assistance is called for to the most vulnerable in
those areas.
2)
Give priority to improving shelter conditions for the more vulnerable of
the IDPs.
3) Support income-generating
activities that inter alia, enable families to pay for healthcare
not provided by NGOs or international donor agencies..
4) Support wider dissemination of
health educational and medical resource materials.[4]
5)
Increase support from the international community to implement WHO
protocols for communicable diseases such as TB, malaria, etc.
6
Improve the international community’s capacity to monitor, evaluate, and
plan assistance for the IDP and refugee populations.
Findings
Vulnerable Groups
Economic crisis since the collapse of the Soviet Union has
driven the vast majority of Azeris into difficult circumstances. Apart from limited labor market impact in
the Baku area, the ongoing development of Azerbaijan’s hydrocarbon energy
resources has not much affected the economic condition of the country’s
population. Because changes since the
Soviet collapse have propelled many
Azeris into various levels of economic
insecurity or impoverishment, many social categories (single elderly, those in
social institutions, large families without fathers, and others) could be said
to be vulnerable. This evaluation,
however, is focused on the victims of the Nagorno-Karabakh conflict, and all
figures on vulnerable populations are limited to this group. Other than to note the more widespread
problem, no effort is made here to make specific comparisons between the
situation of conflict victims and the socially vulnerable population.
Azerbaijan has an internally displaced person (IDP) population
somewhere between 550,000 and 600,000.
Forty percent of the IDPs or 200,000 people are living in urban settings
in Baku and Sumgait. The balance, or an
additional 400,000 IDPs, is scattered across the interior of Azerbaijan. Approximately 10% or perhaps 60,000 live in
camps. Others live in public buildings,
box-cars, squatter settlements, or in a few cases, in caves. Among the IDPs, perhaps (2 %) have been able
to return to their homes.
In addition to the IDPs, there are an additional 200,000 refugees,[5] who are mostly in the vicinity of Baku.
Conventional
wisdom suggests that they are assimilating into the local population without
undue strains on either side. (The team
did not have the time to confirm or refute this conventional judgement.)
In Azerbaijan, the vulnerable population of N-K conflict victims
must be considered primarily as a subset of the IDPs. Of a total estimated IDP population of 600,000 in Azerbaijan,
UNHCR estimates that 150,000 are the most vulnerable, based on surveys of IDP
economic conditions. Factors making
for greater relative vulnerability of IDPs are readily known, and include poor
shelter, lack of access to either employment opportunities or garden plots,
etc. However, precise figures for the
percentage of IDPs affected by these various factors are not available. The total displaced population within
Azerbaijan represents +/- 8% of the total population. The putatively more vulnerable 150,000 within that larger group
are 2% of the total population.
In the time available, it was not possible for the team to
arrive at a reasonable estimate of the IDP population living in unacceptably
bad shelter. Given the scale of the
problem, however, and the fact that large public building rehabilitation
assistance has been under way for just over a year, it seems reasonable to use
the 150,000 most vulnerable IDP figure as a minimum or floor for estimates of
vulnerable conflict victims.
Because shelter is the most readily verifiable factor directly
affecting the health and welfare of refugees, the most vulnerable part of the
population among conflict victims in Azerbaijan are IDPs living in unhealthy
substandard shelters.
In addition to this group, an unknown number of Azeris residing
in the northeast border districts with Armenia, which continue to be affected
by the conflict, could be considered part of the vulnerable population.
Public Health
For the majority of IDPs and refugees, both medical
consultations and
minimal treatment are provided for or subsidized by the international community. The MOH assesses additional charges during hospitalization or special treatment, regardless of socially vulnerable status within the national healthcare system. This policy inadvertently targets indigents, who are frequently IDPs or refugees. Women, as primary caretakers of children and high users of hospital services, are especially vulnerable to a system requiring payment for services. As a result, they sometimes don't seek care or do so outside the health system as is evidenced by the more than 22% of women who give birth at home and an estimated 70% with untreated pelvic inflammatory diseases.[6] Overall, IDPs have better access to health education,
reproductive
health, and charge-free services than the average or low-income Azeri.
Spread of TB is a quiet time bomb in the region due to 1)
improper
treatment of the disease 2) high drop-out from treatment
programs before
being cured and 3) failure to implement WHO protocols . All three have
contributed to increasing drug resistance. However, despite their being a draft
national TB program within the Ministry of Health, it does not appear to respond to adoption of WHO
treatment protocols. Some conclude that
the draft plan has hit a political roadblock and it may be a dead document.
Food Security
Food security does not appear to be an acute or widespread
problem among conflict victims residing in Azerbaijan. Several agencies, including the World Food
Program (WFP), have been providing supplementary rations to IDPs for several
years. The caseload of IDPs receiving
rations has declined gradually, as agencies have scrubbed their lists for IDPs
collecting food aid from more than one source.
In all, WFP estimates that 533,000 IDPs are on food aid distribution lists
in Azerbaijan. All agencies providing
food assistance, like those providing other forms of humanitarian aid to IDPs,
coordinate their activities on a geographic basis within Azerbaijan. They also for the most part have
standardized their rations.
The provision of a supplementary ration by food agencies is a
recognition that most IDPs have some economic resources and in some cases
access to agricultural produce or garden plots where they can grow some of
their own food. Several assistance
agencies have included greenhouse and garden plot activities in their IDP
programs for several years in an attempt to raise the quality of the IDPs’
diets.
In keeping with the Government of Azerbaijan’s policies
regarding IDP assistance, no food aid is provided in the Baku/Sumgait
region. While the Government’s policy
on this region has been modified to some extent in the sector of public
building rehabilitation for IDPs, apart from an earlier and short-lived food
distribution program by a now departed European NGO, there has been no food aid
program in the Baku/Sumgait region. The
approximately 200,000 IDPs resident in the Baku/Sumgait area are presumed to
have greater access to economic opportunities with which to provide for their
own food needs. In visits to several
IDP sites in the region, questions about food access and availability did not
elicit any expressions or observations indicating a food security problem.
The ICRC distributes food aid to 9,000 families in the northern
border districts with Armenia. The ICRC
hopes to increase its understanding of the humanitarian situation for residents
in that region as it improves its access to the area; Azeri military
checkpoints have not been completely cooperative in allowing routine access for
the ICRC to the border areas.
It should be noted that chronic malnutrition (prolonged
insufficiency of dietary intake), as evidenced by stunting among children, has
been observed both within the IDP and resident population in Azerbaijan for
several years by nutritional surveillance activities. This phenomenon can have complex causes, but among these are
almost certainly the economic effects of dislocation and low incomes and the
physiological effects of poor living conditions and diets. As its origins can be complex, chronic
malnutrition is not a problem on which limited, short-term humanitarian
interventions are likely to have much impact.
Shelter
The provision for shelter in Azerbaijan among the IDPs appears to exist along a continuum extending from (1) caves, (2) tents and lean-tos, (3) railway cars, (4) squatter settlements, (5) camps, (6) Rehabilitated Public Buildings, and (7) private dwellings. The quality of the various dwelling types ranges from the seriously inadequate to the relatively comfortable. While virtually the entire IDP population appears to have some form of shelter,[7]
there appears to be
no common definition of what should constitute adequate housing, and no
overall system for monitoring or evaluating the equity of shelter improvement
programs. Within each separate
category of shelter, wide-ranging variations are possible. In some cases it appears that women-headed
families have systematically received access to poorer quality shelter. While no absolute numbers are available, on
balance it appears that thousands of families are living in shelters, which are
seriously inadequate, given the climatic conditions with which the IDP
populations must cope. The inadequacy
of shelter has a direct impact on family’s health, involving significantly
increased incidences of upper respiratory diseases, scabies, and transmission
of communicable diseases.
Water and Sanitation
Water and sanitation are issues that need to be surveyed and
monitored systematically in Azerbaijan.
Generally, problems with water and sanitation correlate with the quality
of shelter. Those IDPs living in the
worst shelters, for example, typically also have the worst access to water and
sanitation provisions. There clearly
are problems in some settlements with the provision of water and its quality,
and some problems with sanitation. In
the event of unseasonable flooding, for example, there could be outbreaks of
water borne diseases. However, in broad
terms, water and sanitation issues should be viewed as a sub-set of the problem
of shelter. The international community
should establish overall norms for the provision of adequate shelter, water and
sanitation. Once such norms are
defined, there should be appropriate efforts to see that minimally adequate
housing with suitable water and sanitation provisions are supplied to all of
the IDP communities across Azerbaijan, including hard-to-reach populations
living in railway cars, squatter settlements, etc.
Other issues
A.) Land mines and
unexploded ordnance have not yet become a major humanitarian problem in
Azerbaijan. It is anticipated that the
problems posed by mines will mount as and when IDPs return to home areas that
were the scene of armed conflict. The
ICRC has had a mine awareness education activity under way in Azerbaijan for
one year, and would step up its efforts in the event of any large-scale return
of IDPs.
B.) Monitoring,
surveillance and planning appear to be areas where the international
community could use some additional resources.
At the present time the international assistance community is somewhat
fragmented. While individual donors and
specific NGOs do good work in their particular part of the country, no
macro-level capacity appears to exist to carry out comprehensive monitoring and
evaluation of the overall IDP/refugee situation. This possible deficiency should be analyzed. If confirmed, an enhanced survey and
monitoring capacity should be created, probably under United Nations auspices.
Potential Program Opportunities
Within the broad framework of the
provision of humanitarian assistance for victims of the N-K conflict, the
United States Government seems to have five broad areas where it might target
expanded assistance programs. These
include:
1. Shelter rehabilitation
2. Public health assistance
3. Income generation activities
4. Community development activities
5. Monitoring, Evaluation, Surveillance
and Planning Capacity
The specific needs in
Nagorno-Karabakh differ from the needs in Azerbaijan, but the differences
typically are ones of magnitude, rather than the kind of assistance
required. The total number of IDPs and
refugees in Azerbaijan, for example, is nearly 8 times the total population of
Nagorno-Karabakh. The need for a
monitoring and evaluation capacity to track the status of IDP populations in
Azerbaijan is correspondingly greater than for Nagorno-Karabakh. Similarly, the displaced communities in
Azerbaijan have negligible social infrastructure in place to help knit them
back together, while the communities in N-K seem to have strong social
cohesion. Thus the absolute need for
community development work in Azerbaijan seems substantially greater than the
absolute need for such work in N- K. In
terms of specific sectoral activities in public health, income generation, and
shelter, the needs are largely a function of
the populations which are on the ground in a given area. All other things being equal, a larger
population in need would generally call for a greater level of effort.
Most of these possible programming
initiatives -- particularly the need for shelter and appropriate public health
interventions -- have been fully described in earlier sections of this
paper. A few things remain to be said
about the other possible interventions.
These are briefly discussed below.
Income generating activities
Income generating activities are a
critical need for all the victims of the N-K conflict. The need for employment is a constant which
cuts across the entire Caucasus. This
requirement for employment generating activities seems to be a key issue in all
three areas. However, there may be some
differences of degree between or among the three areas. N-K has a relatively strong civil
administration in place. Many of its
formerly displaced persons have returned to their homes, and are beginning the
process of reconstructing their lives.
They need assistance, but important social, economic, political, and
community institutions are intact, or are being reconstructed. These people are grounded; have access to
some land; and are resuming agricultural activities at a level somewhat above
subsistence. The primary need now after
some assistance with shelter is for the international community to help promote
income generating activities.
In Azerbaijan, on the other hand,
where there is a much larger IDP population,
people have not returned to their communities, and the incidence of
apathy and alienation appear much greater.
Some NGOs have commenced limited income generating activities among
these populations. Much more work needs
to be done in this area.
Community Development Activities
Community development activities are
an important corollary priority. In
N-K, villages are coming back together utilizing their own resources, with additional support from the Diaspora, and the Government of Armenia. In Azerbaijan, on the other hand, the communities typically lack national government support, but they also lack established socio-cultural networks to help them re-integrate their communities. The communities the team saw were essentially holding camps for displaced people, rather than villages which are coming together with the normal amenities of village life. There were virtually no tea shops, for example, and no villages councils. There are few building maintenance committees. There appear to be a few women’s groups.[8] Schools are used only as schools, and don’t double
as community
centers, where people can come together in the evenings for
social functions, or to work out strategies to help improve their
communities. Many of the NGOs working
in Azerbaijan have some level of experience with relevant community development
methodologies. It seems important to
put additional program resources into developing communities, in order to
utilize the energies of the IDPs. This
seems particularly among the IDP communities in Azerbaijan.
Monitoring and Evaluation
Capacity
In N-K the population is small and
the number of international donor agencies is limited. Coordination does not currently seem to be a
serious problem, but with expanded levels of assistance, this area might need
some limited assistance in the future. Perhaps
a small planning cell should be established, to insure optimum utilization of
U.S. Government and international donor resources.
In Azerbaijan, on the other hand,
the donor assistance community is somewhat balkanzied and fragmented. Individual donors and specific NGOs are
doing good work in their particular part of the country, (although there are
different standards and levels of assistance being provided.) However, currently no macro-level capacity
appears to exist to carry out comprehensive monitoring and evaluation of the
overall IDP/refugee situation. One
simple example of this is the lack of meaningful data on the actual status of
the refugees, (in contract to data about the IDPs). The conventional wisdom is that approximately 200,000 refugees
have largely found new lives for themselves in and around Baku. This particular assumption should be probed
and tested through appropriate survey techniques.
To address this apparent deficiency,
a suitable survey and monitoring capacity should be created, probably building
upon the work which the various United Nations agencies have already done,
including UNHCR, UNDP, and UNDHA. Some
additional capacity needs to be generated, involving enhanced use of computer
based planning technologies, (such as Geographic Information Systems), together
with relevant survey data collection and planning techniques. Save the Children, with support from USAID,
has made an important step in creating a planning framework to hold the results
of such survey data, by generating a software program called Azer-Web. The data which are beginning to flow into
this software program represents a good place to begin working on a larger and
more comprehensive planning and coordination system for Azerbaijan.
Annex A
Field notes, Visit to Nagorno Karabakh
[Dennis Culkin and
David Garner visited the provincial regions of Martakert/Agdara in the North of
N - K, and Hadrut in the South on the 23rd and 24th of January. They met with provincial officials, briefly
toured parts of both regions, and visited three somewhat representative
villages outside the provincial capitals.
Field notes for these visits are given below. The team made the decision to visit particular villages because
of propinquity to the provincial capitals, due to limited available time. These villages were not suggested by the
authorities, and appear to be at least somewhat representative of the regions
visited.]
1. Region of Martakert/Agdara
Principal
informant: Abraham Slavoko, chief of Regional Administration, or
Governor, who has worked in the area since 1988, and has been governor since
1993. Trained as a cybernetics
specialist. The prewar population of
the rayon was 46,000. Now the
population is about 23,000. There are
46 villages in the area, of which 7 remain under Azeri control. The front is 5 km away, and there is still
some shooting. The firing is mostly
snipping across the border. In 1992,
the rayon was 90% occupied by Azeri forces.
It took almost two years for the N-K forces to recapture the 33 occupied
villages.
The 7 villages
still under Azeri control possess 20,000 ha of land, or approximately 70% of
the arable land of the region. The
governor observed that if they were to retrieve those 7 villages, they would
secure a major portion of the region’s
[the region’s, or all of N-K’s?] arable land. In addition, the principal irrigation channel passes through the
occupied territories, so much of the land which normally would be irrigated is
unusable. Before the war, the region
produced approximately 90,000 MTs of grapes each year. Now the vineyards have been destroyed by
fire, and production is negligible. Perhaps 95% of the vineyards are gone. In
addition to those vineyards destroyed by fire, others have been mined. And still others which could be used are
located along the front, so workers are at risk from snipers, and the fields
are left dormant.
After May, 1994,
people started returning to Martakert/Agdara.
At the time, there was hardly one house in the whole area left
standing. Roads had been destroyed. People lived in barns, and whatever shelters
they could find. Initially relief
assistance came from ICRC, in the form of food. The governor emphasized that there have been good relations
between the authorities in Martakert/Agdara and ICRC. After some time the authorities determined that people can’t live
off of humanitarian assistance forever, so they asked ICRC to purchase things
locally to make them available to local vulnerable people. The ICRC appears to have readily complied
with this request, as part of an effort to help return the area to agricultural
self-sufficiency.
In the town of
Martakert,/Agdara there are between 5,000 and 6,000 families, of whom about
2,100 to 2,200 currently don’t have housing.
These families are staying with relatives, or are given temporary
shelters in public buildings, or in a few cases living in barns. The water system for the town comes via the
front lines, so this has caused some problems.
In the summer water runs out, so it is necessary to supplement water
supplies by using tankers.
Martakert (Agdara)
region possesses 70% of the forests of the region. Its higher elevations extend up to 3,200 meters. The Governor characterized his region as
‘the Switzerland of N- K.’ He also said
there was a gold mine in the region, and indicated there might be some coal, (which was not mined
before the war.)
A few years ago the
collective farms of the regions were converted into collectively owned ‘joint
stock’ farms. Now the authorities are
initiating a more comprehensive land reform program. In five villages, land has already been distributed to about 500
people. Currently farmers are leasing
land, but this year the authorities will formally distribute it to small
farmers. The authorities will also keep
some land under its control, [apparently this is either commons lands like
forests, or it is for subsequent distribution.] The governor appeared to say that of the 30 collective farms in
the region, about 80% will be privatized.
He said that before
the war, 90% of the population of the region had been employed in agriculture,
while the remaining 8 - 10% included doctors, teachers, and government
employees. At another time he has said
that the region included 15 - 20,000 farmers, [seemingly meaning people who
worked in one way or another on the various collective farms before the
war.] The region also had had a wood
processing plant, and two small construction companies.
A dam producing 50
megawatts is located about 12 km north of Martakert/Agdara, which provides much
of the electric power for the area. It
was built in 1976. It appears that the
current storage capacity of the dam is sufficient to generate power for 6 to 7
months per year. The turbines at the
dam are said to still be in good condition.
There is good potential for micro-hydropower in the region. There are also plans to divert a river from
the northern part of the region and put additional water into the
reservoir. This would extend the period
when the dam provides power by a month or two each year, and increase power
generation by about 5%. Because there
is a substantial difference in elevation,
it would easy to put two or three additional dams for power generation
along the newly diverted river. While
the two provincial capitals of Martakert and Hadrut had some electricity, the
governor said that some villages in the region had been without electricity for
four years.
The governor
stressed the importance of a hard surfaced internal road network within the
boundaries of N-K, so that it would not be necessary to travel into the
occupied territories (areas outside the pre-war borders of the autonomous N-K
oblast) to have access to paved roads.
He made similar observations about the importance of internal
telecommunications systems, and stressed the region’s needs for agro-processing
and agricultural equipment.
2. Village of Gulatagh, (approximately 10 km outside of Martakert)
Our principal
interlocutor was the Mayor, Valery Danielian, who has been in office since
February, 1994. The town before the
conflict began had consisted of 169 families, with a total of 484 people. Now there were 83 families with a total of
220 people living in the village. In
effect, the village is now 50% of its pre-war size, in terms of
population. At the present time, 66
families live in 66 houses. An
additional 17 families share this housing, for a total of 83 families in the
village. For a while, some of these
families had lived in the village school, although this is no longer the
case. In terms of shelter, therefore,
the village is nominally about 40% reconstructed relative to its pre-war
level. Most of the families living in
the village returned in 1994 or 1995.
The remaining population will return when shelter becomes
available. Our meeting was held in the
mayor’s office, which was located in the school. The school also contained a ‘medical point,’ which seemed to be a
small dispensary for emergency medical care.
It was locked while we were there.
The village was also said to have a small library.
Before the war, the
village had been part of a collective farm with a total area of 2,150 ha,
including 800 ha of vineyards. The farm
had specialized in wine making and cattle.
The winery produced 7,000 Mt of wine / year. Of the farm’s arable land, now only 350 ha is available for
cultivation, and the village is cultivating only 40 to 50 ha, or less than 3%
of the pre-war total. The mayor said
that 27 of the families have household garden plots. [It was not clear if these plots were included within the total
40 or 50 ha.] The current crops are
wheat, corn, and vegetables, some of which was sold in Martakert, but most of
which was consumed locally. Tomatoes in
season appear to be a popular crop for household gardens, and for potential
sale in Martakert.
The labor force is
limited, largely because of the exigencies of the continued war mobilization
effort. The village population includes
86 pensioners or old persons, and perhaps 60 adults (both men and women) of
working age. In a slightly different
context, the mayor estimated the effective labor force at about 45 or 46
persons, including 30 farmers, and 10 ‘nurses.’ Most young men are still in the army. The community also consists
of 50 children, of whom 45 attend a local school. Fourteen teachers are assigned to the school, of whom 12 are
local, and two are volunteers.
Bombs and mines
continue to be a problem. In November
one villager was killed by mines. Halo
Trust has mapped mine fields and plans to come back in the spring to clean some
additional area. One number given with
no additional context was that 9,540 ha of agricultural land had been mined.
[It was not clear if this was a total for the region, or something else.]
In terms of living
conditions, no one was malnourished in the village, but quality of food is
limited. The villagers had been
receiving periodic deliveries of supplemental food rations from ICRC. These consist of 10 kgs. of wheat flour, and
some other provisions every few months.
One delivery had been in July.
The most recent delivery had been two months ago in November. Before the war, the village had a water
distribution system, but this has been destroyed. They seem to have no functioning farm machinery, and now have to
borrow trucks, tractors, and combines to carry out routine agricultural
activities. The total production of the
farm before the war was said to have been 35,000 MT of wheat. Now, said the mayor, the whole region is
barely capable of producing what used to be produced by one small farm.
3. Village of Janatagh (15 kilometers
from Martakert?)
Our principal
interlocutor was Vladimir Martirosian, the mayor of Janatagh, who was a refugee
from Baku in 1990. He was elected
Chairman of the council in 1992, and became mayor in 1994. The town apparently had consisted of about
270 local families, and now seems to consist of about 124 familles, with a
current effective population of about 350 people, (or slightly less than 50% of
its prewar population on a per family basis.)
In addition to this, the mayor seemed to indicate that an additional 400
refugee families from the Baku region had been reassigned to live in or around
this village, so the net effective population if these families were to come
would be somewhere around 1,800.
Because many of the 124 families currently were doubling up, the mayor
felt that the village needed to rehabilitate another 10 to 15 houses just to
take care of its current population. In
addition to this, he estimated that perhaps 8 additional families would return
to Janatagh in 1998, requiring further housing rehabilitation work. [It was not clear where or when the 400
refugee families might arrive; where they were currently housed; or whether any
of the 124 families aside from the mayor himself already were included among
the current population.]
Before the war the
village, (collective farm) had farmed approximately 1600 ha of arable land,
including 800 ha of wheat, and 800 ha of vineyards along the border. In 1998, the village was farming only 70 ha
of land, (or less than 5% of the pre-war total.) In addition to this, neighbors from another nearby village were
leasing an additional 10 ha. which they had planted in wheat. The crops today are wheat, corn, potatoes,
and water- melons. Now, 95% of the land
being cultivated is dryland.
The labor force of
the community consists of 11 teachers, (teaching 74 students from 1st to 10th
grades), plus 2 nurses, 5 people who worked in the Mayor’s offices, 15 laborers
and another 12 pensioners who could do some farm work. The mayor estimated an effective labor force
for the village of about 35 persons. In
addition to this there seemed to be a substantial number of pensioners, most of
who were old and disabled and unable to work.
Agricultural
equipment is a serious problem for the community. They had had two tractors, both of which had been destroyed by
mines a couple of months earlier. They
had one truck, but it was broken.
Before the war, by contrast, they had had 28 tractors, and 1,000 head of
cattle, 500 sheep, and 800 pigs. These
were all destroyed, or stolen when the village had been occupied. Today, however, only that handful of
villages that had not been occupied still have their agricultural equipment
intact. This suggests that these seven
villages are supplying the bulk of the machinery necessary for the region’s
agricultural activities and that the rayon might have approximately 15% of its
pre-war ag machinery capacity. However,
as the mayor pointed out, this remaining machinery is increasingly old and
obsolete.
The mayor
emphasized the importance of agricultural equipment as part of the local
economy. In 1996/97, he said, two
tractors had been destroyed, with one driver being killed and the other being
hurt. Forty cows had been killed by
mines. So while perhaps 80% of the
population of the area was generally in adequate condition, the mayor felt that
without adequate agricultural machinery, things were becoming somewhat more
problematic.
The mayor also said
that the mayors and local village councils were going to be up for election in
April, 1998. He had been appointed, he
explained, but they were shifting over to direct election of local
officials. If N- K proceeds with this
plan, then these newly elected village councils might become interesting
vehicles for channeling reconstruction assistance. The new village councils will have responsibilities for
overseeing such things as local medical services, education, local law and
order issues, and some matters relating to farming. The mayor will oversee the work of each village council, and the
council will have responsibility for each collective farm.
4. Hadrut Region
Our principal
interlocutor for our visit to the Southern part of NK was Serge Sergisian,
"Chief of the Regional Administration of Hadrut Region", or
Governor. Mr Sergisian was trained as
an economist, with an emphasis on statistics.
He explained that Hadrut was not nearly as wealthy as Martakert before
the war. It had had about 6,000 ha of wheat
before the war, and again grows this amount of wheat. However it had had 3,000 ha of vineyards before the war, and of
this only about 100 ha remain. The
population in 1988 had been about 14,500, including 2,000 Azeris. Now the population was about 11,000 people.
Before the war the
Region had consisted of 42 villages.
During the war, 14 of these villages were captured, and 4 seem to be
located along the border or front area, and so perhaps are in no man’s
land. It was not clear exactly how many
of these 42 villages are under N-K control today. The town of Hadrut had had a prewar population of 2,400. During the war this swelled to 4,000 people,
but now it was back down to 2,400.
In terms of
housing, before the war the rayon had about 4,500 dwelling units, of which
1,500 were destroyed, leaving about 3,000 today. The authorities are reconstructing between 25 to 30 houses a
year; private resources are reconstructing an additional 20 houses for a total
of about 50 per year. At this rate
reconstruction will take approximately 30 years.
Before the war the
region had had no industry except for three wineries. Of these two have been destroyed, and the third is not
operating. There were 330 kms. of
roads, of which 3 had been paved. All
these roads were in use now, but 15 villages become inaccessible during the
winter months, because of a lack of maintenance on the roads. From what we could see, there had been
little or no graveling of these mud roads.
The region receives its electricity from Stepanakert. The power went out in the governor’s office
as we were talking, and he said that five villages currently are not connected
to this grid. For water, most villages used springs, although 10 villages had
had piped water systems. Heating was
primarily by wood.
In terms of
agricultural machinery, the region had had 250 tractors, of which 60 remained;
26 combines, all of which remained; and 400 trucks, of which 40 now
remained. (Comparing aggregate totals
for all prewar ag machinery suggests that less than 20% of the prewar capital
stock remains.)
In terms of
students, the region had had 2,500 before the war; it has 2,100 now. The birth rate was essentially constant,
averaging about 240 per year.
Because the Governor had a good feel for overall economic activities in the region, the team asked him how the war had impacted people’s lives in economic terms. He said that for the whole region, wheat production was approaching pre-war levels. He thought that for individuals, per capita income was perhaps 60% of the pre-war situation. However, he felt that total production for the entire rayon was perhaps 20% of the pre-war situation, because the vineyards and wineries were out of production, and cattle production was substantially down. He felt that across N- K, economic production was at about 40% of prewar levels. However he believed that with peace, it would be possible to reach prewar levels within a couple of years.[9] In terms of employment, he
thought that
about 70% of the labor force of the rayon was employed, [suggesting a nominal
unemployment level of 30%, which sounds like it may understate the actual
levels of unemployment, or under-employment.
This number should be probed further during subsequent trips into the
area.]
5. Village of Kochbeck. Located 15 minutes from Hadrut.
The team’s
principal informant was the mayor, Mr Norashan. Notes for this visit are a bit sketchy, as time was running out,
but we learned that the village had been occupied by Azeri forces for about 18
months, and during this time the population had moved to Hadrut. During the war, the mayor said that the
village was about 50% destroyed. The
village seems to have had a pre-war population of about 280 people; now there
were 155 people. The village had had 55
households, of which 12 were destroyed, and 6 were damaged, suggesting that
about 33% of the direct housing stock was destroyed. Other public buildings and agriculturally related structures
presumably were also destroyed through the fighting. Fourteen of the 18 damaged or destroyed houses have been restored
to some level so they can be used; four remain to be restored. Four or five of the existing houses have two
families living in them.
The village
cultivated about 120 ha of wheat before the war, and a similar amount now. They had also tended about 80 ha of
vineyards, however, which are mined, and now out of production. Most of the wheat they grow is used for
local consumption. The sources of cash
income for the villages include some income from pensions, plus a few people
who are able to work in Hadrut. Only an
estimated 20 people now work on the collective farm attached to the village of
Kochbeck.
In terms of health
services, the village has a ‘medical point,’ with a female nurse, who is
present in the village. They also use
the regular hospital in Hadrut, which is 15 minutes away. The town of Hadrut has a 120 bed
hospital. In addition, the region has 4
smaller hospitals with a total of 65 additional hospital beds.
In terms of
priorities, the mayor thought that agricultural equipment was the village’s
highest priority, because they only had one tractor left. To harvest their wheat, they have to rent a
combine from another village.
The pre-war
Fizuli/Nagorno-Karabakh oblast border happens to cut through the village of
Kochbeck, with perhaps 7 or 8 of the 55 houses located across this line. Villagers had restored two of these
houses. One resident of the village
came up to the team as we were leaving and said that he had not originally come
from Kockbeck. He was identified by
other villagers as an immigrant from Armenia.
However, this was the only resident in any of the areas visited by the
team who appeared to be from Armenia; all the other occupants the team saw in
the three villages we visited seemed to be long-term occupants of the area, or
in the case of the mayor of Janatagh, were refugees from Baku.
The two governors
spoke of the local populations as people who had been living there all their
lives. The mayors repeatedly spoke of
people ‘returning’ to their villages.
From our visit the team did not receive the impression of any
significant new population moving into these villages. These villages seemed populated by people
who for the most part either had managed to stay during the war, or returned to
their villages after the war when they could find suitable shelter. The villages also appeared notable for their
cohesion. These are rural communities
which are working closely with the local authorities to put themselves back
together, to return as quickly as possible to a normal rural life.
Annex B
NOTES, PUBLIC
HEALTH
Nagorno‑Karabakh: Public health issues to consider in
program planning to improve the
humanitarian situation
Introduction
Field Visits: In Nagorno‑Karabakh
(N‑K), I visited the five central level hospitals: Maternity, Children's,
Internal Medicine/General/Adult,Psychiatric and the TB hospital. I had the opportunity to meet with each
director, some of the key staff and tour all of the different departments, as well
as speaking to both the "Minister" and "Deputy Minister of
Health". I also visited the diaspora‑supported Arpen Center, a pre‑natal
clinic in Stepanakert and spoke extensively with the pediatrician running the
Center about maternal health issues. I
visited the MSF‑France and ICRC offices, where conditions throughout N‑K
were discussed at length with both expatriate and local staffs. I also visited four nurses and one feldsher
(equivalent to a physician's assistant) working in four northern Martekert Region health units and toured two of
the health units including nearby catchment areas.
Given our mandate to look at humanitarian assistance to victims of the N‑K
conflict, the most expeditious way to support assistance efforts in N‑K
would be, where possible, to work with international organizations already on
the ground (ICRC, American Red Cross, MSF‑France and MSF‑Belgium). Programming options are limited at the
moment in part due to the few organizations on the ground. However, there is an enormous potential to
make some important differences through actions as simple as making health
education and medical resource materials available at different levels within
the health system. The following is a guide to assist in a preliminary look at
some of the health issues and current or proposed programs that could be
approached on a short‑term timeline (6‑18 months) that fall into
humanitarian assistance. Also listed
are some regional reference points for drawing comparisons.
Health System Structure and Problems
Nagorno‑Karabakh's health infrastructure is established and
functioning despite obstacles including: outdated protocols; medical under‑treatment
contributing to drug resistance; lack of hygiene, deterioration of
infrastructure; poor distribution or lack of medicines and despite equipment
shortages. There are 252 MDs in N-K
which is about 1 per 516 people, and an even larger number of nurses and
physician assistants (felshers). A
concern about the large number of medical personnel, is despite their
abundance, it is difficult to evaluate the depth of their training and
different specialization. Many medical
personnel admit to feeling "out‑of‑date" post Soviet
dissolution and after disruption of educational training by the N‑K
conflict. Incorporated into the health
infrastructure, there is a national center for epidemiology with existent but
suspect surveillance system. However,
there are no established early detection or prevention mechanisms outside of
childhood immunization activities.
"MOH"
Stepanakert Republican Hospital
(Obstetrics, Pediatrics,
Internal Medicine, TB, Psychiatric)
6 Regional Hospitals
(plus 3 smaller hospitals)
150 Public Health Care Units
(managed by nurses or felshers)
(1 per village)
Demographics
Our best estimate of N‑K population is 130,000. Approximately 30,000 are concentrated around
Stepanakert. Roughly 20% of the
population is under 15 years. Although
it is difficult to estimate N‑K wide demographic trends, in one village
northern village 60% of that population was over 60 years. This is due in part to out‑migration
as adults in their 20s‑50s have left for better employment opportunities
outside N‑K and with many men still in the army. The average family size is 2.3 children and
despite 1998 government financial initiatives to reward families with four or
more children, women with whom I spoke were inclined to wait and see progress
of N‑K political and economic stability before expanding the size of
their families.
What diseases do medical personnel and parents report?
No current epidemics of serious infectious diseases have been seen. Diseases reported by Karabakhi medical
personnel in adults, are: hypertension; CHD; TB; diabetes; skin infections and
especially now in the winter months, upper and lower respiratory tract
infections. Among children, respiratory
infections, colds and skin diseases are reported. There is a seasonal rise in diarrhea from June to August but with
no associated mortality.
For comparison:
* These are the same diseases commonly
reported in Armenia and Azerbaijan.
Azerbaijan has a more pronounced problem of malaria in the southern
region.
Cost of treatment, Medicines and the Humanitarian Warehouse
The post‑Soviet health care system focuses on the curative side
and many diseases are treated with antibiotics. Treatments not considered "effective" by patient or
medical personnel if non‑injectable.
These attitudes are regional, not N‑K specific. Despite generous donations from the diaspora
and Government of Armenia, medicines are frequently not available in government
stores and are expensive in private pharmacies, when available. Part of the medicine shortage might be
explained by poor storage or logistics problems. Some NGOs have estimated that 80% of pharmaceutical in N‑K
are currently stored in the Stepanakert humanitarian warehouse. Three possible assumptions put forward to
explain the central‑level blockage are: 1) N‑K stock is centralized
in case of war; 2) mangers justify their own employment and protect job
security by not distributing; and/or 3)
there is no political willingness behind drug distribution. Private foreign donations of medicines might
alleviate drug shortages if pro‑active planning and basic management of
distribution can be improved.
In speaking to MSF‑Belgium (in Yerevan), who had managed an MSF
drug store in N‑K during the conflict, they were resistant to tackling
the humanitarian warehouse situation and viewed it as a longer‑term
project involving hands‑on training.
They recommended contact with Belgian‑based Ides, which is their
sister organization that can be rapidly operational using MSF field
logistics.
For comparison:
* In Armenia, a 1996 World Bank Social Assessment found that
39.7% of "persons who were ill chose not to seek treatment because they
could not afford it."
Medical protocols
Feldshers, nurses and MDs are under‑treating diseases. Evidence can be seen from medical
records. As soon as patients feel
improved they stop taking medicine either through lack of strict instructions
to finish regimes from medical personnel, high cost of treatments, and/or a
combination of these two factors. Also,
registries are nicely written but are not a guarantee that medicines are
taken. On entering health units, the
only educational materials readily at hand were 20+ year old medial texts and
if lucky, a well dog‑eared copy of the MSF treatment and medications
guide. This indicates a clear call to
at minimum, provide at‑hand medical references and health education
material, and if possible, do training for prescribers of medicine.
For comparison:
* Failure to follow protocols is common in the southern
Caucasus as is the lack of medical reference or health education
materials. However, NGOs serving IPD
populations in Azerbaijan have been very innovative in creating or translating
health educational materials (i.e. IRC just
translated Where There Is No Doctor into Azeri) to make
available in the camps.
TB and other Communicable Diseases
In N‑K there are an estimated 50 cases of TB per year. Another approximately 200 cases, many of
which present already multi‑drug resistant, would benefit from being re‑treated. Both of these statistics are thought to
considerably underestimate the real prevalence of TB, by possibly as much as 50‑80%. However, N‑K's TB problem is not
dissimilar from the rest of the region.
For comparison (see attached WHO chart):
EU 14/100,000(14
cases of TB per 100,000 population)
NIS 53/100,000
Dagastan 80.9/100,000
The MSF‑France program within the N‑K TB hospital started in
May of 1997 and is projected to continue through 1999 or 2000 (MSF‑F has
been present in N-K since 1992). The
MSF‑F program has involved rehabilitation of the 40 bed facility which
hosts in‑patients for 2‑8 months of treatment. As importantly, they are training local
counterparts to follow WHO protocols (including DOTS) and instituting more
cohesive referral and patient follow‑up systems effective throughout N‑K.
There are cases of hepatitis, STDs and HIV/AIDS. It is difficult to determine their
incidence. Given the medicine supply
problem it is safe to assume a lack of diagnostic supplies as well as failure
to follow correct medical protocols.
For comparison:
* Azeri MOH has a draft National TB Control Program that
appears to have been deadlocked since May 1997 and reportedly may not follow
WHO treatment protocols.
* Yerevan officially reports 46‑56 cases of HIV/AIDS
per year and is formulating a national strategy.
Maternal‑Child Health
Including: family planning, childhood immunization,
breastfeeding, pre or antenatal care, and nutrition
In N‑K, the vast majority of women deliver in the Stepanakert
Maternity Hospital which is the referral facility for all of N‑K. In 1997 there were 1060 deliveries resulting
in 986 live births. The staff tries to
keep women on average 6 days for follow‑up after delivery (compared to 2‑3
days in Armenia). Despite an abundance
of medical personnel, the maternity hospital suffers from a lack of running
water, heating, hygiene, diagnostic equipment, incubators etc. A cursory look at family planning revealed
that the maternity hospital also performs up to 6‑7 abortions per
day. Access to contraception is
problematic, requiring spousal permission.
IUDs and condoms are available but are also reported as expensive.
For comparison:
* In 5 northwesterly Azerbaijani regions (Barda/Agdam/Terter/
Zanlar/ Kashkesan) 35% of rural women delivered at home (MSF‑Holland 1997 survey) Relief
International estimates of home births in Agcadbedi is considerably higher than
35%.
* Armenia official rate of abortion is 62.6 abortions per 100
live births. (UNICEF) Abortion as a method of contraception, and complications
it presents to maternal health, is common in all three areas.
Breast feeding
In N‑K it appears that there is nearly universal initiation of
breast-feeding but after 24 hours, thus infants lose the protective benefits of
their mother's colostrum. An estimated
33% of women cease to breastfeed after the first 3 months, contrary to the
internationally recommended 4‑6 months.
Medical personnel are aware of the breast feeding benefits but are ill
trained to counsel and educate their clients about breast feeding and there
seems to be little emphasis from within the health system to strengthen these
activities. Again, of potential
enormous benefit would be to make available educational materials such as
breast feeding posters for all health units, the maternity hospital and
polyclinics.
Prenatal/Antenatal Care
The main prenatal or antenatal care issues are lack of counseling,
health education and diagnostic equipment.
There is some concern that despite a existence of PNC and ANC care
programs, utilization levels are low, especially among women with more than one
child. Given the N‑K authorities
incentives to increase population, antenatal care is an ideal opportunity to
expand past an increased birthrate to include emphasis on health of the family,
mother and individual children.
For comparison:
* Prenatal care of women outside Yerevan was 40%.
* A recent survey in northwest Azerbaijan discovered that
"more than 3 out of 4 women received some form of antenatal care during
their last pregnancy, 60% of them three times or more." Reasons for not attending PNC were that
women "did not feel a need to go" or felt healthy during
pregnancy. (MSF‑Holland survey in
5 NW districts of Azerbaijan, 1997)
Immunization
MERLIN, a British NGO introduced the WHO/UNICEF guidelines when they
started a program in 1993 to assure N‑K vaccination coverage. The "Ministry of Health" conducts
two vaccinations campaigns a year, in the spring and fall. Post‑war, only
an estimated 3% of children haven't received vaccinations. It is not clear if the "MOH" is
continuing to adhere to WHO/UNICEF immunization guidelines or reverted to the
old Soviet system.
N‑K vaccination coverage reported by the state epidemiological
center, when compared with reported disease, demonstrates some significant
inconsistencies and gaps. For example,
the 1997 "MOH" reported coverage for measles is 95%, yet in 1997
there were 191 cases of measles. An
independent report by Alina Dorian (American University of Armenia) estimated
coverage for measles as low 37.8%. In
1996 there was an outbreak of diphtheria resulting in a "MOH" massive
campaign to re‑vaccinate everyone between ages 3 to 60 years. Another example is despite the reported high
childhood immunization coverage rates, from late 1996‑97 there were 2
clinically proven cases of polio from N‑K reported in Yerevan. An illustration of a major vaccine gap is
the absence of BCG vaccines in the Maternity Hospital since August 1997. This disruption is pending a donation of
4,000 dosages from the Armenian Ministry of Health.
Clearly due to the severe shortage of BCG, MERLIN is not currently assuring
long term vaccination
supply. If MERLIN is no longer involved
or interested, MSF‑France has requested funding for to evaluate the
current immunization program. It is
crucial to determine if coverage inconsistencies are rooted in poor cold‑chains,
problems in vaccine supply, over‑reporting, or elsewhere in the
system. Whatever the root cause, a
training component should be linked to any assistance provided to improve
capacity‑building and pro‑active planning.
For comparison:
* Estimated 39.7% BCG coverage rate in Northwestern
Azerbaijan. (MSF‑Holland survey
in 5 NW districts of Azerbaijan, 1997)
Nutrition
In Stepanakert, there is some reported childhood growth stunting
indicating an absence of micro-nutrients.
This which may be alleviated by increasing variety in diet over the last
year as more different kinds of food are available in the city. At present, there is no serious problem of
malnutrition and in the northern region of Martekert where I visited a health
unit (village Maghavuz) and catchment area, there was no malnutrition reported
at all.
For comparison:
* Although acute undernutrition does not seem to exist in
Azeri (IDP or resident) children, there is a "fairly high prevalence of
stunting", which is more pronounced among IPD children than resident
children (CDC Health and Nutrition Survey, 1996). NGO‑employed healthcare staff working with IDPs classify
malnutrition as not acute, but chronic.
Trauma
Parents report some signs of stress in children and cite the difficult
times during the war where families were sometimes hidden in basements for a
year or had to flee their homes leaving behind everything. They also remind that these events are now
six years past. At present in N‑K
there is no early detection or referral system to catch either children or
adults who evidence signs of stress, psychological or psychiatric
problems.
For comparison:
* UNICEF has psycho-social program within education system by
teachers for children exhibiting signs of stress. In 1997, they did 12‑14 training in border areas of
Armenia.
Psychiatric Care in N-K
Psychiatric in‑patient treatment is abysmal. The psychiatric hospital might have been a
livestock and storage space at one time.
Psychiatric out‑patient "treatment" follows unclear
diagnoses and guidelines. Again, there
is no counseling or early detection. MSF‑Belgium has expressed a desire
to assessment opportunities that might address the absence of psycho‑social
care, capacity building and new out‑patient or alternative methods such
as work therapy. In collaboration with
the "MOH", they would also rehabilitate a more suitable building for
use as a psychiatric hospital and are currently planning to send a consultant
in February to further analyze possible mechanisms for early detection and
referral system based on central consultations with traveling services.
War‑wounded, invalids
A forgotten vulnerable group that was hidden to us in our N‑K
visit, but brought to our attention by ICRC, are the war‑wounded and home‑bound
including paraplegics, amputees etc.
The "MOH" is not prepared to cope with or even offer life-care
to this population who are a tremendous financial and emotional burden on their
families. ICRC has proposed to train N‑K
medical personnel to institute extended‑care to them in their homes.
To view the table and chart graphics listed Click below on the button:
Incidence of Tuberculosis in North Caucasus
Health Care System Overview – Nagorno-Karabagh
Annex C
CONTACTS
Armenia
Zoran Jovanovic, Head of Delegation
International Committee of the Red Cross
Miguel de Clerck, Head of Mission
MSF-Belgium/Armenia
Eric Seguin, Head of Mission
MSF-France/Armenia
Anna Van Gerpin, Program Officer,
UNICEF/Armenia
Fatima Sherif-Nor, Program Officer,
UNHCR/Armenia
Nagorno-Karabakh
Dr Poghossian, "Deputy Prime Minister"
Coordinator of humanitarian assistance
Nagorno-Karabakh
Delegates and staff,
International Committee of the Red Cross
Stepanakert/Kankandi
Serge Arushanian, "Minister of Social Welfare"
Nagorno-Karabakh
Dr. Arno Tsaturian, "Minister of Agriculture"
Nagorno-Karabakh
Slavic Abrahamyan, Chief, Martakert Regional Administration
Martakert/Agdara, Nagorno-Karabakh
Dr. Sergei Ohanian, Director, Martakert Central Regional Hospital
Martakert/Agdara, Nagorno-Karabakh
Valeric Danielian, Mayor, Gulatagh village
Martakert region, Nagorno-Karabakh
Vladimir Martirossian, Mayor,
Janatagh/Chanyatagh village
Martakert region, Nagorno-Karabakh
Serge Sarkissian, Chief, Hadrut Regional Administration
Hadrut, Nagorno-Karabakh
Alexander Petrosian Mienaelovich
"Minister of Health", N-K
Edward Aghokerian
"Deputy Minister of Health", N-K
Vartan Ghurasian
Director, Republican Hospital, N-K
Ernest Grigorian
Director, Psychaitric Hospital, N-K
Director, Maternity Hospital, N-K
Mirop Markarian
Director, Pediatrics Hospital, N-K
Vladamir Mousaelian
Director of the Diagnostic Center, N-K
Registered Nurses,
Maghouz Health Unit
Rosanna, RN
Mingrelsk Health Unit
Margarita, RN
Lulasaz Health Unit
Elfrida Mikhaelian, Feldsher
Nerkin Horatagh Health Unit
Azerbaijan
Lutful Kabir, Country Director
UN Development Program/Department of Humanitarian Affairs, Baku
Didier Laye, Representative
UN High Commissioner for Refugees, Baku
Maureen McBrien, Field Officer
UN High Commissioner for Refugees, Baku
Zeynep Ozgen, Program Officer
UN Development Program, Baku
Michel Dufour, Head of Delegation
International Committee of the Red Cross
Baku
Carl Naucler, Head of Delegation
International Federation of Red Cross and Red Crescent Societies, Baku
Ervin Blau, Relief Co-ordinator
International Federation of Red Cross and Red Crescent Societies, Baku
Cherif Zaher, Country Director
World Food Program, Baku
Luay Basil, Emergency Officer
World Food Program, Baku
Nora Bazzi, Regional Director
Mercy Corps International, Baku
Stuart Willcuts, Program Director
World Vision, Baku
Khalid Hasan Khan, Director,
Save the Children, Baku
Dr Sameh Youssef,
Medical Coordinator
Fouad Hikmat,Country Manager
MSF-Holland
Markus R. Huet, Country Director
UMCOR
Jayhoun Mamedov
Medical Coordinator
UMCOR
Christine Mathieu, Medical Delegate (TB Specialist)
ICRC/Azerbaijan
Sonja Van Osch, Head of Mission/Medical Coordinator
MSF-Belgium
Ramin Hagiyev, Medical Coordinator
IFRC
Lumu (Community Health Worker IDP from Lachin winter grounds)
Caroline (expat coordinator of Reproductive Health Program)
International Rescue Committee
Valerie, RN (expert on war
wounded/amputees)
Philippe (expert on International Humanitarian Law)
ICRC/Barda officeRefugees International
Jamila Kerimova, Medical Coordinator, Reproductive Health Program
Refugees International
Dr. Assif, Mobile Clinic Physician
Refugees International
Myles Harrison and members of local staff
World Vision
Annex D
TERMS OF REFERENCE FOR PARTICIPANTS IN THE EVALUATION OF THE
HUMANITARIAN NEEDS OF N-K CONFLICT VICTIMS
(INCLUDE THE REGION OF
NAGORNO-KARABAKH)
Introduction
The USAID Mission for the Caucasus plans to provide assistance to the
victims of the Nagorno-Karabakh conflict.
The first step of this process is to conduct an evaluation of the
humanitarian needs in the areas populated by these victims.
The evaluation team will:
- Conduct an evaluation of
humanitarian needs of the victims of the Nagorno-Karabakh conflict in such
sectors as food, health, sanitation, communicable diseases, and shelter.
- Primary focus will be on needs
of vulnerable population groups such as mothers, children, and elderly, with an
emphasis on health issues.
- Conduct the evaluation in
Azerbaijan and Armenia, including the Nagorno-Karabakh Region and the vicinity
of N-K.
- Complete the study within two
weeks.
- Consult with U.S. Embassies in
Baku and Yerevan, as well as Non-Governmental Organizations (NGOs) and
International Organizations (IOs) in the region.
- Assess the possibilities
opened up due to recent legislation affecting Section 907 of the FREEDOM
Support Act (FSA). Although Section 907 of the FSA prohibits assistance
to the Government of Azerbaijan, humanitarian assistance for refugees,
displaced persons, and needy civilians affected by the conflicts in the
Southern Caucasus region, including those in the vicinity of Nagorno-Karabakh,
may now be provided notwithstanding
Section 907.
- Avoid focussing on
reconstruction and infrastructure assistance, since such assistance is still
prohibited by Section 907 of the FSA.
The assistance program to be designed as a result of this evaluation
will be implemented through NGOs or IOs and not through local or national
governments.
Evaluation Specialists
A team of no more than three (3) Humanitarian Assistance and Health
(MPH) Specialists will be given responsibility for carrying out the above
evaluation, working in concert with USAID/Caucasus. A total of up to, but not more that two (2) person-weeks of
effort will be the level of effort for each team member. The period of assignment will begin on or
before January 17, 1998.
Scope of Work
Specific issues to be addressed include the following:
- Identification of
vulnerable population groups.
- Total numbers of
vulnerable population.
- Vaccination status of
the populations in the area.
- Prevalence of various
diseases and illnesses in the area.
- Pharmaceutical
availability and affordability.
- Food availability and
affordability.
- Shelter availability
and suitability.
- Water and sanitation
availability and suitability.
- Identification of
donors and implementing agencies already providing assistance.
- Identification of
specific areas not covered or which are not sufficiently covered by current donors and implementing
agencies. This could include
non-humanitarian areas which could
facilitate the peace process.
- Preparation of an evaluation report which includes
recommendations for project/activity options
based on analyses of the above.
As there have been
previous assessments performed in the areas outside of Nagorno-Karabakh, it is
anticipated that most field work involved with this evaluation will be
performed within and adjacent to Nagorno-Karabakh.
Reporting and
Deliverables
Team travel and
itinerary must be coordinated with USAID/Caucasus and U.S. Embassies Baku and
Yerevan.
In-briefings and exit
briefings will be held with USAID/Caucasus and embassy staff.
A final report
containing information gathered and recommended activity options is to be
provided to USAID/Caucasus before departure from the region.
[1] The public health specialist on the team was Kirsti Lattu; the regional specialist was Dennis Culkin; the
development planner was David Garner.
[2] K. Lattu (1/20/98) conversation with Miguel De Clerk, MSF-Belgium Head of Mission and former member
of the N-K MSF Exploratory Mission.
[3] TB is already being addressed through the renovated Karabakh TB hospital.
[4] Examples include MSF’s Standard medical protocols in Russian; IRC’s Azeri translation of “Where There is
No Doctor,” and other publications on Mother Child Health including breast feeding, immunization, and safe
motherhood.
[5] In addition to the 200,000 refugees who are victims of the N-K conflict, Azerbaijan is also host to an
additional 40 - 50,000 Muskadi Turks, who are not victims of the conflict.
[6] Statistics from one NGO’s reproductive health program, unpublished 1997 annual report.
[7] During the trip the team heard no anecdotal evidence of IDPs who were literally homeless.
[8] One member of the team found indications of a few NGO-fostered women’s groups that originally met for
community health activities, but now seem to be somewhat cohesive cohorts that offer peer support to
members.
[9] This judgement may prove unduly optimistic for the following reasons: 1) much of the income of the rayon
seems to have come from grapes and wineries; 2) most of the vineyards have been destroyed, and/or mined; 3)
new grapes take 4 - 5 years to come into production; and 4), perhaps most significantly, the Caucasus seem to
have lost many of their traditional markets, and the farmers and government officials are not currently equipped
with many of the necessary skills to help them find new
international markets for their produce.