In October 2020, an Azerbaijani reconnaissance drone flew over Abovyan, Armenia. In the days that followed, signs were put up on building entrances around Yerevan, pointing residents to the nearest air raid shelter and cautioning them to have a bag packed with their important documents. People described the events as surreal, unexpected. We’re surrounded by unfriendly neighbors; how could this take us by surprise? Still it did.
A disaster is defined as any disruptive or adverse event that outstrips our ability to respond. Inherently, how we define a disaster has a lot to do with our capacity to begin with. There are natural disasters and man-made disasters: tsunamis, hurricanes, plane crashes, earthquakes, wars, sabotage of essential systems. This past year in Armenia was a reminder of the danger of being caught unaware. In 2020, Armenia was drawn into the ravages of the COVID-19 pandemic, overwhelming the health system.
On September 27, 2020, in flagrant violation of the United Nations Appeal for a Global Ceasefire in the midst of the pandemic, Azerbaijan and Turkey attacked Artsakh. The brutal 44-day war saw bombing of civilian areas and the widespread use of unmanned drones, which decimated the next generation. Intensive care units filled up with COVID patients and wounded soldiers. Burn units filled up with civilians attacked with illegal phosphorous bombs. War further strained the healthcare system and emergency response. Ambulances from the capital were deployed over 2,600 times to the war zone and border regions over six hours away. Hospitals and emergency workers were intentionally targeted despite the Geneva Conventions. COVID-19 cases escalated precipitously during this time, profiting from the displacement, crowding and social mobilization efforts that accompany wars. Over 100,000 displaced people sought shelter and security before the cold winter months set in.
In a conflagration of one catastrophe after another, the November 9 ceasefire was followed by two significant earthquakes. Luckily, the population, already at the breaking point, was spared from significant damage. Still, the psychic aftershocks continued. Civil unrest followed threatening the security and safety of the country. This week, incursions by Azerbaijani troops into Gegharkunik and Syunik regions risk restarting a war. The reality is, everything is always hanging on the precipice of disaster. Without planning, we just don’t see it until it’s too late.
Following the 1988 Spitak Earthquake, and the establishment of the Republic of Armenia in 1991, the need to improve Armenian emergency medical systems became evident. In 2009, the Armenian Ministry of Health prioritized the reform of the emergency medical system. Furthering emergency care in the Republic of Armenia, a post-Soviet Republic, has met with many challenges. Even before the calamitous year of the syndemic of COVID and war, disaster response has been of particular importance to Armenia. The republic is in an earthquake-prone region, constantly under the threat of war, and is critically under-resourced to deal with a pandemic. A United Nations Development Program report from 2010 on reducing natural disaster risk revealed that, during 1980–2000, Armenia averaged 325 deaths per million inhabitants due to disasters. In fact, more than 80% of Armenians are at risk of exposure to catastrophic events. These statistics unequivocally call for strengthening emergency systems in order to improve Armenia’s capacity to respond in times of crisis.
What’s the solution? Disaster planning and emergency preparedness aim to avoid or minimize harm from the unforeseen. Preparedness efforts focus not only on medical aspects but also on the preparedness of every single person and every single organization. We all need a plan. Disaster planning spans all fields and starts with an assessment of vulnerabilities. We need to think about cybersecurity, access to water, cellular connectivity, energy supply, the vulnerability of a nuclear power plant in the center of an earthquake zone with hostile neighbors. We need strategies to secure our people and our government. We need to think about underground bunkers and plans for hospitals, escape routes and backup communication systems. It may seem like a luxury, but the true cost of not securing our future will be even more expensive.
Emergency response is complicated in Armenia and involves coordination between the Yerevan municipal ambulance services, regional emergency services, the Ministry of Health, the Ministry of Emergency Situations and both the defensive forces and the medical branch of the military, among other entities. It also involves every citizen and every community. Awareness of the need for disaster preparedness seems to be slowly taking hold in Armenia. There is currently a draft resolution “On Approval of the Concept of Disaster Risk Management and the List of Measures Arising from It” that seeks to “increase the process of organizing the protection of the population at all levels of the disaster risk management system, reduce the number of people affected by disasters, and the material damage caused, coordinate legislation, and methodologies to international standards, develop an effective system of early warning for the population in emergency situations and inclusion of disaster risk management measures in targeted state and community development programs, plans and budgets.”
Although disaster planning spans all fields, medical response is the lynchpin. Emergency response relies on a functional emergency care system. The global burden of disease has recently shifted toward trauma and non-communicable diseases. The World Bank estimates that, in low- and middle-income countries, more than 50% of deaths and 40% of the disease burden could be alleviated with adequate emergency medical care. Emergency care focuses on providing prompt care to patients with time-dependent and life-threatening conditions, such as traumatic injuries, heart attacks, cardiac arrest, stroke and respiratory failure.
The development of emergency care systems can multiply the functioning of the health system overall and improve outcomes for all other disease processes. Weak delivery systems are especially dangerous when pushed to their limit, potentially due to a pandemic, a foreign attack or a natural disaster resulting in mass casualties. Some cite cost as a reason to not strengthen emergency care and response, but globally the development of emergency systems has proven to be an extremely efficient way to provide care across many different conditions. Surprisingly, emergency care is among the most cost-effective public health interventions. Globally, emergency medical care is in various stages of development, ranging from rudimentary care to hospital-based stabilization and intensive care unit support. Where does Armenia stand?
An investment in emergency systems is clearly needed, but this past year raises many questions. The WHO Assessment of Health-System Crisis Preparedness and the Emergency Care Systems Assessment Tool takes an inventory of resources within the country to assess areas for improvement. Countries in conflict regions are particularly vulnerable in the assessment phase when disaster preparations are made public. A fear of providing a roadmap to their enemies or highlighting weaknesses can be paralyzing. This is especially true when hospitals, ambulances and healthcare workers are targeted, as they were during the 2020 Artsakh War.
In emergency medicine, we talk about teachable moments, when patients are particularly vulnerable and likely to understand the link between their behavior and their presentation to the hospital. Armenia is now in a teachable moment. The time to double down on disaster preparedness and emergency care development is now, when the need is imprinted in everyone’s mind. We need systems building and proactive measures. We need to move from reaction to prevention and mitigation. Despite all that has happened this past year, the time to act in Armenia has not passed; it has become all the more urgent. It’s not an exaggeration that the future of the Republic depends on it.