War in Nagorno-Karabakh highlights the vulnerability of displaced populations to COVID-19

Food insecurity among displaced populations in Armenia during the 2020 Nagorno-Karabakh conflict

Background

The 2020 Nagorno-Karabakh conflict resulted in displacement of approximately 90,000 ethnic Armenians from Nagorno-Karabakh to Armenia, exacerbating existing vulnerabilities in the region. This study investigated food insecurity among displaced populations and host communities in Armenia during the conflict.

Methods

This study is a secondary analysis of cross-sectional data obtained from the 2020 REACH ARM Database Multi-Sector Needs Assessment (MSNA), which was conducted across six Armenian provinces. The original data collection was designed to assess humanitarian needs in Armenia in the aftermath of the 2020 Nagorno-Karabakh conflict. In this analysis, we examined the associations between displacement status and two outcomes of interest: the household's ability to purchase food and reduced portion sizes. Multivariable logistic regressions were performed for each food security outcome.

Results

The study sample included 1,309 households, with most male heads (68.1%), an age distribution mostly under 50 years (81.2%), a majority having general education (55.7%) and higher education (22.8%), and 74.0% not employed. 134 households (10.2%) were displaced and staying in collective centers, 658 households (50.3%) were displaced and staying with family or friends, and 517 households (39.5%) that were not displaced but hosting displaced people. Displaced individuals staying in collective centers had 3.89 times higher odds of reporting a reduced ability to purchase food compared to non-displaced individuals (aOR: 3.89, CI: 2.396.45). Additionally, displaced individuals staying with friends or family had 2.5 times higher odds of experiencing food purchasing difficulties (aOR: 2.53, 95% CI: 1.87-3.42). Households in debt and those with children and lactating women also faced higher food insecurity risks. Similarly, displaced individuals in collective centers had 1.94 times the odds of reducing portion sizes (aOR: 1.94, 95% CI: 1.12-3.29). Female-headed households and households with lactating women also experienced higher rates of portion size reduction, while higher-income households were less likely to face such issues.

Conclusion

Our findings underscore the critical need for targeted humanitarian interventions to address food insecurity among displaced populations in conflict settings. Displaced individuals, especially those in collective centers, faced higher risks of food insecurity, compounded by household vulnerabilities such as debt, children, and lactating women. Female-headed households were particularly affected, necessitating gender-sensitive humanitarian interventions.

Managing Patients With COVID-19 in Armenia Using a Remote Monitoring System: Descriptive Study

BACKGROUND

The COVID-19 pandemic has imposed immense stress on global health care systems, especially in low- and middle-income countries (LMICs). Armenia, a middle-income country in the Caucasus region, contended with the pandemic and a concurrent war, resulting in significant demand on its already strained health care infrastructure. The COVID@home program was a multi-institution, international collaboration to address critical hospital bed shortages by implementing a home-based oxygen therapy and remote monitoring program.

OBJECTIVE

The objective of this study was to describe the program protocol and clinical outcomes of implementing an early discharge program in Armenia through a collaboration of partner institutions, which can inform the future implementation of COVID-19 remote home monitoring programs, particularly in LMICs or low-resource settings.

METHODS

Seven hospitals in Yerevan participated in the COVID@home program. A web app based on OpenMRS was developed to facilitate data capture and care coordination. Patients meeting eligibility criteria were enrolled during hospitalization and monitored daily while on oxygen at home. Program evaluation relied on data extraction from (1) eligibility and enrollment forms, (2) daily monitoring forms, and (3) discharge forms.

RESULTS

Over 11 months, 439 patients were screened, and 221 patients were managed and discharged. Around 94% (n=208) of participants safely discontinued oxygen therapy at home, with a median home monitoring duration of 26 (IQR 15-45 days; mean 32.33, SD 25.29) days. Women (median 28.5, mean 35.25 days) had similar length of stay to men (median 26, mean 32.21 days; P=.75). Despite challenges in data collection and entry, the program demonstrated feasibility and safety, with a mortality rate below 1% and low re-admission rate. Opportunities for operational and data quality improvements were identified.

CONCLUSIONS

This study contributes practical evidence on the implementation and outcomes of a remote monitoring program in Armenia, offering insights into managing patients with COVID-19 in resource-constrained settings. The COVID@home program's success provides a model for remote patient care, potentially alleviating strain on health care resources in LMICs. Policymakers can draw from these findings to inform the development of adaptable health care solutions during public health crises, emphasizing the need for innovative approaches in resource-limited environments.

Effects of armed conflict on maternal and infant health: a mixed-methods study of Armenia and the 2020 Nagorno-Karabakh war

INTRODUCTION

Armed conflict worldwide and across history has harmed the health of populations directly and indirectly, including generations beyond those immediately exposed to violence. The 2020 war between Armenia and Azerbaijan over Nagorno-Karabakh, inhabited by an ethnically Armenian population, provides an example of how conflict harmed health during COVID-19. We hypothesised that crises exposure would correspond to decreased healthcare utilisation rates and worse health outcomes for the maternal and infant population in Armenia, compounded during the pandemic.

METHODS

Following a mixed-methods approach, we used ecological data from 1980 to 2020 to evaluate health trends in conflict, measured as battle-related deaths (BRDs), COVID-19 cases, and maternal and infant health indicators during periods of conflict and peace in Armenia. We also interviewed 10 key informants about unmet needs, maternal health-seeking behaviours and priorities during the war, collecting recommendations to mitigate the effects of future crisis on maternal and infant health. We followed a deductive coding approach to analyse transcripts and harvest themes.

RESULTS

BRDs totalled more in the 2020 war compared with the previous Nagorno-Karabakh conflicts. Periods of active conflict between 1988-2020 were associated with increased rates of sick newborn mortality, neonatal mortality and pre-eclampsia or eclampsia. Weekly average COVID-19 cases increased sevenfold during the 2020 Nagorno-Karabakh war. Key informants expressed concerns about the effects of stress and grief on maternal health and pregnancy outcomes and recommended investing in healthcare system reform. Participants also stressed the synergistic effects of the war and COVID-19, noting healthcare capacity concerns and the importance of a strong primary care system.

CONCLUSIONS

Maternal and infant health measures showed adverse trends during the 2020 Nagorno-Karabakh war, potentially amplified by the concurrent COVID-19 pandemic. To mitigate effects of future crises on population health in Armenia, informants recommended investments in healthcare system reform focused on primary care and health promotion.

The Casualties of War: An Excess Mortality Estimate of Lives Lost in the 2020 Nagorno-Karabakh Conflict

Who and how many died in the 2020 Karabakh War? With limited evidence provided by authorities, media outlets, and human rights organizations, still little is known about the death toll caused by the 44-day conflict in and around Nagorno-Karabakh. This paper provides a first assessment of the human cost of the war. Using age-sex vital registration data from Armenia, Azerbaijan, and the de facto Republic of Artsakh/Nagorno-Karabakh, we difference the 2020 observed mortality values from expected deaths based on trends in mortality between 2015 and 2019 to offer sensible estimates of excess mortality resulting from the conflict. We compare and contrast our findings with neighboring peaceful countries with similar mortality patterns and socio-cultural background and discuss them against the backdrop of the concurrent first wave of Covid-19. We estimate that the war led to almost 6,500 excess deaths among people aged 15-49. Nearly 2,800 excess losses occurred in Armenia, 3,400 in Azerbaijan, and 310 in de facto Artsakh. Deaths were highly concentrated among late adolescent and young adult males, suggesting that most excess mortality was directly related to combat. Beyond the human tragedy, for small countries like Armenia and Azerbaijan, such loss of young men represents a considerable long-term cost for future demographic, economic, and social development.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11113-023-09790-2.

Health professionals' perspectives on the impact of COVID-19 on sexual and gender-based violence (SGBV) and SGBV services in Rohingya refugee communities in Bangladesh

BACKGROUND

The COVID-19 pandemic has acutely affected Rohingya refugees living in camps in Cox's Bazar, Bangladesh. Reported increases in sexual and gender-based violence (SGBV) were attributed in part to pandemic-related public health measures. In addition, the Government of Bangladesh's restrictions to prevent the spread of COVID-19 have impacted the provision of comprehensive care for survivors of sexual violence. This study sought to understand how the COVID-19 pandemic affected SGBV and the provision of services for Rohingya survivors in Bangladesh.

METHODS

Interviews were conducted with 13 professionals who provided or managed health care or related services for Rohingya refugees after the onset of the COVID-19 pandemic in March 2020.

RESULTS

At the outset of the COVID-19 pandemic, organizations observed an increase in the incidences of SGBV. However, health care workers noted that the overall number of survivors formally reporting or accessing services decreased. The pandemic produced multiple challenges that affected health workers' ability to provide essential care and services to Rohingya survivors, including access to the camps, initial designation of SGBV-related services as non-essential, communications and telehealth, difficulty maintaining confidentiality, and donor pressure. Some emerging best practices were also reported, including engaging Rohingya volunteers to continue services and adapting programming modalities and content to the COVID-19 context.

CONCLUSIONS

Comprehensive SGBV services being deemed non-essential by the Government of Bangladesh was a key barrier to providing services to Rohingya survivors. Government restrictions adversely affected the ability of service providers to ensure that comprehensive SGBV care and services were available and accessible. The Government of Bangladesh has not been alone in struggling to balance the needs of displaced populations with the necessary precautions to prevent the spread of COVID-19 and its response can provide lessons to others overseeing the provision of services during epidemics and pandemics in other humanitarian settings. The designation of comprehensive services for survivors of SGBV as essential is vital and should be done early in establishing disease prevention and mitigation strategies.