by Stella Arakelyan, MD, MPH, MSc, PhD ^1,2 , Jemma Arakelyan, MD, PhDc ^2,3 , Gevorg Tamamyan, MD, MSc, PhD, DSc ^2,4,5

1. Advanced Care Research Centre, Usher Institute, University of Edinburgh, BioCube 1, Edinburgh BioQuarter, 13 Little France, Edinburgh, EH16 4UX, UK
2. Institute of Cancer and Crisis, 7 Nersisyan str., 0014, Yerevan, Armenia
3. Department of Chemistry, City University of Hong Kong, Hong Kong Special Administrative Region, China
4. Yerevan State Medical University after M. Heratsi, 2 Koryun St, Yerevan 0025, Armenia
5. Pediatric Cancer and Blood Disorders Center of Armenia, Yeolyan Hematology and Oncology Center, 7 Nersisyan St., Yerevan, 0014, Armenia

Forced displacement is increasingly becoming a normalised worldwide phenomenon, affecting millions of children, adults, and the elderly who are coerced to leave their homes and livelihoods behind to save their lives. ¹ Armed conflicts, civil violence, human rights violations, and disasters are among some of the root causes of this, with adverse repercussions to the health and well-being of displaced populations well-documented. ^2,3 Noteworthy, most conflict-affected countries are among the least developed and poorest in the world, where health systems struggle to deliver basic healthcare services. ⁴ People in these settings, therefore, experience longstanding challenges to universal healthcare, including those with long-term conditions (e.g., cancer, cardiovascular diseases, diabetes, mental health issues) way before any displacement activity. ⁵

It was perhaps premature to assume that the COVID-19 pandemic was a powerful wake-up call for humanity to foster a sense of collective responsibility for one another’s health and well-being. It was naïve to believe that the pandemic has weakened global powers and that the global calls for ceasefires might serve as a catalyst for a cessation of military hostilities. Contrary to these hopes, the pandemic has added another layer of crisis in countries with ongoing conflicts and/or affected by conflict, and if anything, increased insecurity and heightened nationalism and quests blinded by power. ⁶ The pandemic had a damaging effect on peace and political stability, resulting in a continued rise in humanitarian needs globally, including in Africa, the Middle East, Ukraine, the Western Balkans, and the Caucasus.

On the 12^th of September, clinicians, public health specialists and most importantly ordinary citizens shocked by the humanitarian crisis in the Nagorno-Karabakh Republic submitted a piece to the Lancet trying to amply the voices of ethnic Armenians calling for freedom and the right to survival on their land and land of their ancestors. The Nagorno-Karabakh Republic is a conflict-affected region in the South Caucasus that was populated largely by Armenians. Since the last armed conflict in the autumn of 2020, Nagorno-Karabakh has experienced challenging political, social, and economic dynamics, with disrupted provision of essential health and social welfare services to its people. Ethnic cleansing of Armenians, provoked by the prolonged blockade of the Lachin Corridor (a humanitarian corridor that connected to neighbouring Armenia) by Azerbaijani military forces, was underway for over nine months, with the international community reporting ‘deep concerns’ only. ^7,8 Little did we know that 24 hours following the publication of the Lancet piece, ⁷ we would be witnessing an unfolding crisis of silenced democracy in Nagorno-Karabakh, where freedom became a hollow concept and people had to flee for their lives. ⁹ We have failed children, pregnant women, the elderly, ill, and disabled in Nagorno-Karabakh. We have heard the screaming voices of starvation, malnutrition, and lack of access to basic healthcare services and essential medication but felt powerless to act.

Over 100,600 people including 30,000 children, traumatised by the long-lasting military blockade and armed violence, have now fled to Armenia. ¹⁰ For most of these vulnerable people, Armenia is their final destination and their ‘survival’ is dependent on the assistance provided by the authorities, local community, and humanitarian organisations. Almost everyone affected by a humanitarian crisis experiences psychological distress, with one in five likely to experience anxiety, depression, and post-traumatic stress disorder. ¹¹ Reports from the ground suggest physical and psychological exhaustion, malnutrition, hunger, poverty, and severe distress and anxiety, particularly in children, women, the disabled, and the elderly from Nagorno-Karabakh. ¹⁰ There is also a significant burden of chronic conditions including cancer which often remains neglected in the forcibly displaced people in situations of adversity, especially those without acute symptoms. ¹²

In recent days, the UN Refugee Agency has launched the inter-agency refugee response, complementing the ongoing efforts by the International Committee of the Red Cross to ensure people’s access to water, food, shelter, and life-saving medication. Finding sustainable solutions and providing a comprehensive response to meet the psychosocial, financial, and healthcare needs of forcibly displaced Armenians and all affected communities, however, is going to be an ongoing challenge. Multi-agency working is essential to pool international aid and available resources in the most efficient way to provide targeted and ongoing psychosocial and mental health services, welfare, and healthcare support to the most vulnerable. Further, given the prognosis and costs associated with delayed diagnosis and management of cancer and other chronic conditions, humanitarian and local organisations should also prioritise and devote adequate resources and expertise to target chronic diseases in people affected by the tragic events in Nagorno-Karabakh.

References
1. Lancet T. Rethinking our approach to refugees. Lancet (London, England). 2023 Jun 17;401(10393):2013.

2. Mesa-Vieira C, Haas AD, Buitrago-Garcia D, Roa-Diaz ZM, Minder B, Gamba M, Salvador D, Gomez D, Lewis M, Gonzalez-Jaramillo WC, de Mortanges AP. Mental health of migrants with pre- migration exposure to armed conflict: a systematic review and meta-analysis. The Lancet Public Health. 2022 May 1;7(5):e469-81.

3. Arakelyan S, Ager A. Annual Research Review: A multilevel bioecological analysis of factors influencing the mental health and psychosocial well‐being of refugee children. Journal of Child Psychology and Psychiatry. 2021 May;62(5):484-509.

4. OECD. States of Fragility 2022. https://www.oecd.org/dac/states-of-fragility-fa5a6770-en.htm.

5. Thomas SL, Thomas SD. Displacement and health. British medical bulletin. 2004 Jun 1;69(1):115- 27.

6. Mustasilta K. From Bad to Worse? The impact (s) of Covid-19 on conflict dynamics, Conflict Series, European Union Institute for Security studies.

7. Gale RP, Muradyan A, Danelyan S, Manukyan N, Babak MV, Arakelyan S, Tamamyan G, Arakelyan J. The humanitarian crisis in Nagorno Karabakh. The Lancet. 2023 Sep 28.

8. Magee, C. “We are starving to death:” residents of Nagorno-Karabakh fear for the future under blockade. 2023. https://edition.cnn.com/2023/09/06/europe/nagorno-karabakh-blockade-azerbaijan-armenia-intl-cmd/index.html.

9. Write, G. Nagorno-Karabakh: Armenia says 100,000 refugees flee region. 2023. https://www.bbc.co.uk/news/world-europe-66969845.

10. ReliefWeb. Armenia Refugee Response Plan (October 2023 – March 2024). 2023. https://reliefweb.int/report/armenia/armenia-refugee-response-plan-october-2023-march-2024.

11. Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. The Lancet. 2019 Jul 20;394(10194):240-8.

12. Carew JW, Hamze M, Atassi B, Abbara A, Khoshnood K. Investment in Cancer Prevention and Care for Forcibly Displaced Syrians Is an Urgent Priority. JCO Global Oncology. 2023;9.