I am a third generation Armenian-American. That dichotomy has always been a point of deliberation. My grandparents never saw Lake Sevan, Yerevan, Ararat, Artsakh or an independent Armenia, but they dedicated every fiber of their being to anything and everything Armenian. This is my third time in Armenia. My first visit was under the auspices of a USAID grant after the 1988 earthquake. My second trip took place in 2007 with a group from St. Hagop Church in Florida; we saw every church known to man and God. If the Armenians built as many forts as churches, we would have ruled the world.
Much of Armenia’s medical system has remained mired in Soviet-era mentality despite years, untold funds and human resources spent in attempting to uplift the quality of care. General medical care is free. Pharmacies dispense medication (except for narcotics) without prescriptions. Specialists, testing and radiologic imaging are available but must be privately paid for. There is an anticipated and expected gratuity built into every level of healthcare service.
Nurses are called “kouyrig” (sister). They are given little latitude to do anything without direct physician supervision. High and often low-tech equipment sit behind locked doors or glass cabinets collecting dust, because the instructions may be in English or the original trainee guards the property as their personal treasure or the $3,000 EKG machine is out of $2 paper or the 25 cent light bulb on an otoscope has burnt out. I am on the verge of despair until I see Robbie the Robot, a mobile interactive computer whose function is to make those children who are taken hostage by cancer smile. At least one person is doing something right.
Tsovagyugh primary care clinic
Tsovagyugh is in stark contrast to Yerevan. The village is peppered with homes that date back at least 200 years. There is a 12th century church nearby. Various dwellings with gardens and grazing animals tethered to rusted-out shells of what once were cars or farm implements define the village. Dismantled and rusted car doors, roofs and auto frames serve as fences between properties. Across the street from the clinic is mighty Lake Sevan. Layers of abandoned Soviet-era structures claim the shorefront. Stone construction is ubiquitous. There are stacks of dried cow patties (used for fuel in the winter) in front of every home.
Inside the recently renovated clinic, sinks are sparse. Cold water is the only water. The walls are covered in old Soviet healthcare posters and new ones warning of COVID. The uneven steps leading to the exam rooms are a cardiac stress test. If you can climb the stairs, you really can’t be that sick. Armenian hospitality shines with coffee, sweets, fruit and brandy (yes, brandy) in between patients. There are flies everywhere. The head doctor Viken shakes my hand and is genuinely happy to see me. He assumes I know more because I am from America. I have no medical license here, but that is okay.
The patients have been waiting for hours. Everyone is complaining of some type of pain. I have become an expert in trigger shots, a combination of Marcaine and steroids, given directly into the source. During my weeks here, I have administered over 500 shots. I know, because that is how many syringes I brought with me, and I ran out of syringes. While they are temporarily hostage to the American doctor, we use the opportunity to screen their blood pressure, sugar and cholesterol. Invariably the readings are all ridiculously high. Their glucose monitors are European standards, and I must remember to multiply by 18. Soon we are out of test strips. They are “consumables” specific to our electronic monitor. The manufacturer makes money, not so much in the monitor but in the test strips. Who knows if that manufacturer is still even in business? Even if they are, supplies are two hours away in Yerevan.
I assess my generic medication supply, almost 300 pounds I carried on-board with me at the clinic’s request. I can rescue these patients for one or two months, but what happens after that? There is a universal theme in every patient’s medication compliance. They take a blood pressure pill or diabetic medication for only a few days. When I ask ‘why,’ they reply that the medication worked, and they don’t need it anymore. When I explain that these drugs must be taken forever, I receive a polite smile or a blank stare.
I can’t wash my hands in between patients. There is no soap, no towels. I use a bottle of hand sanitizer that I brought from America, which is running low. No one changes the covers of the exam beds in between patients. Gloves are unavailable.
They can still see the primary doctor at the clinic for free; but the follow-up prescriptions are not free. Everything is from Russia or China. Of course, in America, half our medications are from India and Israel, so who are we to throw the first stone? The CT scans, MRIs and any technology including lab tests are not free. Invariably every patient I am seeing has been told they have disc problems in their back and are advised to have surgery. But the operations are $5,000-$10,000—a bargain at American prices but impossible in a country where even doctors make an average of $500 a month.
Semyonovka village in Gegharkunik Province
I step over a large pile of cow manure to enter the clinic. My translator is AWOL. I have a clinic full of patients, and my Western Armenian is limited. The nurses stare helplessly at me as phone calls are being made to get me help. I instruct the nurses and doctors to write eight numbers on every patient: height, weight, pulse, oxygen, temperature, blood sugar, cholesterol and blood pressure.
The Journey to Artsakh
Armen: Tall. Sleeve tattoos. Smart. Cardiologist, gynecologist, sonographer, anesthesiologist rolled up into an amazing human being. I would trust him with my life. Makes diagnosis after diagnosis with the wave of his ultrasound probe.
Haig: Driver and translator. Adventurer extraordinaire. Paragliding, hiking, motorbiking, forest ranger, drone operator. He drives 12 hours nonstop. Wears a lumberjack jacket in 40 degrees Celsius to hide his psoriasis. “There are treatments for that now that are 98-percent successful,” I tell him. “How much,” he asks, hopefully. I am ashamed to say. The monthly costs of the drug are more than he makes in several years.
Armine: A fireball, mother, wife, physician and bright as a nova. Founder of Traveling Doctors of Armenia and principal trip coordinator. She’s worked in Sudan, Kenya, Somalia, Syria for months at a time.
The road to Artsakh is tortuous. You leave the fertile Ararat Valley and head down a road flanked by a 10-foot earthen wall. The Azeris are a sniper shot away. The land becomes barren. We drive up an impossible mountainside with one switchback after another. We cross over the Azeri border and drive the Lachin corridor, a road that snakes up the mountains. The Azeris are building a new highway from Baku. The passengers are in awe as they take pictures. They were last here a few months ago on another medical mission, but the rate of construction of tunneling and a multilane highway is phenomenal.
There are five manned checkpoints and several that are not. The guards are Russian or Russian/Azeri based on the flags and the patches on the uniforms. Everyone has a Kalashnikov and are heavily body armored in full combat gear. Most have their faces covered. Everyone looks like they are barely 18. Tanks and armored personnel carriers lie underneath sandbags and camouflage nettings. They check our IDs, and there seems to be a focus on my American passport. They are always having to make several calls before they let us through.
Getavan village, Martakert region
The clinic in Getavan is on par with the Semyonovka clinic: flies, no running water, one live power plug that has 100 extension cords tapped into it, no lights and most noticeably, an EKG machine that has never been used because the medical staff were not trained on it. The process begins. Armen takes his ultrasound machine and heads to a dark room. It is battery operated so he does not need additional power. We open our supplies and start the work.
My wife calls outside our prearranged window. We are having a new driveway installed. The contractor inadvertently ruptured our sewer line. My wife informs me the plumber just gave us a bill that exceeds the cost of my first car. I am grateful. I need to have that grounding that tethers me to my other life back in the US. I left the ER after 30 years because I couldn’t stand to see dead babies anymore. She keeps me whole because it’s easy to get lost here.
There is a five year old boy. His mother gives us a pile of papers, all in Russian and Armenian, that relates the story of kidney stones. Kidney stones? In a five-year-old? Unheard of. The boy gets an ultrasound. He has a five-centimeter stone. When I had a kidney stone, it was three millimeters, and I was in agony. The ureter is blocked and 10 times the size it should be. Worse, there is an abscess where the ureter meets the bladder. He needs emergency surgery. The family doesn’t have the resources to go to Yerevan, 12 hours away. They promise to take him to Stepanakert. What can we do? Without surgery, he may never see next week.
The next patient is a diabetic in his fifties. He’s already blind, a sign of progressive disease. His kidneys have failed, and several toes have been amputated from gangrene. “Can you help?” he wants to know. “Are you taking your medications?” I ask. He’s supposed to take insulin, but that’s impossible, not because it’s costly, but because it requires refrigeration and his home has no electricity. His sugar is over 25 on the Armenian scale. I multiply it by the conversion factor of 18…over 450 on the US scale. “I don’t eat sweets,” he reassures me. I look away.
Village of Nakhichevanik in Askeran Province
It’s our second day in Artsakh. The 16th century fortress of Askeran is in the distance. Who planned the highway bulldozed right through the middle of this major archaeological treasure? Unbelievable. Along the road we see remnants of tank berms and charred soil, evidence of missile or artillery strikes within a meter of those former tank placements. I cringe to think about the men caught inside as I take several photographs with my phone. A Russian soldier stops our van, waves his finger at me and says “forbidden.” I think he is going to confiscate the phone. He stands by the weapon close enough that I can read its serial number, as I delete the images one by one. He waves us through. Frustrated with the censorship, my colleagues help me retrieve the deleted pictures from a folder on my phone.
It has taken us almost an hour to drive to the village, an elevation of 2,600 feet, even though it is only a few kilometers from the main highway. It is all uphill and has never been paved. To the east is an unending plain that stretches to the horizon—Azeri territory; it used to be Armenian.
“We don’t care what the Azeris do,” the village headman says. Every night, they send one of their few remaining young men to the very top of the mountain with what looks like a WWI Mauser rifle to stand watch for another Azeri invasion. That rifle was all they were permitted to keep after the last war. Mauser versus drone? Far from a fair fight. But the people are resilient. They have been totally disarmed. The Armenian losses in the last war would be the equivalent of the US losing 250,000 troops, and that was in a two-month period. Totally surrounded, all the Azeris need to do is turn off the water or electricity, and the village is doomed.
We are sizzling, sweaty, stinky and exhausted. There are no markets or stores, just the same unfinished stone houses scattered around a few occupied dwellings with the ubiquitous mismatched front gates and fences made of any metallic material discarded years before. We see a man on a horse. They are stopping at a fountain built into the side of the mountain road that leads up to the village we just tended to. We pull over the green Ford diesel all-wheel drive van. “If horses can drink the water, so can we,” I am told. Our priest in Florida was a young man when he volunteered in Armenia so many years ago. He ended up with giardiasis from drinking water in the countryside. “Don’t drink the water,” he always said. I feel desperate like John Wayne’s character in the 1948 movie “Three Godfathers.” The water is cold and sweet. Unfortunately, I did contract giardia and was sick for days.
Drmbon Village in Martakert
Again, another long drive. There are khachkars everywhere. Armenians have been here a very long time. My back is killing me. My knees ache from climbing steps. By far, some of the sickest patients I’ve seen yet are here. Again, one power cord, no lights, flies everywhere, no running water…just a basin above the sink. There is one stretcher covered by a dirty blanket. They prepare a small feast for us in gratitude. I wonder how much of their meager supplies did they divert to provide us with this meal.
She is complaining of back pain. She is square in build, 250 pounds. Her hands are coarse and thick. My exam is neutral and unimpressive, but I know an MRI is an impossibility. As I pour the ibuprofen into a paper Kleenex for her to take home, I make the mistake of asking her when her back hurts most. She replies, “When I lift my son.” My face reveals a need for further explanation. Her son was injured in the last war. The bones in his arm were splintered by a shell and went into his brain. He lays in bed having seizures and cannot walk.
There is commotion outside the clinic door. A nurse asks everyone to move aside as two men drag and carry an elderly and frail man. He’s covered in vomit and urine that are layered over time. His belt is cinched tight to hold up his pants that are 10 sizes too big. He is pale and yellow. He cannot stand on his own. They lay him on the bed in the exam room and look expectantly at me. What is the problem? For how long? Years. Apparently, he drinks alcohol. A lot. How long has he had the problem? Again, the answer is since the first war. If he can’t leave the bed, how does he get the alcohol? The family supplies him. Don’t they worry? Of course, but it is better that way. Why does he drink so much? He and his two sons were fighting in battle, and they both died. He survived. He hasn’t stopped drinking since. He has cirrhosis and anemia. He needs to go to the hospital in Stepanakert, which is four hours away, if they want him to survive, I tell them. Apparently, they did that a year ago, but nothing changed. I feel helpless as this family beseeches me for help. I pour omeprazole into a plastic bag and hand it to a family member. I give the man a shot of B-12. They are not going to take him to the hospital. The flies are ubiquitous as they bathe in the poor man’s effluents. I want to wash my hands in Lysol for a week. The sheets have not been changed. The next patient comes in, lays down on the same bed and waits for an examination.
This was our last village in Artsakh on the way out of the Lachin corridor. The village lies at the bottom of a valley and, very unusually for Armenia, looks uniform. All roofs are red, all the homes are neatly laid out and the streets are relatively straight. It was built by NGOs after the first war. The village has since been handed over to Azerbaijan. When I was there, there were tanks and soldiers everywhere, and nobody was smiling. We tell the commander we are on a medical mission and are expected. The Russians tell us there has been some “trouble,” and no one is allowed in the village. Another Russian with an elevated rank again rejects our entry. Armine gets on the phone for an hour. They finally let us in. We met Mayor Antranig Chavoushian. The Armenians will sell out, he says. “If only we had Monte. If only we had Antranik.” The country is treading water waiting. Waiting. Waiting.
From 10,000 miles away, CVS sends me a text about my overdue prescription. Please contact my primary care physician and have him renew it. Otherwise, it will cost me $40 instead of my $10 co-pay. My mind borders on schizophrenia. Which of these two worlds is real?
She is 18 and has yet to have her first menstrual cycle, her mother whispers. The other girls in the village are either married or engaged, and the people are starting to make fun of her. She is pretty. Long hair. A cautious smile. A sonographer performs an ultrasound. There is only one ovary, not two. Her uterus is almost nonexistent, smaller than that of a toddler. She will never bear children. How can she marry? We recommend she goes to Yerevan 10 hours away to see an endocrinologist, but that will not happen. What else can we do?
She’s in her sixties. She says she is doing fine and has no complaints. Why did you come in then, I ask? She heard there was an American doctor in the village and just wanted to see him. Her blood pressure is 220/120. Your blood pressure is high, I say. She nods yes. Do you take your medications? No. Why not? I can’t afford them, she says. Cardizem 360 mg 30 count is $15 dollars—a bargain by American standards. She says she can’t buy anything until her husband’s pension comes through—the equivalent of $100 a month. I slip her 20,000 drams, about $45. My Armenian physician/translator frowns. I can’t buy medication for everyone in the village. Please tell her I insist and that if she doesn’t take her medications she will die from a stroke. I’m told she has eight grandchildren and that the money will go to them.
One of my last patients is a man in his fifties. He complains of back pain. As he leaves, he grabs my hand and kisses it. I treated his wife last week, and she is “cured.” I don’t remember her. He is a shepherd and left his flock 20 kilometers away to see me. “I want to give you a lamb.” Would I honor him by letting him kill a lamb tonight? As much as I love shish-kebob and am flattered by the idea, I cannot think beyond my lamb dinner coming from Publix. After much protest, he leaves for his sheep, and I am left in wonder.
My youngest daughter is a TV news producer. There’s been another mass shooting. “We have to get rid of the guns,” she says. I hate firearms of any kind. After 30 years in the ER, trauma medicine has hardened me to the destruction of human flesh those weapons foster. Get rid of guns? Isn’t that what the Azeris are doing to the Armenians in Artsakh?
Dr. Armine’s husband is Vardan, an award-winning film producer of Bard Media. He has a thousand ideas and a hundred projects. He knows everyone. Everyone knows him. Everything he does in life, he does with gusto. He’s in his fifties and has fought in both wars. He is entitled to be a little bit crazy. He is 12 years into the diagnosis of myelofibrosis—an almost uniformly fatal disease after 10 years. He will never get stem cell surgery.
“Ask him how he escaped from the Azeri prisoner of war camp, twice,” Armine whispers. Vardan tells me a story about his friend, a brother in arms during the first Artsakh war. The man was called Chut because he was the youngest in the group. At one point in the battle, they were sent to negotiate the release of captured Armenian villagers. Everyone was frightened because there was so much hatred, and neither side trusted the other. As they approached the truce line, Chut showed Vardan that he had a grenade hidden in his armpit with a string attached along his sleeve to one of his fingers so he could pull the pin if anything were to go wrong. Chut whispered for Vardan to stay close just in case, and they would die together.
After the war, the men tried to keep in contact with each other, but their lives took different paths. Vardan became a successful film producer, but Chut could not keep a job and struggled with every aspect of life. He went to Russia and got married. When the 2020 Artsakh War broke out, Chut returned to Armenia with his family and went to fight again. He was killed. When Vardan found out, he went to see the family. He said the man’s children were brilliant and decided to provide for their education.
Nations are like human beings. Individuals may have a genetic predisposition toward cancer or heart disease. A nation has the same potential. For 30 years Armenia had a collective euphoria, a sense of invincibility after their military victory in Artsakh. Now, the mood is one of depression. Is there a national gene of hubris, of false pride? Can the cancer of greed, bribes and oligarchs be excised as pictures of young men killed in the recent wars stand guard, on every building, to the smallest of markets, shaking their heads in disbelief, of betrayal?
With Artsakh disarmed and vulnerable, the next few years will be pivotal. It’s easy to say, “another war,” but whose sons and daughters will be sent to fight and possibly die? The spirit is willing, but the government is weak. Armenia has no petrol dollars. There is no ‘garrison’ or ‘fortress’ Armenia like Israel. The country is surrounded and outmanned 10-1 by adversaries. Except for the Diaspora, there is no international support. And there is always the specter of Russia. Putin will pretend to be a peace broker to the last Armenian.
That leads to the final philosophical agony, Diaspora versus Armenia. To paraphrase Saroyan, whenever two Armenians meet, they will form another Armenia. That is a Diasporan perspective that has sustained the survivors of the Genocide for over a century. But there is a very different perspective in Armenia proper. Allegiance to the “land” permeates almost every discussion and supersedes almost every rational approach to the future of the country.
I leave here a better physician than when I came. I leave behind patients, nurses and doctors better because I was here. I have helped those who live in a world of uncertainty. I have brought some sense of caring, that someone cares they exist. It isn’t the easy way of giving money, but of actually touching another human being. The road from Yerevan to Sevan is plastered with highway signs advertising everything, including Kilikia beer. “Celebrating 70 years.” I am older than Kilikia beer, and it’s still in business. My journey is not over. At least, I’d like to think so.