Razmik Minasian, his face tanned from laboring in the sun, swiftly paces up and down a white sterile hallway in Tiramayr Narek Hospital in Armenia’s northernmost town of Ashotzk. Again and again, he looks worriedly at the closed door from where the cry of his 4-month-old son can be heard.

“Had we managed to get here earlier, this wouldn’t have happened,” he said as he approached his wife who sat nervously beside the door.

The Minasians live in Samtskhe-Javakheti, a predominantly Armenian region in southern Georgia near Armenia’s northern border. The couple made the three-hour journey to Tiramayr Narek because the infant’s temperature had reached a dangerous 104 degrees and the Catholic-run facility is the only one in the vicinity that offers quality care at little or no cost.

“The baby had been sick for a week,” Lilit Minasian said later, as she stroked her infant son’s hair. “There is no proper hospital near us. The doctors at the clinics prescribed treatment, but the condition worsened.

“At first, they were treating the baby for acute enteritis. But then he got even worse and it appeared he had pneumonia, for which they prescribed a totally different treatment,” she said.

The Minasians are not the only Georgians who travel to Armenia for medical care. Sister Hakint Muradyan, an Armenian Sister of the Immaculate Conception, lives and works in Ninotsminda, one of the Samtskhe-Javakheti region’s six districts. She explained why residents, regardless of their ethnicity, prefer to cross the border and get treatment in Ashotzk rather than the local Georgian hospital.

“I wouldn’t be mistaken at all if I said the health care situation in this part of Georgia, which has a large Armenian community, is desperately bad,” she said.

“I have seen with my own eyes the way they deliver babies; women survive only by the mercy of God. There is no equipment, and it’s simply senseless to speak about cleanliness and professionalism,” said Sister Hakint, who has spent the past 14 years serving the villages in this part of Georgia.

She currently leads an effort to build a medical clinic equipped with an ambulance to reach and treat patients in isolated areas, especially in winter, when roads are closed.

“We received financing from the Oeuvre d’Orient to buy and restore a house in the village, but the sum was not sufficient to complete the project and purchase the equipment. We still depend on the mercy of God.”

Tiramayr Narek Hospital, which is dedicated to the Virgin Mary, opened its doors in 1992 after an earthquake devastated northern Armenia in 1988, leaving 25,000 dead, countless injured and a million homeless. To cope with the massive and urgent health care needs at the time, a number of international organizations built some 10 hospitals in the province of Shirak, the area hit hardest by the quake, including Tiramayr Narek. These days, however, Tiramayr Narek is the only facility that still boasts modern equipment and offers free health care services.

Built with funds from Caritas Italy and CNEWA and financed and operated by the Camillian Fathers, Tiramayr Narek Hospital serves some 30,000 patients from as far away as Gyumri (62 miles south) and Vardenis (124 miles southeast) and conducts about 1,800 complicated surgeries per year.

“This is the best equipped hospital in the region, but the biggest advantages are the good conditions and free services — even the medicine and meals are offered free of charge. This brings people here from hundreds of kilometers away,” explained Dr. Sargis Vardanian, the hospital’s head surgeon.

The hospital, however, struggles financially, largely as a result of dramatic fluctuations in the exchange rates. The Armenian dram has increased in value against the dollar by 48 percent and against the euro by 30 percent in the last five years, whereas the price of diesel fuel used to heat the hospital has almost doubled.

“We get the same one million euros every year, but we do much less with it year after year,” said Father Mario Kukarollo, the hospital’s director.

The hospital not only treats tens of thousands of sick and needy patients each year, it employs some 200 people, making it the largest employer in the region. Most employees live nearby and earn monthly salaries ranging from 40,000 to 150,000 drams ($130 to $490) — a decent living in a country where the average monthly salary is 83,780 drams ($272).

“We frequently say the people in Ashotzk and the neighboring villages who do not have debts at the stores are those who work at the hospital,” joked Gayane Poghosian, a resident of Ashotzk.

Natives of Shirak often refer to the area as the Armenian Siberia and consider themselves exiled from much of the country’s cultural and economic life, especially the prosperity many compatriots in Yerevan, the nation’s capital, have been enjoying in recent years. Indeed, the gap between the socioeconomic development in Yerevan and the lethargy of Armenia’s rural, impoverished north widens by the day. Whereas newly constructed supermarkets, boutiques and luxury high-rise buildings illuminate Yerevan’s streets, the only signs of modern life in Ashotzk are the occasional car and Tiramayr Narek Hospital.

Ashotzk rises some 6,600 feet above sea level and is covered in three to five feet of snow six months out of the year. During the winter months, temperatures often drop to 40 degrees below zero and many of the roads are closed.

One road, known as the “life road,” is kept accessible throughout the winter and is used only in the case of medical emergencies. It extends 17 miles from the village of Berdashen, the neighboring community closest to Armenia’s northern border, directly to the hospital. Before the hospital commissioned the construction of the “life road,” residents had no way of reaching medical care in the winter months. To this day, residents still try to plan their pregnancies so that mothers give birth between the months of April and October.

“Getting to the medical center in Gyumri was impossible in winter before there was the hospital,” said Mariam Simonian, a nurse who lives in Berdashen.

“That is why in the cases of home delivery the number of deaths among babies and mothers was high. The hospital and the medical clinics in 21 villages are life buoys for all of us.”

Despite Armenia’s consistent annual double-digit overall economic growth during the last five years, people in the north enjoy no substantial improvement in the quality of their lives. Shirak, where 9 percent of Armenia’s population lives, ranks as the poorest among Armenia’s 11 provinces. Armenia’s Statistical Service estimates that both the poverty and unemployment rate hover around 40 percent.

Ashotzk, which has a population of 15,000, is the poorest among the five towns in Shirak. A national survey conducted in 2005 classified 40 percent of the town’s residents as needy and another 40 percent as poor.

The region’s cold climate and the barren soil severely limit local agriculture, and there are no industries. Livestock husbandry represents one of the few ways to make a living. Luckier residents receive remittances sent from family members working abroad, mostly in Russia. The least fortunate have to scrape together a living from the government’s meager poverty assistance program and charity.

Forty-year-old Mayis Atoian receives $167 a month from the government. However, the sum is not enough to feed himself, his wife, mother and six children much less cover the cost of housing, clothing and other basic necessities. A large sack of flour, which provides the nine-member family with enough bread for a week, costs $40; the family spends its entire government allowance on a month’s supply of bread alone.

“The Catholic Church provides children with donated clothes and shoes. Were it not for that, they would be barefoot in winter,” said Mr. Atoian’s 70-year-old mother, Kima Atoian. She added sadly that she receives a monthly pension of just $92, despite having worked for 48 years and having earned medals for her contributions as well as the title of labor hero during the Soviet years.

The family lives in a dilapidated house with concrete floors. The whole family spends winters in the smallest room, which measures 50 square feet. It is the easiest room to heat, allowing them to stretch their fuel supply.

“When we run out of fuel, we all roll up in a bed together to warm each other. But, it does not help and we frequently get sick. And paying for a doctor or buying medicines means the end of us,” continued Mrs. Atoian.

“Were it not for the hospital, people all around this region would be dead by now. This is no exaggeration; they would not survive.”

Armenian law guarantees that individuals and families living at or below the poverty line have access to free health care. In reality, however, everyone — poor and affluent — pays.

“They won’t let you past the door of a hospital if you show them your poverty pension card, let alone treat or operate on you. The first thing you hear is that the hospital is poorly financed and that you need to pay both for the service and the needles and the medicines,” said Gayane Avetisian, a Yerevan woman who traveled to Tiramayr Narek for a thyroid operation.

Some 500,000 Armenians qualify for free health care, 15 percent of whom have a disability and 10 percent of whom are single pensioners.

“All the persons who get a poverty allowance and are enrolled in the system have the right to free medical treatment; the problem is that there is abuse in many hospitals,” said Ruslana Gevorgian, press secretary for Armenia’s Ministry of Health Care.

“The eradication of corruption is not something you can accomplish in one day.”

After the Soviet Union collapsed, Armenia’s health care system, as with most government-run services, fell into a state of disarray. Public expenditure on health care dropped off drastically. In the early years of independence, Armenia’s fledgling democratic government spent less than a tenth of what the Soviet authorities had spent on health care.

“In the 1990’s, doctors earned $23 monthly. It was impossible to blame doctors for taking money from patients. It was the population that literally provided for the doctors in those years,” added Ms. Gevorgian.

Since the late 1990’s, Armenia’s health care budget has grown by 300 percent. Still, it only accounts for 6.6 percent of the national government’s total budget. Doctors’ salaries have also improved, now ranging from $130 to $490 a month. And since 2006, simple outpatient procedures are free of charge.

A study conducted by the World Bank’s Armenian office ranked the health care system among the three most corrupt systems in Armenia. The study found that unofficial fees make up 65 percent of what patients pay out of pocket and that 35 percent of the population can’t afford to see a doctor.

Parunak Zelveian, chairman of the Armenian Medical Association, lamented that while the health care budget has expanded significantly, some employees at hospitals often misappropriate large amounts of the taxpayers’ money.

“The state transfers the funds [aimed at covering the expenses of the poor population] to the hospitals; the hospitals show they have treated people, have held surgeries on a certain number of people, but no one verifies who those people were, whether or not they were really poor or were relatives of the heads of hospitals,” said Mr. Zelveian. He added the best solution would be to introduce a medical insurance system.

The province of Lori adjoins Shirak to the east and includes much of Armenia’s northern border. Like Shirak, unemployment and poverty are widespread. But unlike Shirak, quality health care in Lori is largely inaccessible.

In a 2007 survey conducted by Caritas Armenia, 76 percent of the elderly respondents and 60 percent of the rest of the respondents considered adequate medical services to be unavailable. And 64 percent of the elderly respondents said they could not afford a doctor’s visit despite legislation guaranteeing free medical treatment to all persons over the age of 60.

Nestled high atop a mountain near the Georgian border lies the town of Tashir. Once home to the Molokans, a Russian Orthodox sect exiled to the region in the late 18th century, the area today is now largely Armenian Catholic.

The 1988 earthquake devastated the region, from which it never fully recovered. Many families still live in the metal shelters built immediately after the quake as temporary housing. The ruins of a large cheese factory on the outskirts of town serve as the only reminder of bygone prosperity.

“These villages have become elderly asylums. Young people leave; there is no future for them here,” said 90-year-old Sargis Chakhalian. Two of his four children now live in Russia; the other two have died.

Mr. Chakhalian lives alone. He has difficulty walking and has to crawl up the stairs in his house like a small child. Frequently, he cannot manage to climb the stairs, and remains bedridden, sometimes for days before neighbors come to help.

“I felt bad two days ago, but I could not reach the table to take my medicine. I cried because of the anger I felt. A woman was passing by on the street. Maybe she heard my voice. She came in and gave me my medicine and stayed with me a bit,” recounted the elderly man, wiping his eye from beneath his large spectacles.

Mr. Chakhalian receives a monthly pension of $90 — his only source of income. While this does not cover his basic needs, he does not qualify for government poverty assistance.

“My neighbors spend their days fighting the municipality. They say: to whom do you give the allowance if this man doesn’t get one? Who is in more need? But it is no use.”

About 100 other seniors in Tashir share Mr. Chakhalian’s lonely fate. For most, their only hope is a center for disabled elderly, which provides free meals, checkups, clothing and other basics. Funded by the European Union and Caritas Austria, the three-year program was launched last year.

“People from the elderly center bring me dinner every day, which keeps me alive,” said Mr. Chakhalian, his hand shaking.

“I at least had a good youth, but poor children today don’t have one.”

Based in Yerevan, Gayane Abrahamyan writes on the Caucasus for a number of journals. Justyna Mielnikiewicz’s photographs appear in newspapers and magazines worldwide.