Arctic cooperation between Norway and Russia in healthcare delivery and emergency preparedness on Svalbard: barriers and facilitators

ABSTRACT This interdisciplinary study explores whether increased cooperation in healthcare delivery and emergency preparedness between Norway and Russia on the Arctic archipelago Svalbard may increase the quality of these services and whether cooperation is desired. Ten semi-structured interviews were conducted and the respondents were asked to describe the current cooperation. Further, they were questioned about what they considered the main facilitators and the main barriers to cooperation. By analyzing the results, the study explores these facilitators and barriers and identifies how healthcare delivery and emergency preparedness are organized on Svalbard. Moreover, the study detects potential areas of cooperation within the given field, and the desire for such cooperation. The findings show that there are both facilitators and barriers regarding cooperation in healthcare delivery and emergency preparedness. Main facilitators include mutual trust, shared challenges, and existing administrative structures, equipment, and infrastructure. The main barriers involve differences in language and culture, high personnel turnover, and divergent systems for emergency preparedness on the Norwegian and Russian mainland. Mine rescue, emergency preparedness, and joint exercises focusing on health challenges are areas where Norway and Russia may cooperate in the future.


Introduction
Securing robust structures for healthcare delivery (including emergency preparedness) is a vital task in all populated areas.In the Arctic, a region characterized by harsh climatic conditions, sparse infrastructure, and vast distances to advanced health services, this task is particularly important (Rowe, 1995;Artuso, 2012;Farmer et al., 2012;Sydnes et al., 2017).Svalbard, the Norwegian archipelago located between the mainland and the North Pole, may in this context provide a suitable example of challenges to healthcare delivery and emergency preparedness in the Arctic and in other remote areas characterized by the features named above.
Previous research has demonstrated that, as elsewhere in the Arctic, health risks on Svalbard are associated with accidents, including snowmobile and aircraft crashes, shipwrecks, polar bear attacks, and avalanches (for an overview of health challenges on Svalbard, see Sandmo, 2005;Hanoa, 2017;Waehler & Ingebrigtsen, 2022).Also diseases, exemplified by the COVID-19 pandemic, pose a significant health risk (Jonassen, 2021).International cooperation on Svalbard has earlier been described as promising (Kelman et al., 2020).With reference to emergency preparedness, Svalbard is presented as a suitable example of a place where people often rely on collaborative and multinational disaster-related activities (Duda et al., 2022).Also within healthcare delivery, multinational cooperation may be beneficial (Hutchinson, 2005).There are, however, no studies that examine whether increased cooperation in healthcare delivery and emergency preparedness between Norway and Russia may increase the quality of these services or whether cooperation is desired.
To contribute to filling this gap, this interdisciplinary study borrows elements from both social sciences and health sciences and looks into current and past cooperation between Norway and Russia, in order to assess whether increased cooperation in healthcare delivery and emergency preparedness may be positive.The respondents (N = 10) were first asked to describe the current cooperation.Second, they were questioned about what they considered the main facilitators, and third, the main barriers to further cooperation.By analyzing the results, this study identifies how healthcare delivery and emergency preparedness are organized on Svalbard.Furthermore, the study explores facilitators and barriers to cooperation.Finally, the study detects actual and potential areas of cooperation within the given field and the desire for such cooperation.
Therefore, the aim of this study was to examine whether an increased cooperation in healthcare delivery and emergency preparedness between Norway and Russia on Svalbard may increase the quality of these services.This is the first study to explore such a topic systematically.It therefore makes an important contribution to both Svalbard Studies (described by Chekin & Rogatchevski, 2020) and to research on international health cooperation.

Structure of the paper
In the introduction section, the purpose and the aim of this study are presented and a section with background information is added.Further, materials and methods are presented followed by results.The findings are discussed against the backdrop of security and the discussion section opens with a conceptual discussion about security issues on Svalbard and ends with recommendations for further research and the strengths and weaknesses of this study.The last section presents concluding remarks.

Background information
Svalbard is governed in accordance with the Svalbard Treaty (1920), which assigns citizens of all 46 signatory countries rights to engage in commercial activities, such as resource extraction, tourism, and scientific research.Today, Russia is the only other country except for Norway to exercise these rights almost continuously, for about a century.Both Norway and Russia have the infrastructure for providing healthcare delivery and emergency preparedness on the archipelago, with centers in Longyearbyen and Barentsburg respectively.The term 'emergency preparedness' is understood as efforts to conduct risk-based calculations that will ensure that the consequences of crises are as limited as possible (Larssen, 2021).Nevertheless, this infrastructure is scaled for the permanent population of some 3000 people (approximately 2600 in Longyearbyen and 400 in Barentsburg, according to the last census by Statistics Norway in 2022) and is tested by a large influx of tourists and other visitors (approximately 150,000 in 2019; see Nord et al., 2020, and approximately 130,000 the first nine months of 2022, according to Visit Svalbard in personal correspondence 24 October 2022).
The Mining Code for Svalbard (as stipulated in the Royal Decree of 7 August 1925) states that all mining settlements shall provide basic health services (Hanoa, 2017).Traditionally, there have been hospitals in all the mining settlements, including Longyearbyen, Barentsburg, Ny-Ålesund, Grumant, and Pyramiden.The two latter settlements were abandoned in 1967 and 1998 respectively (with limited activity in Pyramiden revived since 2007), and hospitals today are located in Longyearbyen and Barentsburg.Health services for the inhabitants in Ny-Ålesund are covered by the hospital in Longyearbyen.
Long distances, harsh climate, limited local emergency preparedness resources coupled with a high staff turnover and an increasing number of visitors are some of the challenges with emergency preparedness on Svalbard.The emergency preparedness system on the archipelago is not scaled for major or simultaneous incidents (Meld. St. 32 (2015-2016), p. 95).It is therefore critical to take preventive measures, including rescue drills, and to make sure that all the stakeholders involved cooperate in the best possible manner.Norway is responsible for emergency preparedness on Svalbard and in the waters surrounding the archipelago.Emergency preparedness, including medical services, is provided to everyone traveling on the archipelago and in the surrounding waters.
The carrying principle in Norwegian emergency preparedness is that cooperation between public, private, civilian, and military actors is mobilized in the emergency preparedness system (Lovdata, 2019).Norway is committed to a number of international agreements that establish the existing legal frameworks for search and rescue (SAR).The most significant is the International Aeronautical and Maritime Search and Rescue (IAMSAR) manual, which is jointly developed by the International Maritime Organization (IMO) and the International Civil Aviation Organization (ICAO).Within the framework of these international agreements, an agreement specifically regulating SAR in the Arctic was signed by the eight Arctic states in 2011, known as the Agreement on Cooperation in Aeronautical and Maritime Search and Rescue in the Arctic (Arctic SAR Agreement) (Meld. St. 32 (2015-2016, p. 105).In addition, Norway and Russia collaborate on SAR at sea.This cooperation is regulated by a bilateral SAR agreement (Elgsaas & Offerdal, 2018).
Norway and (Soviet) Russia have been engaged in the coal mining industry on Svalbard for more than a century.For the last decades, both countries have been increasing their efforts in developing tourism and research on Svalbard, too.Both Norway and Russia have long-term ambitions of maintaining their presence on Svalbard (Kaltenborn et al., 2020) and strengthening and diversifying economic activities on the archipelago (Olsen et al., 2022).Although the contact between Norwegian and Russian settlements on Svalbard has been limited due to distance and challenging infrastructure, official meetings and sporting competitions have been taking place on an annual basis.
Discussing the relationship between Norway and Russia is not possible without addressing the ongoing war in Ukraine.The good relations between Norway and Russia took a hit already after the Russian annexation of Crimea in 2014, when Norway joined the EU sanctions against Russia (see Rottem, 2018).After Russia's full-scale invasion of Ukraine in February 2022, this dynamic has deteriorated further.Russian settlements on Svalbard have been enjoying only a partial exception from the sanctions regime (Volkov, 2022).Norwegian stakeholders in Longyearbyen have argued for a boycott of the Russian companies on Svalbard, and some 45 people (or over 10% of its population) have left Barentsburg since the escalation of the invasion ('Ukraine war casts,' 2022).This is a clear sign that conflicts are simmering under the surface (see also Skjaeraasen, 2022).It adds to the tensions that of the roughly 400 citizens in Barentsburg, some 70% are Ukrainian citizens, primarily from Eastern Ukraine, which has been affected by the war most heavily ('This is the home,', 2022).

Materials and methods
Semi-structured interviews (N = 10) with stakeholders engaged at various levels in healthcare delivery and emergency preparedness in Norway and Russia were performed.In addition, document analysis has been applied in order to retrieve background information prior to and during this study.Archive material from the Governor of Svalbard (in the National Archives of Norway), in addition to articles from various newspapers and other sources (i.e.Svalbardposten, Russkiy vestnik Shpitsbergena, Poliarnaia kochegarka/Shakhter Arktiki, High North News, The Independent Barents Observer, nrk.no); reports about healthcare delivery and emergency preparedness (see Irtun (1997) or Norwegian Ministry of Health and Care Services (2013) for examples); government reports (i.e.white papers about Svalbard) and reports from Statistics Norway constitute a solid information base that illuminates the research questions of this study.These were used when designing the interview guide.Moreover, the literature analysis highlighted issues that were important to include in the discussion, such as shared health challenges and concrete examples of cooperation between Norway and Russia.

Interviews
Semi-structured interviews (N = 10) with stakeholders engaged at various levels in healthcare delivery and emergency preparedness in Norway and Russia were performed (see attached table of respondents).Interviews were conducted until relative saturation was reached (Bryman, 2012) and no new themes materialized from the data.
All interviews except three, were audiotaped with the participants' consent.Technical errors beyond the author's control were the reason as to why three of the interviews could not be audiotaped.Nevertheless, thoroughly written notes were made during each interview.An interview guide consisting of thematic questions provided the framework for each interview and was adjusted for each interview.

Online interviews versus in-person interviews
Online interviews were conducted when in-person interviews could not be performed.As many of the interviews took place during COVID-19-related lockdowns in 2021, online interviews proved a good second solution when in-person interviews could not be conducted due to COVID-19-induced meeting restrictions.When using online tools to conduct interviews, efforts should be made to ensure that the online respondents feel comfortable with the online technology applied in the interviews (Lyon et al., 2015).Such efforts were made in this study.Also, the interview questions were the same for all respondents to ensure that the online and in-person interviews were consistent.

Choosing respondents
Purposive sampling, i.e. choosing available respondents who possess qualifications and positions relevant to the research topic (Patton, 2002) was used in order to recruit respondents.Also snowballing, i.e. asking the respondents to point out other potential respondents who may contribute to the study, was applied.The respondents have all been de-identified and will be referred to by the numbers R1 1 , R2, etc.
All respondents were stakeholders engaged at various levels in healthcare delivery and emergency preparedness in Norway and Russia, or in the Svalbard administration.Three of the respondents were Russian and were interviewed in Russian.The remaining seven respondents were Norwegian and thus interviewed in Norwegian.Three men and seven women were interviewed and they were all of working age between 20 and 70 years old.The interviews lasted between 30 and 90 min.The initial plan included respondents representing decision-makers from mainland Russia.Nevertheless, the current tensions between Russia and the West made such interviews challenging and inappropriate for the time being.Anyhow, the three Russian respondents included in the study represent a broad specter of institutions and responsibility areas.They are thus constituting a representative and sufficient selection of Russian respondents.Also, the Norwegian respondents represent a wide selection of institutions and responsibility areas in healthcare delivery and emergency preparedness.Moreover, all interviews provided solid and rich data.The overall selection of 10 respondents is thus considered to constitute a rich and sufficient data selection appropriate to answer this study's research question.There were no significant variations between the answers of administrators and health personnel.

Analysis
Based on the transcript of the interviews, analyses have been made through coding and categorization of the themes identified in the interviews.Each interview was transcribed and analyzed, in parallel with continued data collection.The interview data have been analyzed through coding, where keywords deriving from the interviews and the literature analyses were identified and connected into different text segments.Data with similar characteristics were categorized, and examined for cohesiveness and variation.Depending on the content, the same data could be coded into more than one group.The data collection was completed when new data did not make any significant changes to the result patterns.

Ethics
As the study processes personal data in the form of contact information, it was reported to the Norwegian Centre for Research Data (NSD).All respondents were asked to hand in informed consent and their data was treated with confidentiality.The participants were deidentified in accordance with principles regarding privacy regulated by the Personal Data Act (Lovdata, 2018) and the Health Research Act (2008), meaning that characteristics have been blurred in the published material in order to make the respondents unrecognizable.All interview data have been stored in a password-protected area and only the main author has access to the data.All personal data will be deleted at the end of the project.Some claim that coding reduces polyphone meaning to what can be captured by a single category (Maggie, 2013).Moreover, critics may argue that coding leads to categorization, which implies that the meaning of long interview statements is reduced to a few simple categories (Brinkmann & Kvale, 2015).However, when performed cautiously, coding is useful to identify relevant themes deriving from research interviews, create an overview, and find connections in the interview material.In this study, coding is valued as a useful tool to extract data from different interviews about the potential for increased cooperation.
Four of the interviews were conducted before Russia's invasion of Ukraine on 24 February 2022.The remaining interviews (N = 6), however, were conducted after the war in Ukraine had escalated.As this development for obvious reasons was believed to affect the relationship between Norway and Russia, the war became a topic in the last interviews.

Current cooperation between Norway and Russia regarding healthcare delivery and emergency preparedness
Aspects such as being limited in size and located far from advanced health facilities were considered the main challenges by several respondents (R1, R2, R7, and R8).Also, an increasing level of activity in the waters surrounding Svalbard, because of more fishery and tourism, is considered a challenge: 'We are small, and that means that we are vulnerable'.(R2).Several respondents (R1, R2, R6, R7, R8, R9) stressed the fact that Norway is legally responsible for emergency preparedness on Svalbard and that cooperation in this field with any other party is therefore limited.Conversely, cooperation in terms of healthcare delivery takes place regularly, as this is seen as practical and applies to patients as well as equipment and medicine.Patients at Barentsburg Hospital who need more complex treatment than what is offered there, are frequently sent to the hospital in Longyearbyen (and further on to UNN in Tromsø if necessary).This can be exemplified by the 'Aurora Explorer' accident in Barentsburg in 2018 when a catamaran crashing into the dock resulted in 18 injured passengers (Kjøllesdal, 2018).Now such a transfer only goes one way, from Barentsburg to Longyearbyen.Nevertheless, there are many earlier examples of Norwegians being treated by doctors from one of the Soviet settlements, such as an employee at the Norwegian radio-and weather station Isfjord Radio who suffered from serious toothache and was treated by a dentist in Barentsburg in 1978, and the Norwegian tourists on snowmobiles who were rescued by a team from Barentsburg and received treatment at the hospital in Barentsburg in 2015 (Shepelev, 2015).None of the respondents report about patients who have been sent from the hospital in Longyearbyen to Barentsburg.There has been a significant decrease in accidents and subsequent transfer requests from the hospital in Barentsburg for the last couple of decades.According to one respondent, this tendency is probably due to the fact that there are fewer people employed in the mines than earlier and that there is an increasing concern for security and safety in the Russian mining industry (R1).Increased allocations from Russian state actors to Trust Arktikugol are also believed to have contributed to this development (conversation with A. Moe, 16 February 2022).

Example of cooperation in healthcare delivery: COVID-19 vaccination
Several respondents illuminated the vaccination process during COVID-19 as a good example of cooperation.Norway was responsible for providing vaccines for all inhabitants.Employees from the hospital in Longyearbyen went to Barentsburg to vaccinate and were surprised to find that almost everybody agreed to accept the vaccines.By the time of the relevant interviews (June-September 2021), almost 90% of the inhabitants in Barentsburg had accepted the first shot.This was a clear contrast to the vaccination rate on the Russian mainland, which at that time was low (in July 2021, only 43% of the Russian population was vaccinated, see Stepanov & Komendantova, 2022).A respondent (R1) underlined two reasons why the residents in Barentsburg accepted the vaccines.On the one hand, the residents had a good understanding of the use and effect of the vaccines as a preventing measure against the COVID-19 virus.On the other hand, they seemed to value the fact that being vaccinated implied that traveling between Svalbard and Russia/Ukraine, where most of the Barentsburg residents have their origin, would be easier.

Example of cooperation in emergency preparedness: Cape Heer accident in 2017
Several respondents (R5, R7, and R9) described the Mi8 accident on Cape Heer in 2017 as a good example of cooperation in terms of emergency preparedness.A Russian Mi8 helicopter operated by Convers Avia Airlines JSC crashed in poor weather on approach to the Cape Heer helicopter base and all eight people on board died.The Norwegian state was in charge of the rescue operation as the accident happened on the Norwegian territory.The rescue operation was led by the Joint Rescue Coordination Centre of Northern Norway and involved stakeholders from the Governor's office and Svalbard's Emergency Preparedness Council, the Norwegian Coast Guard, as well as the Norwegian and Danish Air Force, and the Russian emergency ministry EMERCOM (Aircraft Accident Investigation Board, 2020).The latter sent a team to participate in the search for passengers and wreckage ('Rossiyskiy Mi-8 upal,', 2017).Representatives from the Russian helicopter design agency were present when the helicopter wreckage was lifted and gave advice on how the lifting gear should be attached.In addition, a mine rescue team from Trust Arktikugol participated (R5).
After the accident, the Norwegian Safety Investigation Authority identified certain safety recommendations (see the report by the Aircraft Accident Investigation Board from, 2020).They found that the Convers Avia Airlines JSC's organization at the landing site at Heerodden deviated from the airline's usual procedures, despite the fact that the base is subject to quarterly internal audits.Further, no one on board used survival suits nor were they wearing life vests.The helicopter was equipped with neither a life raft nor emergency floats.Also, Convers Avia Airlines JSC allowed only VFR flights 2 on Svalbard.In the challenging conditions during the flight, the pilots' visual references became confused, which led to the subsequent loss of control.

Cooperation facilitators
The respondents highlighted mutual trust, shared challenges, and existing administrative structures, equipment, and infrastructure as facilitators for cooperation.Most of the respondents (R1-R9) stressed that in terms of emergency preparedness, the current organization reflects the shared challenges and is well-functioning: 'The system for emergency preparedness is good, almost oversized', according to a respondent from a Norwegian institution directly involved in rescue missions (R1).Also, existing administrative structures, equipment, and infrastructure (including the existing cooperation between the Governor in Longyearbyen and the general consul in Barentsburg, plus the Governor's rescue helicopter and service vessel Polarsyssel) have been named facilitators for increased cooperation.Despite differences in language and work culture, the contact between Norway and Russia is described as solid: 'We talk to each other when needed and we have a good dialogue.'(R8).'We are in the same boat here.Of course we help each other!' (R4).
Several respondents naturally highlighted the pandemic as a health challenge of great impact on Svalbard.At the same time, the situation made it evident that Norway and Russia enjoy solid administrative structures for cooperation when needed, with command chains going between the Governor and Trust Arktikugol and the general consul.
The way the corona situation was handled on Svalbard, with the vaccination of different settlements and all, leaves no doubt that we can handle a real crisis.And that Norwegians and Russians respect each other's systems and help each other out.(R1)

Cooperation barriers
The main barriers that have been mentioned, include differences in language and culture, high personnel turnover, and divergent systems for emergency preparedness on the Norwegian and Russian mainland.
The biggest obstacles concern differences in the countries' respective systems and authorities.Russia is considered more hierarchical and Norwegian stakeholders describe the system of emergency preparedness in Russia as difficult to grasp.The language issue is also considered a significant challenge.Many Barentsburg inhabitants are quite isolated from Longyearbyen's international atmosphere (where some 40 different nationalities are represented) and have no immediate external motivation to use other languages than Russian.These challenges were summarized by one of the respondents: 'Language has always been a problem that will be difficult to bypass.And the system for emergency preparedness in Russia is almost impossible to comprehend'.(R7).
Frequent major replacements of personnel, many of whom are on short-to mediumterm contracts that may or may not be extended, form yet another barrier.'Such replacements make initiating new cooperation projects more challenging, both in general and when you talk about healthcare delivery and emergency preparedness' (R8).
All the respondents who were questioned about the effects of the ongoing war in Ukraine (R7, R8, R9, R10) stated that the war indeed had direct consequences.The war can thus be added to the list of barriers.Most projects involving Russian partners, including rescue drills, have been put to a halt.
However, other activities and treatments that are directly relevant to Svalbardians' life and health continue.'Cooperation about life and health will always persist', said one respondent (R8).This echoes statements by the Norwegian government that activities to do with the emergency preparedness in the Arctic Sea, fisheries and administration of Svalbard will be exempt from the sanctions (The Norwegian Government, 2022).

Potential areas of increased cooperation
The respondents were asked whether they could think of any potential cooperation areas.Mine rescuing, emergency preparedness, and joint exercises focusing on health challenges were mentioned as examples of areas where Norway and Russia can cooperate in the future.
As one of the respondents put it, there are no outspoken wishes regarding changes in the current organization of the system for emergency preparedness (R6).Still, many respondents suggested specific changes.Cooperation between the mine rescue teams was mentioned by several respondents (R4, R5, R10): 'The mine rescue teams in Barentsburg and Longyearbyen meet many of the same challenges.They could meet and exchange experiences, learn from each other.' (R4).This suggestion will, however, not result in substantial efforts, as the only remaining coal mine in Longyearbyen will close in 2025 (Ylvisåker, 2022).
Also, closer cooperation in emergency preparedness was mentioned by several respondents.Both during the Operafjell accident in 1996 and the Cape Heer accident in 2017, several Russian stakeholders based in Barentsburg and on the Russian mainland expressed their wish to participate in the rescue work (R7).There have also been informal talks about creating a joint emergency preparedness base for the Arctic Sea on Svalbard (R7), both on the Norwegian and the Russian side: Russia's Foreign Minister '(…) Lavrov has mentioned it on several occasions' (R8).A Russian respondent (R4) claimed that this is unfeasible as long as Norwegian legislation regulates the use of helicopters in order to protect the environment in a way that restricts the use of Russian helicopters in certain areas.The activity level in the Arctic is increasing and more specialized personnel and equipment would be beneficial for all stakeholders in the area.For the last couple of decades, the ship traffic over the North Pole has been expected to increase drastically, but this expectation is yet to materialize: 'So this type of traffic is not something we should scale emergency preparedness efforts for at the moment' (R7).
There are also informal talks about creating a formal agreement about healthcare cooperation (R8).The cooperation today is based on personal connections and concerns practical matters: If an agreement should be formalized, the initiative must come from stakeholders in Barentsburg through the Russian authorities.The process must happen on a bilateral level (…) The best way to cooperate is perhaps to have joint exercises with different health challenges' scenarios.(R8) Emergency preparedness structures, including equipment and infrastructure, have been expanding in the last few yearsamongst others, by means of more operational time for the Governor's vessel Polarsyssel, which travels around the archipelago, and more positions in the police department at the Governor's office.Several respondents illuminated the need for further expansions.A Russian respondent addressed the need for a round-the-clock helicopter service in Barentsburg (R3).In cases of acute situations, for instance, if a patient suffers from a stroke, such a service would be very useful.This statement was elaborated upon by another respondent from Barentsburg, who considered it a significant challenge that the Norwegian state introduces restrictions on the use of helicopters: If it hadn't been for these restrictions, Russia could have established a rescue base in Barentsburg.There are many fishing vessels in the Barents Sea.From time to time, fishermen from these vessels need medical care.In such cases, it would be helpful for the fishermen to use the infrastructure in Barentsburg and talk to a Russian-speaking doctor.(R4)

Discussion
This is the first systematic study to use interview data from both Norwegian and Russian respondents in order to detect facilitators and barriers with regard to healthcare delivery and emergency preparedness on Svalbard and to explore whether cooperation is desired.The respondents highlighted mutual trust, shared challenges, and existing administrative structures, equipment, and infrastructure, as facilitators for cooperation.The main barriers include differences in language and culture, high personnel turnover, and divergent systems for emergency preparedness on the Norwegian and Russian mainland.Mine rescuing, emergency preparedness, and joint exercises focusing on health challenges were mentioned as examples of areas where Norway and Russia can cooperate in the future.
The current situation, where Norway (as a NATO member and Ukraine and sanctions supporter) and Russia currently stand against each other in a mode of conflict, shows how geopolitical state of affairs is reflected on Svalbard.The situation also showcases how security issues unfold on Svalbard, with Norwegian actors arguing for a boycott of Russian companies, as seen above, being only one example.Another example was when Trust Arktikugol, the Russian state-owned mining company on Svalbard, together with the Russian Consulate General, staged a military-style propaganda parade in Barentsburg (Nilsen, 2023).
Traditional approaches to security are rather state-centric and describe the security concept as a state's territorial integrity and the physical safety of a state's inhabitants.Since the 1990s, the idea that the state is not the only referent object of security and includes other spheres such as environmental, economic, societal, and political in the security concept has been prevailing (Buzan et al., 1998).This article adopts the latter approach and includes actors such as institutions, human individuals, and groups, in addition to the state, in the security concept (Peoples & Vaughan-Williams, 2015), because this allows me to methodically link security aspects by healthcare delivery and emergency preparedness.For Svalbard, which is located in the strategically significant Arctic region, the security aspect has always been of vital relevance to Norway, also in a broader sense of security.With Russia engaged in warfare with one of its neighboring countries, the security question is currently of particular urgency.The increased focus on security on both sides permeates multiple areas of international cooperation and thereby affects healthcare delivery and emergency preparedness.On the one hand, there is a narrow line between the assets stemming from international cooperation and the need for the protection of territorial borders.On the other hand, security can be a key motivator for cooperation.This follows the ideas of collective security and that states who engage in cooperation and rely on the same structures and organizations.
A key dilemma in this context is whether or how to cooperate with an enemy country.Addressing this dilemma in the context of Svalbard requires addressing Svalbard's geopolitical location.Many have argued that the Arctic region, including Svalbard, is a unique place in a geopolitical context.The region is often referred to as a region disconnected from global political dynamics and as a place for peaceful and scientific cooperation despite other disagreements and political tensions existing globally and among Arctic countries (Kornhuber et al., 2023).Arguments following the idea of a kind of Arctic exceptionalism have been increasingly challenged since Russia's annexation of Crimea and others have argued that the Arctic on the contrary is a global region where global political dynamics are played out (Finger & Heininen, 2019;Hoogensen Gjørv & Hodgson, 2019).
When two countries, in this context Norway and Russia, regard each other as existential threats in the military domain, this view may spread to other dimensions of the relationship, such as healthcare delivery or emergency preparedness on Svalbard.Through such multifaceted securitization, each state reads the other as a threat.When this interpretation spreads beyond the military sphere to dimensions such as healthcare delivery and emergency preparedness, or trade, culture or diplomacy, mutual recognition declines and cooperation is harder to achieve (Wilhelmsen, 2021).

Examples of Norwegian-Russian cooperation during the soviet period
There are numerous cases where Norway and Russia have cooperated on healthcare delivery and emergency preparedness.Examples from the Soviet period include for instance the famous rescue of the Umberto Nobile expedition in 1928 by both Norwegian and Russian stakeholders (other countries contributed to the rescue mission, too).The Italian explorer Umberto Nobile and his crew capsized with the airship Italia in the Arctic Sea and an ambitious rescue operation involving more than 1500 people from seven different countries was initiated (Kristensen, 2018).The rescue operation was poorly coordinated and characterized by competition rather than cooperation between the different rescue teams (Ingebrigtsen et al., 2003).Nobile was rescued by the Swedish pilot Einar Lundberg and some of the remaining survivors were saved by the Russian icebreaker Krassin, but several perished in the attempt to save them, including the famous Norwegian explorer Roald Amundsen.
The rescue of the icebreaker Malygin in 1932-33 (it ran aground in Isfjord) involved much less cooperation between Norway and Russia, as the Norwegians did not have the necessary equipment for conducting a rescue mission during the polar winter (Sadovskii, 1934).A rescue mission that, on the contrary, did involve a high level of cooperation, took place during the accident with the cruise ship Maxim Gorkiy in 1989.The Soviet cruise liner started to sink after hitting an ice floe west of Svalbard.The Joint Rescue Coordination Centre in Northern Norway informed their Russian counterpart in Murmansk, and the Soviet consulate in Barentsburg sent helicopters that assisted in the rescue operation.All 954 people onboard were evacuated by the Norwegian coast guard, and the episode is often referred to as a potential Arctic disaster that was avoided due to excellent cooperation (Waehler & Ingebrigtsen, 2022).
The newspaper Poliarnaia kochegarka (issued in Barentsburg from the early 1930s until the early 1990s) describes several cases of cooperation.Some cases were unplanned, such as when two Norwegians en route to Longyearbyen from Kapp Linné were seriously injured after a skiing accident and received medical treatment in Barentsburg (Romaniuk, 1978).Another unplanned event described by the same newspaper happened when a Russian fisherman was picked up by a Soviet helicopter and transported to the hospital in Longyearbyen, where he was operated on.Communication posed a potential challenge in all encounters between Norwegians and Russians, simply because the countries did not have a language in common.In this particular example, the newspaper underlined that the Governor's interpreter was of crucial importance for communication between the involved actors (Sandmo, 1990).Cases of bilateral cooperation could also be utilized to illuminate ideological virtues, such as in the example from Isfjord radio described earlier.Other cases were well-planned, like visits from medical workers from Longyearbyen to Barentsburg (see for instance Shirikov, 1979) and Pyramiden (for one example, see Tsymbalyuk, 1989).Another example is found in the Governor's archive, about a Soviet boat carrying several Soviet citizens stranded in Advent Bay in 1940.It was rescued in a joint mission involving both Norwegians and Soviets (Governor of Svalbard, 1940).

Examples of Norwegian-Russian cooperation after the Soviet period
With the post-Soviet period, fundamental social and economic changes became manifest on Svalbard.The Soviets made up the majority of citizens (in 1991, almost 2500 inhabitants in the Soviet settlements against approximately 1100 inhabitants in the Norwegian settlements (Statistics Norway, 2022).The collapse of the Soviet Union led to harsh economic conditions for Russians and Ukrainians on Svalbard, and many workers from the Soviet/ Russian settlements returned home due to diminished production in the mines.Simultaneously, the Norwegian government started to initiate steps that would transform Longyearbyen from a more or less pure worker population to a family-oriented society (Meld. St. 32 (2015-2016), p. 6), a step that led to major social changes.Between 1993 and 2008, the number of people employed in Longyearbyen increased from approximately 780 to around 1600.Since the 1990s, tourism has bypassed coal mining as the main industry.Facilities for healthcare and emergency preparedness have changed accordingly.For instance, the SAR system is now adapting to the increasing numbers of tourists visiting the archipelago.
There are many examples of cooperation also after the collapse of the Soviet Union.One such example is the Operafjell accident in 1996, which is still the worst airplane accident ever in Norway with 141 passengers (Russians and Ukrainians) killed (Ivert & Due, 1997).According to international guidelines, the country where the accident occurs is assigned the main responsibility for the rescue operation.In this case, however, it was agreed that both Norwegian and Russian personnel should take part in the rescue operation.In addition, a joint commission was created to establish the cause of the accident.
These examples illustrate that cooperation has been taking place when needed and understood as beneficial, and the same tendency is evident also today.Further, the examples show how cooperation is and has been rather imbalanced, as Russia benefits more from Norwegian resources when needed than vice versa.

International cooperation in healthcare delivery and emergency preparednessexamples from other places in the Arctic
Examples of bilateral and international cooperation with concern to healthcare delivery and emergency preparedness can be found also in other places in the Arctic, such as efforts to enhance national policies for health among indigenous groups between Canada and USA (Inuit Circumpolar Council Canada, 2015), or between Denmark (Greenland) and Canada (Rønn et al., 2017).Other international or bilateral SAR cooperation projects in the Arctic include the SAREX exercise in the Greenland Sea in 2012, which involved Canada, Denmark, Iceland, Norway, Russia, and USA (Island Commander Greenland, 2012); the Arctic Chinook held in Kotzebue, Alaska in 2016 between USA and Canada (Sydnes et al., 2017), or the annual Barents Rescue exercise in the Barents Sea between Norway and Russia, now put on hold due to the sanctions against Russia (Rottem, 2014).A peculiar case of international SAR cooperation in polar areas happened in Queen Maud Land in Antarctica in 2001, where a crew member from a Norwegian research expedition fell on the ice and suffered a serious head injury.The patient was in acute need of advanced medical treatment, and a rescue operation involving personnel from six nations secured transport of the patient 4348 kilometers over the Antarctic continent and then 4000 kilometers further to Christchurch in New Zealand (Ingebrigtsen et al., 2003).
International cooperation in healthcare delivery and emergency preparednessexamples from outside the Arctic Svalbard is not the only remote island community where different nations with disparities in language and culture and with deviating health and emergency preparedness systems cooperate in healthcare delivery and emergency preparedness.A suitable example can be found on the island of Saint Martin in the Caribbean, which is divided between the Dutch Sint Maarten and the French overseas collectivity of Saint Martin.Residents from Sint Maarten have access to healthcare services in Saint Martin and vice versa.The two countries collaborate to address shared health challenges, exemplified by the joint efforts to combat the vector-borne disease chikungunya (Henry et al., 2017).The two countries share epidemiological information on the disease on a routine basis, have strengthened their diagnostic capacity, and collaborate on joint vector control activities and public awareness strategies.Just like on Svalbard, there is no physical or ecological barrier separating the nations on the island, enabling the free movement of people and vectors.
Similar comparisons can also be found in the border areas between Norway and Russia on the mainland, where the two countries share an almost 200 kilometer-long border.Cooperation with concern for healthcare delivery and emergency preparedness has been taking place here, too.The health administrations in Helse Nord (the northernmost part of Norway) and Arkhangelsk oblast in Northwest Russia since 1996 have been engaged in formal cooperation (Helse Nord RHF, 2017).Examples include disease prevention, competence development and exchange of experience, and development of joint infrastructure.Moreover, biannual joint exercises in emergency preparedness in the Barents Sea have involved stakeholders from both Norway and Russia.Before most of this cooperation was put on ice as part of the EU sanctions against Russia, which Norway supports, it had been characterized as particularly solid (Holm-Hansen et al., 2022).

Solid cooperation in volatile surroundings
The war between Russia and Ukraine has created tensions on the geopolitical stage that are also observable on Svalbard.However, manifestations of tensions between Russia and NATO countries and countries allied with NATO are no new phenomena on Svalbard.During the Cold War, Svalbard was the only place where the Soviet Union coexisted with a NATO country on the NATO member's territory, as the USSR's successor Russia does today.Even when the tensions between USSR and NATO countries and countries allied with NATO were at their strongest, cooperation on Svalbard continued to take place in various areas, including healthcare delivery and emergency preparedness, as earlier mentioned examples illustrate.Although the tension between Russia and other countries may be evident on a geopolitical level, the relations between Norwegians and Russians on Svalbard can be described as fairly relaxed from a historical perspective.
In this study, none of the respondents mentioned tensions between Russia and NATO as a direct barrier to increased cooperation.Nevertheless, the Russian war on Ukraine was termed an obstacle to cooperation, both in a moral context and also because the EU sanctions toward Russia that Norway supports make cooperation challenging from a practical perspective.The war in Ukraine undoubtedly constitutes a backdrop of moral and practical obstacles to cooperation.

Trust decisive for cooperation
The Norwegian-Russian cooperation demonstrates that cooperation in acute cases such as large accidents or during a pandemic is easier when the involved stakeholders know each other from before.Organizing joint meetings between the hospitals where treatment, routines, and resources are discussed will make these hospitals better prepared for efficient cooperation in acute cases (Hutchinson, 2005).Cooperation and expertise exchange requires a fair amount of trust between the participating actors.A significant level of trust between Norwegians and Russians/Ukrainians living on Svalbard seems to be evident.Inhabitants in Barentsburg express faith in the existing disaster-related mechanisms, which are made up of both local Russian entities, such as the Mine Rescue Squad, Barentsburg Hospital and the operations manager for the Arctic Tourism Centre, and the Norwegian rescue services, especially Svalbard's Governor (Duda et al., 2022).Several respondents in this study (R1, R4, R8, and R10) illuminated that the cooperation is relational and that it is well-functioning because the involved stakeholders know each other.

Cooperation facilitators
Mutual trust and shared challenges, combined with existing administrative structures, equipment, and infrastructure were considered facilitators for increased cooperation.The historically good relationship between Norwegians and Russians on Svalbard, despite tensions on the global scale, should be regarded as an additional facilitator.Drawing experience from the Norwegian-Russian cooperation on the mainland and from other areas where different countries cooperate with regard to healthcare delivery and emergency preparedness may prove beneficial in a Svalbard context.

Cooperation barriers
The results indicate that differences in language and culture, high personnel turnover, and divergent systems for emergency preparedness on the Norwegian and Russian mainland are considered the main barriers to increased cooperation.The ongoing war in Ukraine constitutes a moral and practical obstacle for cooperation between Russia and other countries, so far unprecedented on Svalbard.It is hard to say at this stage which role will the war continue to play on Svalbard (and elsewhere) even when the military activities stop.
According to one respondent (R7), the fact that the Governor acts both in the capacities of chief of police and county governor, whereas the latter role entails responsibility for emergency preparedness, may be challenging.This duality may be problematic in situations where people in need of rescue hesitate to contact rescue personnel because they for some reason are apprehensive about the police authorities.This may constitute a barrier to cooperation both between Norwegian and Russian stakeholders and between the authorities and the public, irrespective of nationality.

Potential areas of increased cooperation
Mine rescue, emergency preparedness, and joint exercises focusing on health challenges were mentioned as examples of areas where Norway and Russia can cooperate in the future.Mine rescuing is not, however, a feasible area for cooperation, as the only remaining Norwegian coal mine will close in 2025.The current cooperation is rather imbalanced, with Russia benefitting more from Norwegian resources than the other way around.Potential future cooperation efforts should strive to be more balanced.Nevertheless, at the moment Russia's intolerable warfare in Ukraine makes further cooperation initiatives both morally undesirable and challenging from a practical perspective.The war must come to an end before potential arrangements for increased cooperation can be made.

Knowledge gaps and recommendations for further research
Including interview data from central Russian decision-makers might have strengthened the knowledge of Russia's future plans for Svalbard.Nevertheless, conducting such interviews proved impossible due to the current tensions between Russia and other countries.In the current situation, however, this knowledge is irrelevant due to the uncertainty that results from the tensions between Russia and the rest of the world.Clarifying whether the respondents from Barentsburg were of Russian or Ukrainian background, could in today's situation have illuminated interesting nuances in how these nations consider their presence on Svalbard and whether the relations between Russians and Ukrainians have changed on Svalbard as a result of the development in Ukraine.

Strengths and weaknesses of the study
Conducting interviews with both Norwegian and Russian stakeholders representing a variety of institutions secures a broad representation and multi-faceted illumination of the research topic.Including data from archives that has not yet been explored in the context of healthcare delivery and emergency preparedness, such as the Poliarnaia kochegarka and the Governor's archive, has provided solid evidence regarding former cooperation on Svalbard.Together, these factors constitute this study's main strengths.
Among the weaknesses of this study is that inconsistency in methods caused by the use of in-person and online interviews.This deviation from the original protocol was a necessary act to conduct data gathering during COVID-19-induced meeting restrictions.Efforts were made to ensure that inconsistency in methods would not influence the results.These efforts included training the respondents in the use of the online tools applied in the online interviews and providing the same interview questions for all respondents.
Moreover, the results would have been even more solid if interview data from decisionmakers in mainland Russia could have been obtained.Unfortunately, the current tensions between Russia and the West have made such interviews impossible.
Finally, this study does not distinguish between Russian and Ukrainian respondents from Barentsburg.The interviews with these stakeholders were all conducted before the full-scale invasion of Ukraine, and such a distinguishing was irrelevant at the time.In the current situation, however, this knowledge could illuminate potential differences between Russian and Ukrainian stakeholders on Svalbard.

Conclusion
There are both facilitators and barriers regarding cooperation between Norway and Russia in healthcare delivery and emergency preparedness on Svalbard.Main facilitators include mutual trust, shared challenges, and existing administrative structures, equipment, and infrastructure.Main barriers involve differences in language and culture, high personnel turnover, and divergent systems for emergency preparedness on the Norwegian and Russian mainland.Mine rescuing, emergency preparedness, and joint exercises focusing on health challenges are areas where Norway and Russia may cooperate in the future.Mine rescuing is not, however, a feasible area for cooperation, as the only remaining Norwegian coal mine will close in 2025.The results make it evident that the cooperation is rather imbalanced, as Russia benefits more from Norwegian resources when needed than vice versa.Potential future cooperation should strive to be more balanced.
The war in Ukraine does, however, constitute a backdrop of moral and practical obstacles to cooperation.Svalbard is often referred to as a region disconnected from global political dynamics and as a place for peaceful and scientific cooperation despite other disagreements and political tensions existing globally and among Arctic countries.However, Russia's aggression in Ukraine since 2014 has seriously challenged this idea.Norway and Russia increasingly regard each other as existential threats in the military domain and this view may spread to other dimensions of the relationship, including healthcare delivery or emergency preparedness, thus making cooperation much harder to achieve.
As the war in Ukraine continues, a considerable knowledge gap evolves concerning how the war will affect the relations between Russia and other countries, also on Svalbard.

Notes
1. R = respondent 2. Visual Flight Rules, which means that the aircraft is intended to operate in visual meteorological conditions (i.e.nice and clear weather).