Mortality rate of every country is calculated based on a number of deaths per 1 000 inhabitants. It is influenced by the number of deaths within a certain period and person-years lived. Some countries occupy the last or at least middle positions in this rate, but others have been in the leading top for decades. The main reasons are their unbeneficial location, climate, poor economy and educational system, political conflicts and undeveloped healthcare system. Some above-mentioned facts are hard and impossible to change, but many of them cause problems and make inhabitants’ lives shorter because of neglect.
General Information about Afghanistan
Afghanistan occupied the second place in the list of world mortality rates in 2011. In 2014, the situation has somewhat changed and the country took the seventh position. This statistics makes Afghanistan one of the most interesting countries in terms of analysis. The country has proved that even when the economy is still poor it is possible to save the lives of the people with implements of knowledgeable nurses and informational healthcare programs. With the change of the political regime, Afghanistan has changed its attitude to women’s education. Nowadays, female nurses care about mothers and infants without any harm to their cultural beliefs in regard to the mortality rate. Nowadays, daily medical consultations for women are a norm in many districts of Afghanistan. Inhabitants help each other when the Parliament and President find and show way.
Today, the economy of Afghanistan is still weak, but it is possible to improve the mortality rate of the country, if the government supports the initiatives of international organizations, funds the healthcare system as much as possible and lets more females work.
Location and Geographical Position
The Islamic Republic of Afghanistan is located in Central and South Asia. Its territory is 653000 square kilometers, which makes it the 41st largest country in the world. The country borders Turkmenistan, Uzbekistan, Tajikistan, China, Iran and Pakistan.
Mountainous and desert areas cover three-fourth of the Afghanistan territory. The highest mountain is Naw Shakh that is 7485 meters above sea level. Plains spread in the Northern and Southwestern parts of the republic. Earthquakes are rather common in the country. Almost every year at least one earthquake takes place resulting in the deaths of people. The most dangerous in this regard is the territory of the Badakhshan Province.
Afghanistan has many rivers, but most of them start in the mountains and are rather dry in all seasons except spring and early summer. Hilmand is the biggest river in the country.
The climate of the country is dry continental with large day and night temperature amplitudes.
Geographical position of the country is rather weak. It is landlocked and has a lack of water resources. It is a mountainous territory with changeable weather.
Population
Population of Afghanistan in 2015 equals to 33 101 803 people. Kabul is the capital of the country with over 1 million inhabitants, while some other bigger cities like Kandahar, Herat, Mazar-i-Sharif have less than 500 000 inhabitants. Sex ratio in the country is almost equal. According to the statistics, 55,3% of the population are 15-64 year old and 42,3% are under 15 or above 65. The site Country Meters analyzed the data of United Nation Statistics Division and concluded that such kind of population distribution pyramid as in Afghanistan “is common for developing countries with high birth and death rates. Relatively short life expectancy as well as low level of education and poor health care also describe such kind of population age distribution model” (Country Meters, 2015).
The majority of the population lives in distant districts of the country, which are hard to reach by medical personnel and primary civilization. Afghanistan families have many children, but half of them die before reaching the teenage age.
Government System
Afghanistan became independent on the 19th of August in 1919. The country consists of 34 provinces with the capital Kabul. Islamic republic has three branches of power: executive, legislative and judicial. In 2015, Ashraf Ghani became the head of Afghanistan. Legislative branch of power is bicameral. It is represented by the House of People and the House of Elders. According to Transparency International, a non-government organization, which was founded in Germany in 1993 specializing in monitoring world corruption rates, Afghanistan is the 4th most corrupt country in the world.
Afghanistan has a standard international three-branched government system functions, but the role of traditions is still significant and a head of a family sometimes can perform the functions of the main judge and doctor. Moreover, it was considerably influenced by the Taliban regime.
Economy of Afghanistan
Afghanistan is one of the poorest countries in the world. The situation can be explained by the long years of conflicts and wars without investments as well as a landlocked geographical position. It has led to a weak government capacity, high level of corruption, poor public infrastructure, anemic job creation and low revenue collection. Unemployment rate in the country is 40%. The rest of the population works in the spheres of agriculture, customer service and mining. Afghanistan exports fresh and dry fruits, nuts and crops (wheat, rice, barley and corn), wool, karakul skins and rugs. Agricultural sphere brings two thirds to the overall income of the country and provides employment for 85% of the population.
Current President of Afghanistan Ashraf Ghani focuses on economic reforms. Over the previous decade, investment of the country has grown 10 % per year, while the construction branch has considerably developed. The country also invests in mining, as it has rather big reserves of copper, lithium, iron ore, minerals and gold.
Economy of Afghanistan is recovering, but the country still has the poorest living standards, problems with clean water and proper housing, electricity access and medical care. According to the United States Central Intelligence Agency (2015), in 2003 more than 53% of the country’s inhabitants lived below the poverty level.
State of Health in Afghanistan
Diseases
General life expectancy in Afghanistan is approximately 45 years. Infant mortality rate is 149 babies per 1000. One Afghanistan woman dies every 30 minutes during childbirth. These sad statistics could show more optimistic results if the population had access to clean water, more hospitals in the proximity, qualified personnel and better access to information.
Afghanistan often experiences the lack of water, because of its geographical location. People are too poor to search for distilled water; consequently, they use any water they have access to. Because of difficulties related to sanitation access, fecal materials can often be found in water and consequently in food. It leads to the spread of such infections as tuberculosis and hepatitis A. Afghanistan is the 22nd country of the world that has the highest tuberculosis rate. Over the recent years, the country has initiated many projects and programs to struggle against its most common disease. The number of infected has reduced, but the problem still exists.
Because of poor sanitation in the country, one of ten children dies before reaching the age of 5 years. The list of the most common food and waterborne infectious diseases contains diverse kinds of diarrhea, hepatitis A and E and typhoid fever. Mosquito-borne viral diseases cause Dengue and Yellow fever, Japanese Encephalitis and malaria. Fleas and rats transmit plague. Inhabitants of Afghanistan get rabies through contact with infected animals. Poppy cultivation and opium production remains a part of Afghanistan government limitation but still exists. Because of the economic condition, 85% of drug addicts share a needle in urban centers. It leads to the spread of the Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS).
The spread of this or that disease in Afghanistan may vary depending on the location, inhabitants’ activities, accommodation and season of the year. The main problem of the infections’ transmission is ignorance of the population. Most people simply do not know how to prevent them.
Violence
Even nowadays Afghanistan remains an unsafe and unpredictable country because of outgoing violence. In 2007, 45% of the country’s territory was dangerous to access because of landmines and explosive devices. Suicide bombers, kidnapping for ransom, narcotics trade are not the only examples of the outbreaks of violence in the country. Years of war and conflicts facilitated the approval of the international humanitarian law about respect, protection and care of sick, wounded people and medical facilities and personal invalid. The country also suffers from violence against healthcare staff in health facilities (in 2004, 40 medical workers were killed “including 5 who were murdered specifically for being health care workers” (Acerra, Iskyan, Qureshi, & Sharma, 2009), wounded and sick and theft of medical transport. Protective medical emblems were often misused to achieve military goals. As a result, in 2008, 300 000 people lost access to medical services, and those who still had it were afraid to ask for help. Despite the measures taken by international organizations in 2014, Afghanistan still had prominent violent attacks. That year, 58 districts of the country were not able to get elementary medical help due to the conflicts. There were 41 incidents in hospitals in 2014 during the period from January 1 to August 15. Most of them took place in the Eastern and Central parts of the country.
Along with the political conflict, violence is widely spread in Afghanistan. In many cases it penetrates hospitals and local staff, which makes a small number of medical personnel even smaller.
Accidents
The number of victims in traffic accidents in Afghanistan equals to 2,86 % of the total death rate, which shows that cars are not the main danger in the country. The statistics of air crashes have been rather optimistic for the previous 2 years. In 2015, two aviation accidents occurred and in 2014 there happened four of them, while in the period from 2009 to 2011 each year more than 10 air crashes were observed. Apart from the transport system war landmines played their role so that nowadays, 80 000 people live without their limbs.
Afghanistan is an economically poor country. Only the richest inhabitants drive cars and use planes as means of transportation. Therefore, most accidental deaths are related to war consequences.
Culture. Traditional Medicine
Afghanistan is Islamic country and 99% of its population is Muslims. This religion emphasizes the dominant role of man in a family and presumes strict traditions. Being the most significant social institution in the country, the family is endogamous, patriarchal, patrilocal, patrilineal and polygyny. The man is the head of the family and the woman should serve and obey him. Women cannot talk in private or stay in one room alone with another man, even if he is a doctor. Most men in the country prefer bringing medicines to their homes rather than bringing their wives to a male doctor. The cases of female doctors are rare, because Islam women as a rule do not get any education including medical. As a result, women and infants mortality in the country is very high. Husbands bring wives mostly to the village midwives, who are not properly educated and often provide fatal practice. Moreover, Muslims believe that every illness is God’s will and a person can recover from an illness through praying and reading the Koran. Linda Merrill, Donald Paxson, and Thomas Tobey (2006) refer to another cultural belief of Muslim people and write that “…an Afghan belief that treatment of illness relates to temperature of food and beverage. For example, consuming food or drink that is cold would by contrast reduce a fever”, which adds numbers to the mortality rate of the country.
Afghan people avoid hospitals in favor of the traditional medicine, which exists for millennia and helps only in rare cases. The most popular kind of traditional doctors without any education are bonesetters and herbalists. They handle down their knowledge and skills from generation to generation and are very popular among poor and ignorant inhabitants of small towns. Bonesetters often put bones to close in their practice, which leads to further amputation. Rahimullah Hamid, a head of the hospital’s orthopedic ward, points to the fact that “over the last three years he had amputated limbs from around 60 children and young people, who could have been spared amputation had they been brought for hospital treatment rather than taken to a bonesetter” (Sahak, 2010). Harm from herbalists’ activity has another consequence. As a rule, they relieve pain, often with the use of drugs, but do not cure the illness. A person feels good while the illness becomes more serious and sometimes leads to death.
The majority of the Afghan population chooses traditional medicine due to its cheapness and availability and their cultural and religious beliefs. There are two solutions to this problem. All traditional doctors should get proper medical training to provide qualified medical help. Muslim women should study medicine to provide better medical services for the female part of the population.
Healthcare System and Delivery
Government Health-Related Agencies
The Ministry of Public Health is the main state health-care body in Afghanistan. Over the previous decade, many hospitals and medical centers around the country have been built and reconstructed, but it is still not enough. The situation with public health in Afghanistan is not based exceptionally on building medical centers and training qualified personnel. It depends on the general economical level of the country, access to clean water, roof shelter, and various nutrition. The main goals of the Ministry of Public Health in Afghanistan are to improve the health of the nation, increase proficiency and coverage of proper medical services, improve emergency help and health structure, make essential drugs widely available and provide a number of health and hospital services. The World Health Organization (WHO) helps the government of the country to reconstruct the healthcare sector, because the budget of Afghanistan is too small to cope with it on its own. Leading medical centers and hospitals of the country are located in the capital. The largest two are the French Medical Institute and Indira Gandhi Children Hospital.
Non-governmental charity organizations actively participate in providing medical help and assisting orphans. The situation of healthcare and its delivery is so dire in Afghanistan because of the years of neglect and underfunding. Even in 2015, the country experienced a shortage in funds in this sphere, which is mostly financed by contributions from donors. Today, the country faces shortage in 7 000 physicians and 20 000 nurses. The problem is hard to solve, because Afghanistan lacks standardized medical personnel training programs. Besides professional workers and hospitals, the population needs simple information about the basics of first aid, most common diseases prevention, the dangerous aspects of maternity and childbirth and elementary hygiene rules.
Healthcare Personnel in Afghanistan
Many years of war, conflicts and the Taliban regime greatly influenced the healthcare system and personnel in contemporary Afghanistan. During the war, many medical workers were killed. Those who stayed alive preferred to leave the country and find a safe job abroad. As a result, there are just a few highly qualified doctors in Afghanistan. The WHO conducted a survey that showed that only 70% of nurses, midwives and allied health personnel had minimum knowledge in their professional sphere. The role of international organization’s participation in problem solving is vital and decisive. They provide help to small towns and distant regions located far from the capital. Aid organizations implement 70% of healthcare programs in the country. Non-governmental organizations (NGO) send medical personnel to the most forlorn and neglected areas. Statistics show that 82% of the population in distant regions experiences lack of primary health care services.
WHO indicates that every 28 millions of Afghans need 6000 physicians and 14000 nurses more today to feel healthcare protection. The reasons, which make the situation even worse are the low salaries of the doctors. Most qualified personnel choose to work in or near the capital and combine governmental and private practice. Each medicine worker realizes that he/she agrees to be hungry and needy if he/she practices in districts. NGO might improve the situation, but the government cannot employ personnel they train, because they do not correspond to its strict demands and norms. Meantime standardized government programs for such kind of training are still not developed.
The Afghan population feels a constant inconsistent lack of training and informational programs too. The main reason is the educational culture of the population. Taliban regime forbade women to obtain education, thus today 78% of the female population of Afghanistan is illiterate. The percentage for males is 48%. Even today, 60% of primary school children do not receive education. For this reason, leaflets with the information on diseases and their prevention are not effective. The government should give lectures and training to provide minimum health knowledge to the population, but even this should be done in two main languages Dari and Pashto to be understood.
Nursing Educational System and Accrediting Organizations
Nursing education in Afghanistan mostly does not focus on higher education and teaches personnel only to provide primary medical help. The main reason is shortage of funds, low payments for teachers and critical healthcare situation in the country. There are five main government medical schools and five private colleges. Medical schools have 11 000 students, while nine Afghanistan Institutes of Health Science have 2 500-3 500 students, but a lack of medical workers is still severe. If the government provides the licensure examination by the Ministry of Public Health, it will make it possible to train medical workers by NGO, which will help to solve the mortality rate situation in distant districts of the country. The other prospective aspect for the government to consider is gender discrimination. More women should learn medicine to help other women.
According to strict cultural beliefs, it is unappropriate to let male doctors examine one’s wife, daughter, mother or sister. The Taliban era removed women from the sphere of education and made it impossible to provide even elementary medical help to females, as soon as most doctors and nurses in the clinics were male. In 2002, only 21% of healthcare providers had at least one female worker, when in 2015 the situation improved to 60%, but it is not enough. The existence of two languages, Dari and Pashto, divides the society into two groups and makes the situation with education, which suffers from the lack of qualified teachers, even more complicated. That is why it is reasonable to provide medical education of all levels in English. It will also make it possible to involve more foreign volunteer teachers to Afghanistan health education.
Nursing Associations
Afghanistan is one of the top countries in the world with high women and infants mortality. This situation was provoked by cultural, religious and political factors. The president of the Afghanistan Midwives Association (AMA), Sabera Turkmani (2011) reports that only “8% of births were attended by a skilled provider in 2003” (p.5). AMA was created in 2005 to improve this sad statistics and provide available security to all Afghan women. The main aim of the association is to ensure the provision of quality services across the country, create a positive work environment for female workers and establish proper governmental regulatory mechanisms. Association plays a critical role in pre-service midwifery education and is the main board of Afghanistan Midwifery and Nursing Accreditation Board. Association started by employing 15 members, but later in 2011 the number of its members counted 2600. Within 10 years of its activity, AMA made motherhood in Afghanistan much safer.
Afghanistan Health Priorities
Healthcare system has been neglected, unfunded, disorganized and male oriented for many ages. That is why the country faces so many problems and has a very high mortality rate today. Its condition is dire, but possible to improve. The first priority in this sphere is restoring and upgrading medical clinics in urban and underserved areas. Many poor people just cannot get to the capital to receive proper help and try to survive themselves. Drug availability should follow the clinic availability. There is no use to consult a doctor if a patient cannot buy drugs in his/her district. Government should help expand the medical care services around the country and fund them properly by accepting diverse initiatives of international organizations. Information and knowledge about the symptoms and prevention of communicable and noncommunicable diseases among the population is vital and can save many lives. The system of emergency medical help provided in every corner of the country for both sexes should be designed and developed. Government should focus on immediate education and graduation of qualified female doctors and nurses.
Nursing Implications
Afghanistan’s healthcare system faces two main problems. These are the lack of money and lack of doctors and nurses. Both of them are interdependent. Inhabitants do not want to work as nurses in distant regions of the country, because there they would be poorly paid. The government on its side does not have much money in disposition to pay more. It is obvious that the more medical workers work in the country, the more professional help will be provided to the people so that there will be fewer deaths. The situation in the country is getting better very slowly after years of war and political conflicts. Its income increases by 10% per year. There are too many things, which need financing and rebuilding, but the government should put the healthcare system and medical personnel first place. If doctors are well paid, they will be interested to work even far from the capital to provide medical help to the inhabitants on a regular basis in the given location. The situation in Afghanistan is partially improving even today, with the implementation of educational programs for female nurses. The role of female medical workers is vital, because only a woman can examine and consult another woman according to Muslim culture. Moreover, as women used to have no right to obtain an education, they are glad to see even such a small opportunity as being a nurse. Female nurses are not as demanding as male ones and agree to work far from their homes in far-away mountainous settlements. They even prefer to be paid poorly than unpaid at all. This aspect plays a key role today, but the government should not neglect the situation, because it will not continue forever. Soon females will feel their power and understand their leading role. Soon they will demand more, as male doctors do.
Conclusion
Training of knowledgeable medical workers is the main and the fastest solution to the poor healthcare situation in Afghanistan. Poverty, illiteracy and widespread ignorance of the population often lead to fatal results and high mortality levels. The majority of the population does not have available medical providers and drugs in their area. Moreover, they do not have money to go to the capital and receive proper help and consultations. More than half of the population understands just one language out of the two existing in the country and less than half can read just one of them. Printed words are not effective, and people need a knowledgeable person nearby to hear what treatment is good and what is dangerous in their case. If each town in Afghanistan has at least 2 nurses (one man and one woman) to provide inhabitants with healthcare services, the threat of fatal mistakes and mistreatment of bonesetters and herbalists will be eliminated immediately.
According to the fact that the emergency medical system is poorly developed in Afghanistan, it once again underlines the necessity of medical providers in proximity. Moreover, nurses and doctors can give lectures and training among the population in their area to provide people with information and teach them first aid basics.
Poor state of the health system and health knowledge is not the only reason for the high level of mortality among the population in Afghanistan, but it is the one that is easy to improve and moderate, although it cannot be said about the geographical position, water balance or influence of the past political conflicts and regimes. That is why Afghanistan has changed its second position to the seventh in the world in terms of the mortality rate and is likely to go down in this list, if the government does not start caring and properly funding its healthcare system in future.
