Health in Afghanistan

AN OUTLOOK ON HEALTH IN AFGHANISTAN By Jason Davidson HAS 4620 Dr. Moss Spring 2014

Health in Afghanistan Afghanistan is located in an obscure area of the globe bordered by Iran, Pakistan, Tajikistan, Uzbekistan, Turkmenistan, and China. The country has well-defined boarders recognized and accepted globally and by the government but are not accepted locally by the majority of the people. The land is

beautiful and diverse with rugged mountains, green forests, fertile green valley floors, and low land where the enormous red desert lies. Within this varied landscape there is another tale to be told. Political and armed conflict has plagued the country for over three decades and has created an illusive almost eerie feeling through out the land. Afghanistan holds many insights as to what war and political unrest can do over time to infrastructure and its overall affects on the progress of its people. From the Soviet War (1979-1989), to Civil War (1989-2001), and now Operation Enduring Freedom (2001- present), Afghanistan has been riddled with war and the consequences have taken their toll in many ways, but most prevalent has been on the health of its people. Burden of Disease The burden of disease in Afghanistan does not mirror the rest of the globe. Where many countries are more concerned with non-communicable disease, Afghanistan is still very concerned with the death toll communicable diseases are having on their countries population. 64 percent of all deaths in 2005 were attributed to communicable disease and perinatal, nutritional deficiencies (Organization, 2005). Of the top twenty causes of premature death in Afghanistan 11 of them are communicable diseases, five are from injuries, and four come from non-communicable diseases. The top three causes for premature death are lower respiratory infections, diarrheal disease, and preterm birth complications (Evaluation, 2013). Mothers and babies do not have the access or quality of care they need to receive during the critical prenatal stage and during the first few years of the new babys life. Many women are not seen by trained health care providers and deliver babies in less than sanitary conditions. Maternal mortality rates are among the highest in the world at 1575 per 100,000 births in 2008. The infant mortality rate is 117.23 deaths per 1000 births and the under five mortality is 128 deaths per 1000 (CIA, 2014 estimate). The life

Health in Afghanistan expectancy at birth, according to the world health rankings for men, is 58.6 and 60.8 for women, this figure ranges up to 8 years less for both genders depending on the source. The UN Children's Fund (UNICEF) estimates that only 23 percent of Afghanistan's estimated 30 million people have access to clean drinking water and 12 percent to safe sanitation. Additionally up to

50,000 children die from diarrheal diseases each year (IRIN, 2009). Lack of infrastructure is killing these people. 92 percent of the people in Afghanistan do not have access to proper sanitation. This tops the state of the Worlds Toilets 2007 report as, the worst places in the world for sanitation (IRIN, 2007). The majority of the population accesses water from rivers, streams, lakes, and wells. With so many people accessing water from native sources and a minimal public health education presence, it is clear to see why these water sources are contaminated with human and animal waste. It is all too common for the rural nomadic Kuchi tribe to drink, bathe, use the bathroom, and water their herds up stream and a village down stream to do the same. This route of disease transmission can be curbed with a little education (Mark R. Wallace, 2002). Overcrowding, mass population movements, and a collapse of vaccination programs are the leading causes of the spread of respiratory tract infections in Afghanistan. Respiratory infections include tuberculosis, pneumonia, pertussis, and bronchitis. Recent data from Afghanistan have established lower respiratory tract infections as one of the leading causes of death in children less than five years old (Kenneth C. Hyams, 2005). Due to the lack of plumbing in rural areas, defecating on the open dirt is a common practice. The feces are left uncovered to bake and dry in the hot sun. After it is completely dried, the feces breaks down and particles are carried by the wind and breathed by the neighboring villages population. This practice contributes to the high rate of respiratory infections. The root of many of these problems stems from several complicated factors: lack of personal security, poor infrastructure, no public and extremely limited private transportation, poor education and an underwhelming number of skilled medical personnel. Examples of these factors from real day to day life are pockets of terrorists scattered through out the country, especially among the rural population, that inhibit travel even in an emergency situation. Second, there is one paved highway in the whole country,

Health in Afghanistan

appropriately named Highway 1. Beyond this, the majority of travel is done on unimproved dirt roads and dried out riverbeds; travel is very difficult and strenuous. Supposing you have a car or motorcycle, even if a hospital is relatively close, it takes a considerable amount of time to travel any distance in these circumstances. If not, which is generally the case, it becomes that much more difficult (John R. Acerra, 2009). Socioeconomic Determinants of Health Three major socioeconomic determinants of health stand out far above the rest. They are; place of residence, gender inequality, and education. Limiting these factors would improve the overall all health of Afghans, but infrastructure improvements would have to progress and improve at an equal rate for longterm improvement to be had. 42 percent of the population lives below the poverty line and another 20 percent are very close to the poverty line. Many people struggle to earn enough money to feed themselves and their families. With that, there is still a significant inequality between the rural nomadic tribes and the urban population. Nomadic tribes such as the Kuchi tribe generally live a good days journey or more by car from any clinic and even further from a hospital. Owning a car would be impossible on an income equal to $14 U.S. dollars per month. The journey by camel, donkey or by foot would take several days. For many of these people there is little to no access to health care. As previously mentioned, terrorists also poses a dangerous complication in getting to medical facilities. Gender inequality is one of the highest in the world, as the vast majority of women do not participate in paid economic activity. The Gender Development Index (GDI) is the second lowest out of all countries at 0.310. Females constitute about one half of the country but their status remains undermined in a male dominated society. Almost 2/3 of tuberculosis patients in Afghanistan are female, this reflects the poor living conditions and limited access to healthcare that Afghan women experience. There are nearly one million widows in the country. Because of the cultural constraints, moving is not a real option and access to work outside the home is limited. Unfortunately, these women suffer tremendously (John R. Acerra, 2009).

Health in Afghanistan Education is the final staggering determinant of health in Afghanistan. 28 percent of the population is literate. Similarly to the poverty rate, the literacy rate is much improved in urban areas than

rural areas. Among the rural Kuchi tribe there is an average of a six percent literacy rate (John R. Acerra, 2009). Limited schools, teachers, and educational materials inhibit the school system from true growth and improvement. Another major inequality exists in the school setting where there is a four to one ratio of boys to girls in secondary school. A direct reflection of the gender inequality previously addressed. Improvements are being made, but many statistics reported may not be as accurate or clearly portray the poor access Afghans have to healthcare facilities. According to recent reports, 57 percent of Afghans are with in an hours walk to a healthcare facility. In 2001 it was as low as nine percentThe drastic improvement is partially due to urbanization. The more revealing part of this number is that the report says a, healthcare facility, this can mean, a building with limited supplies, physicians, nurses, or no supplies at all or may be a building that does not even exist. If 57 percent of the population is one hour from a facility such as this, than 43 percent of the population has it even worse. Regrettably, Many reports coming out of Afghanistan may not be as accurate as one would hope. Access to Health Care and Health Inequality The struggles Afghans have in accessing medical care is due to a combination of insecurity, distance and high costs. In a land where health care is supposed to be free to the public many people and families are amassing medical bills paying for their medicine and doctors. This might seem strange, but the reality is, the free facilities are insufficient to meet the needs of the patients (Doctors With Out Boarders, 2014). Families are then forced to travel even further and incur debt in order for the sick family member to receive care that is most likely better, but still insufficient. In the United States 80 percent of Americans are with in 60 minutes or less of a hospital that has advanced cardiac intervention readily available (Brahmajee K. Nallamothu, Eric R. Bates, Yongfei Wang, Elizabeth H. Bradley, & Harlan M. Krumholz, 2006). There really is no fair standard with which to compare Afghanistan. As one of the least developed nations in the world the level of health is almost expected, but is not and should not be

Health in Afghanistan acceptable. With all the technology and wealth that exists in the world, sufficient interventions can be made to raise the overall health of the people of this country. Status of Child Health

Much like womens health, childrens health in Afghanistan is one of the worst in the world. Only one out of four children have a chance of surviving until their first birthday. Of those that survive past their first birthday one in four will die before there fifth birthday. Most of these deaths result from preventable disease and malnutrition (John R. Acerra, 2009). The death rate for children under five is 128 per 1000 (countdown to 2015: maternal, newborn, and child survival, 2013). All though these numbers are staggering things are improving. The death rate for children less than five was a startling 191 per 1000 back in 2002 (Kenneth C. Hyams, 2005). Control of Infectious Disease In Afghanistan, like various other countries, malaria continues to be one of the leading infectious diseases. Multiple factors contribute to the prevalence of malarial infection. Included in these factors is no vector control, poor shelter, over crowding, displaced persons, standing pools of water, and limited to no antimalarial medication (Mark R. Wallace, 2002). With the beginning of the War Against Terror commencing in Afghanistan in 2001, much more attention has been brought to the prevalence of malaria in that region of the world. With soldiers from all over the globe coming into Afghanistan to fight terror with malaria medication in tow, many of the villages surrounding these troops have been blessed with free supplies of Mefloquine and Primaquine, a common anti-malaria medication. Non-Communicable Diseases Non-communicable disease accounted for 46 percent of the total number of lives lost in 2011. The most prevalent NCDs are cardiovascular disease 30 percent, injuries 14 percent, mental health 14 percent, cancer nine percent, and respiratory disease five percent. These numbers are not out of the ordinary and need little to no explanation. The most interesting thing to note about NCDs in Afghanistan is that the population structure is changing and the demographic in the near future will now include a larger older population. 2.1 percent of the population is 65 and older and that number will climb to nearly

Health in Afghanistan three percent by 2025. Older populations are more likely to be affected by NCDs. The health burden

currently experienced from NCDs will only increase along with the aging population (Engelgau, Saharty, Kudesia, Rajan, Rosenhouse, & Okamoto, 2011). Nutrition There is limited research and reports in regards to specific diseases and ailments attributed to malnutrition in Afghanistan. Certainly all forms of disease from beriberi to vision problems exist, but to what degree and prevalence is uncertain. Nutrition services are limited at all levels and have only started to be addressed in recent years. Stunting, severe acute malnutrition, and micronutrient deficiencies are underestimated and receive much less focus than they should (UNICEF, 2011). Nutrition is both an immediate and an underlying cause of maternal and under five mortalities. 54 percent of Afghan preschool children are malnourished. 39 percent were underweight; and seven percent wasted (John R. Acerra, 2009). Afghanistan has one of the worlds highest rates of stunting in children under five at 60.5 percent (UNICEF, 2011). Although some locations and populations with in Afghanistan are not malnourished the existence of chronic diarrheal diseases due to unclean water sources, is depleting people of macro and micro nutrients needed to sustain life. Other factors contributing to the astonishing malnourishment problem are prolonged drought, long-standing effect of war on agriculture, large families with low income, poor nutrition education, and gender discrimination (John R. Acerra, 2009). Among these problems there is also limited land on which to grow crops, about 15 percent of the land in the country is suitable for farming. Much of that farmland is not used for crops but to grow poppies and marijuana, as Afghanistan is a major supplier in the international drug trade. The Afghan Ministry of Health is up and running and is armed with a vision and mission. In their comprehensive strategic plan, first on the list is to improve the nutritional status of the Afghan population. Current donors and partners of the Ministry of Health are: USAID - United States Agency of International Development, WB - World Bank, EC - European Commission, JICA - Japan International Cooperation Agency, GF - Global Fund, UNFPA - United Nations Population Fund, WHO - World Health Organization, UNICEF - United Nations International Children's Emergency, and CIDA- Canadian International Development Agency.

Health in Afghanistan Partnering with these agencies will prove a great advantage immediately and ensure greater success for the future. Sadly, Afghanistan is far from being self-sufficient. The country has received billions of

dollars in foreign aid, 100 billion and counting from the United States alone, and will not be able to carry out the vision, mission, and strategic plan without the help of international governmental foreign aid and that of NGOs. Conclusion and Recommendations

The Ministry of Public Health (MOPH) is critical to the mission of improving and sustaining the health of the Afghan people. Funding is and will continue to be a major concern their government faces. The MOPH needs to build credibility through public health programs taught and maintained by properly trained public health and medical personnel. Additionally the MOPH is responsible for overseeing and running several secondary and tertiary hospitals. Funding from the federal government, international funds, and NGO donations are of the utmost importance for these hospitals to remain open and provide low cost, good quality care, and reasonable access in the urban environment. NGOs and foreign aid appear to be the most critical resource that will sustain Afghanistans attempt to improve the overall health of its people. For example, Japan has recently committed 12 million dollars to help in the eradication of polio. If these generous donation sources dry up, Afghanistan stands no real chance for change. Relying on donations alone would prove unsustainable and not create a need for self-reliance and would cripple the nation even further. However, donations alone are not enough to cover all the needs in the country. Where the MOPH and funding from various sources previously mentioned fall short, contracting out services is a viable option to fill gaps in the health care system. Contracting will stimulate the economy, provide jobs and training and may inspire others to seek more education (Aneesa Arur, 2010). A final recommendation worth investigating is a subsidy program for the agriculture industry. Subsidies will stimulate the poor farming communities to continue farming, influence others to become farmers, and encourage poppy and marijuana farmers to stop growing drugs and start farming food crops. These subsidies can also help stimulate the incentive to cultivate new land. There is a great need to

Health in Afghanistan stimulate the agriculture community and grow and produce more crops from within the country and subsidies are a way to stimulate the industry. Afghanistan is one of the least developed nations in the world, despite three decades of war and political unrest progress is being made, albeit very slow, it is still progress. The past struggles have molded and shaped their culture and has given them a resolve to withstand difficult trying times. With this experience and new found resolve, the future will produce a healthier Afghanistan.

Health in Afghanistan 10 Bibliography Aneesa Arur, D. P. (2010). Contracting for health and curative care use in Afghanistan between 2004 and 2005. Oxfords Journal , 25 (2), 135-144. Brahmajee K. Nallamothu, M. M., Eric R. Bates, M., Yongfei Wang, M., Elizabeth H. Bradley, P., & Harlan M. Krumholz, M. S. (2006). Health Services and Outcomes Research. Circulation (113), 1189-1195. CIA. (2014 estimate). Central Intelligence Agency. Retrieved March 3, 2014, from The World Fact Book: https://www.cia.gov/library/publications/the-world-factbook/geos/af.html Countdown to 2015: maternal, newborn, and child survival. (2013, May). Countdown to 2015. Retrieved March 10, 2014, from Afghanistan Maternal and Child Health Data: http://www.countdown2015mnch.org/country-profiles/afghanistan Doctors With Out Boarders. (2014). Between Rhetoric And Reality: The On Going Struggle To Access Healthcare In Afghanistan. Brussels: Medecins Sans Frontieres. Engelgau, M. M., Saharty, S. E., Kudesia, P., Rajan, V., Rosenhouse, S., & Okamoto, K. (2011). Capitalizing on the demographic transition: tackling non communicable diseases in South Asia. washington D.C., U.S.A.: The World Bank. Evaluation, I. f. (2013, March). GBD Profile: Afghanistan. Retrieved March 17, 2014, from IHME, Global Burden of Disease country Profile: http://www.healthmetricsandevaluation.org/gbd/country-profiles IRIN. (2009). Humanitarian News and Analysis. Retrieved march 1, 2014, from AFGHANISTAN: Health Ministry reports cholera deaths: http://www.irinnews.org/printreport.aspx?reportid=86130 IRIN. (2007, march 5). Nouvelles et analyses humanitaires. Retrieved march 24, 2014, from Afghainstan: poor sanitation, bad toilets cause deaths, misery: http://www.irinnews.org/fr/report/77122/afghanistan-poor-sanitation-bad-toilets-cause-deathsmisery

Health in Afghanistan 11 John R. Acerra, K. I. (2009). Rebuilding the health care system in Afghanistan: an overview of primary care and emergency services. international Journal of Emergency Medicine , 2 (2), 77Kenneth C. Hyams, M. M. (2005, October). Endemic Infectious Diseases of Southwest Asia. Retrieved March 15, 2014, from Veterans Health Initiative: http://www.publichealth.va.gov/docs/vhi/infectious_diseases.pdf LeDuc Media. (2010). world life expectancy . Retrieved February 27, 2014, from World Health Rankings, Live Longer Live Better: http://www.worldlifeexpectancy.com/country-healthprofile/afghanistan Mark R. Wallace, B. R. (2002). Endemic Infectious Diseases of Afghanistan. Oxford Journals, 34 (5), 171-207. Organization, W. H. (2005). The Impact of Chronic Disease in Afghanistan. Retrieved march 18, 2014, from Facing the Facts: http://www.who.int/chp/chronic_disease_report/media/impact/afghanistan.pdf?u a=1 UNICEF. (2011). UNICEF.org Afghanistan. Retrieved march 25, 2014, from Health and Nutrition: http://www.unicef.org/afghanistan/health_nutrition_2179.htm 82.