Researching the topic of health in Afghanistan and the health of Afghans in the diaspora is a complicated enterprise, as is anything on the topic of Afghanistan. It becomes especially complicated due to the (at least) two dimensions which, in a certain sense, are in a relationship of tension: The dimension of the “objectively measurable” epidemiology and social epidemiology on the one hand, and the dimension of resources of the lifeworld, resiliencies, and health-related competences on the other hand.
With regard to the dimension of physical, objectively measurable signs, the strong relationship, dependence and influence between the health of the population and Afghanistan’s geography (e.g., the distance to the nearest hospital), agriculture (e.g., available resources of nutrition), economy (e.g., money for the offer and consumption of services regarding supply and health), and level of education (e.g., as the officially decisive determinant for health literacy) becomes especially obvious in Afghanistan. Furthermore, the ongoing civil war (since 1979!) and the concomitant armed conflicts are an especially decisive dimension of the population’s health. Many sources state that the number of death victims is currently at 1 million, but the data situation is convoluted.
There is better documentation of the time right after the drawback of the Soviet troops. Thomas Ruttig calculates a total of 200 316 victims. In other words: extensively independently from the health supply structure, it is hardly possible to detach an analysis of the topic of health from the military conflicts and invasions. Due to the current political situation and the decade long military conflicts including the secondary effects of forced migration, flight, return, as well as the topography of Afghanistan, the common health indicators of the World Health Organization and of the United Nations Developmental Program (cf. HDR 2018; retrieved on 1.2.2019) turn out quite bad.
According to the Human Development Report, the average life expectancy, which has officially increased continually since 2006, is at the age of 64 in 2018 (even in the contiguous Pakistan it is 2 years above, and in Iran, it is more than 10 years above). The rates of infant and child mortality have been among the five highest of the world for years (e.g., in 2015, the infant mortality was at an estimated 54,9 per 1000, as opposed to an estimated 8 per 1000 in Europe (WHO: Global Health Observatory; retrieved on 02.02.2019). Further, there are regional differences with regard to the situation of the provision of health care: Especially in the rural regions, the accessibility of health institutions as well as the availability of medical staff is heavily limited. Especially female doctors, female nurses, and female midwives are missing. Furthermore, the majority of healthcare services (78,38%) are paid by the population itself (and 54% of the Afghans live below the poverty line) or are co-financed by international sponsors through the large-scale projects BPHS and EPHS. Thus, it is majorly influenced by international geopolitical developments.
In summary, Afghanistan is regarded a clear problem case with regard to healthcare. However, the situation is a bit more complicated at second glance: First, substantial effort has been made in order to improve the health situation in all regions in Afghanistan, which has led to a substantial increase in medical staff and health institutions in the cities (by public as well as private providers). Second, the data published in the relevant reports are extremely vague. For instance, there is currently no saved data as to how many Afghans live in Afghanistan and it is hardly possible to estimate it in a reliable and sustainable way due to the high flight mobility. Thus, when data about the average life expectancy or sickness rates are presented, their validity is highly limited. Here, a medium-term set-up of regional or communal health statistics which are closer to the actual relations than data collections usually controlled and managed from Kabul would be reasonable.
And third, the picture of Afghanistan as a health problem case is at least incomplete because the familial or neighborly health care, the traditional healing procedures, and the present health competences are either ignored or devalued as deficient from the start through the lens of the Western healthcare. We do not wish to deny the real problems, but a picture of Afghanistan which makes do with a deficit-based inventory of Western criteria is anything but helpful. In this sense, we believe that the focus should be to pay more attention to the health competences (despite the illiteracy!) and the health-related everyday actions of Afghan families. In our view, this is crucial because most of the decisions and behavior patterns relevant for health are not made in the clinic or in the hospital, but in everyday life.
With our research, we would like to contribute to a broader understanding of behaviors, conceptions, attitudes and decision-making processes relevant for health. In short: to a theoretically and empirically comprehensive understanding of the health situation in Afghanistan. In addition to our interest in health in Afghanistan, we would also like to contribute to the (health) situation of people with Afghan origin who immigrated to Germany, which is hardly researched thus far. We would like to approach this topic by way of various research plans which are conducted within the scope of health literacy research financed by the Federal Ministry of Education and Research.
In Germany, our research interest does not focus exclusively on the long established and mostly well-integrated group of those Afghans who immigrated to Germany many years or decades ago, but it also considers the most recently immigrated people. In a three-year research plan, we accompanied young Afghans in their everyday life and conducted research on their resources, competences, behavior relevant for health (cf. the elaborations on the ELMi-project). In the following project, we considered the Afghans in their language courses and how these educational settings touched upon their resources, competences, etc. and how this contributes to the strengthening of health (you can find details on the SCURA-project here).