After reading this chapter, the nurse will be able to:
Describe differences between the national languages of Afghanistan.
Identify topics of conversation that may be considered private by Afghans.
Discuss situations in which variations of time are utilized by Afghans.
Describe how Afghan beliefs about health and illness and practices affect risk reduction.
Describe generational differences that may be observed among Afghans in the United States.
List several potential health risks associated with the Afghan refugee experience.
Overview of Afghanistan
Afghanistan, a poor, underdeveloped, and landlocked country of approximately 251,825 square miles, is slightly smaller than Texas. It is located in south-central Asia. Afghanistan is bordered by Iran on the west, Pakistan on the east and south, and Turkmenistan, Uzbekistan, and Tajikistan on the north; a narrow finger, the Vakhan (Wakhan) Corridor, extends in the northeast along Pakistan to the Xinjiang Uygur Autonomous Region of China ( ). Afghanistan is split east and west by the Hindu Kush mountain range that rises in the east to a height of 24,000 feet (7314 m). With the exception of the southwest, most of the country is covered by snow-capped mountains and traversed by deep valleys. It was invaded and colonized for millennia by the Persians, Alexander the Great, the Arabs, Genghis Khan, Tamerlane, and the Moguls of India, all of whom influenced language and religion and created an ethnically diverse population. The largest and most lasting impact on the region that includes the Middle East was the introduction of Islam in the seventh century. There is no census, and no one knows exactly how many people live in the largest cities—some estimates are the capital of Kabul (4,436,260), Kandahar (459,000), Herat (249,000), and Mazar-I-Sharif (183,000).
Modern Afghanistan emerged in 1921, but the last Afghan king was deposed in 1973. The invasion of Union of Soviet Socialist Republics (USSR) troops in 1979, intended to shore up the Communist faction of the government, precipitated one of the largest migrations of people in modern history. Afghanistan’s population was reduced from 15.5 million to 8 or 9 million people between 1979 and 1992. More than 1 million Afghans have been killed, and more than 80% of the population has had to move at least once to avoid war or conflict since the late 1970s. The country has been devastated by war and littered with more landmines and unexploded ordinance than there are people in the country. What the war did not destroy, 10 years of the worst drought in modern history devastated. In 2010, the population of Afghanistan was 28,395,716, with an average annual rate of natural increase of 2.58%. Ethnic groups in Afghanistan are Pashtun (42%), Tajik (27%), Uzbek (9%), Hazara (9%), and smaller groups, including Aimaks, Turkmen, and Baloch ( ).
For almost two decades, Afghans were the largest refugee population—at its peak, more than 6 million people—in the world. Of the 4 million refugees in October 2001, 2.3 million returned to Afghanistan. Although Afghans were coming to the United States for education well into the 1970s, the situation changed dramatically when the United States began processing refugee claims as it fought a proxy war against the USSR on Afghan soil. Between 1980 and 1988, when the USSR withdrew from Afghanistan, between 50,000 and 100,000 Afghan refugees came to the United States. Since 1989, most Afghans have been admitted to the United States under the family reunification classification (immigrants) rather than as refugees.
The first arrivals in the early 1980s were the urban, formerly wealthy, and highly educated elite, and later family reunification brought middle-class relatives who were less educated. The majority were from Kabul and other cities and came through Pakistan and India. Many families spent time in Europe, especially Germany, before coming to the United States. Relatively few people came directly from refugee camps. There is a small group of Afghans from rural areas who had little previous contact with Westerners; they maintain a traditional lifestyle and are illiterate in their own languages.
Although many Afghans in the United States talked about repatriating to Afghanistan, very few did so because of war, food and energy shortages, earthquakes, drought, and famine. Then, despite some peace that followed the takeover of most of the country by the fundamentalist Taliban, repression of women’s and human rights further discouraged people from returning. With the demise of the Taliban and a newly elected government in 2004, young Afghan Americans in particular are returning to help rebuild the country ( ). Those who have returned usually leave their families in the country where they resettled. Very few have returned permanently; most of those hold positions of power and are over 45 to 50 years of age. Younger Afghans, such as those from the San Francisco Bay Area, return to Afghanistan for short-term contracts, bringing with them vitally needed expertise and skills, but at a price. Most demand high expatriate salaries and prefer to live with other expatriates. They form a small but very tight community in Kabul because they are not really trusted by Afghans who never left the region and because they do not share the values or experiences of those who stayed behind. Many find it difficult to live with family members, preferring the international community or their own group of returnees. They return to Western countries for medical care and for a break from the harsh conditions of working in a war-torn country.
During the recent U.S. economic and unemployment crises, some Afghans have taken translator positions with the U.S. government in Afghanistan because of lucrative pay ($150,000 to $250,000 yearly salary if they are fluent and literate in the national languages, Dari and Pashto).
In Afghanistan, both men’s and women’s life expectancy is about 50.49 years. In the United States, they appear to be living at least a decade longer, but the population does not yet reflect national U.S. norms in longevity. Life span is shortened by stressors associated with migrating to a foreign land with no English language skills or expectations for the future. Elderly men tend to suffer from heart disease related to expectations of being breadwinners in the context of lack of jobs and lost status—for example, a CEO of a company in Afghanistan now working in a fast-food restaurant. Women tend to suffer from depression, dealt with by constantly visiting physicians to complain of physical symptoms based on psychological difficulties.
Life Today for Afghans in the United States
Afghans are one of the newer U.S. refugee populations, having fled a war that began in 1978 and has continued on and off to the present. Afghans have been mistakenly called Afghanis in the media; in actuality, the unit of money is the afghani. The term Afghan(s) is used as a noun, whereas Afghan (not plural) is used as an adjective.
Accurate estimation of the Afghan population in the United States is notoriously difficult ( ). The 2010 U.S. census listed 95,453 persons of Afghan descent residing in the United States ( ). This is likely an undercount because many Afghans reported their ethnicity to census takers rather than their national origin. In 2010, there was a concerted community effort to increase Afghan participation in the U.S. Census. Community estimates range from 30,000 to 60,000. The Afghan Coalition estimates that the largest population, in the San Francisco Bay Area, numbers 30,000 to 40,000 people, many of whom are second generation. There are eight mosques and many cultural organizations and Afghan-owned businesses.
The city of Fremont, California, in Alameda County, is known as “Little Kabul.” Many families live in large apartment complexes that are heavily Afghan. After the Fremont/Union City/Hayward area, the largest Afghan populations, in order of magnitude, are the New York City suburbs, especially Flushing and Queens; Los Angeles; and the Alexandria, Virginia/Washington, DC, area. However, Afghan programs on satellite TV have callers from all over the United States. Many who lived in Europe for a few years resettled on the East Coast. There are some variations in economics and ethnic clustering in different communities; for example, Afghans in Los Angeles are spread throughout the city and are wealthier overall than Afghans in the San Francisco Bay area.
Afghans are a young population, the median age being 29.8 years. There are far more younger- than older-generation Afghans and very few elderly in comparison to the number of children. Families are large, with an average of four children. Most of the 25- to 35-year-olds are the children of the many families that arrived in the United States with young children in the late 1970s or early 1980s ( ).
In 2011, the median household income of Afghans and Afghan Americans was $49,217 ( ). The largest group, including the formerly wealthy, has a middle-class income; very few are currently wealthy, and a significant number depend on public assistance. In 1994, community leaders estimated that 90% of San Francisco Bay Area Afghan families were supported by Aid to Families with Dependent Children. The percentage of people on public assistance in the Bay Area reportedly dropped to about 55% in 2006 because of welfare reform and the young adults who have graduated and moved into the job market. Current estimates are more than 50% among the immigrant/refugee adult generation and 25% in the second generation, most of whom are working or in school. The number of families using public assistance is lower in other areas of the country.
Occupational issues are most difficult for middle-aged men educated in Afghanistan. Although those from middle-class backgrounds have been more willing to accept entry-level jobs, well-educated professionals and former government officials are rarely able to obtain the kind of work they did in Afghanistan. They lack experience perceived as relevant and “connections,” face discrimination because of an accent or being Muslim, and are unfamiliar with job interview expectations and multiple-choice tests. Most physicians, for example, are unable to pass the licensure exam because of finances, English-language problems, or outdated medical training.
In Islam, education is more highly valued than wealth. However, war, poverty, and the recent fundamentalist emphasis on teaching only Islam have ruined the educational system of Afghanistan. In 2000, 43% of men could read and write but only 13% of the women were literate ( ). In the rural areas today, the literacy rate for women is below 2%. It is hard to find women who can write their names, much less read. Afghanistan also experienced a “brain drain” in which many of the best educated people fled to other countries.
In the 1980s, the refugees who fled from urban areas became one of the most highly educated refugee populations in the United States, with an average education level of 15 years among men and 14 years among women and a literacy rate of about 90%. Later refugees and immigrants had less education. However, there is an extremely wide range of educational levels, from no formal education among some women and many elderly to doctoral and professional preparation, especially among Afghan Americans.
Education is very important to the young generation, illustrated by their high enrollments in San Francisco Bay Area universities and community colleges, which have increased markedly over the past 3 to 5 years. During this time, even older men have entered college. However, the children of the first arrivals in the early 1980s, who then ranged in age from 3 to 15 years, have been unable to pursue higher education because they must work full time to help support their families. A number of young men with high school diplomas or less work in blue-collar jobs, running restaurants or car repair shops, because the older son or sons in the family are responsible for providing family income, even if they desire a college education. Afghan women are by far more college educated; the ratio of women to men earning their bachelor’s degrees or equivalent is 3 : 1. Women are also attending graduate school more than men are. They more often have the luxury of attending college because their income is not an essential source for the family ( ). The U.S. Bureau of the Census now has fairly reliable educational attainment data on Afghans. In fact, according to these data, 20.2% of Afghans have less than a high school diploma; 20.8% are high school graduates or its equivalent; 27.3% have some college or an associate’s degree; 21.9% have a bachelor’s degree; and 9.7% hold a graduate or a professional degree ( ).
When the value of real estate and demands for mortgages burgeoned in 2003, some younger men delayed college when they could make a six-figure income buying and selling homes or becoming mortgage brokers. The economic and real estate collapse beginning in 2007 devastated many families who regret that their children did not pursue their education.
The Afghan Coalition of Fremont has developed a number of programs to meet the needs of the Afghan population, especially the first generation. The first program, aimed to reduce elderly women’s isolation and depression, has been hugely successful (see the “ Mental Health Issues ” section). There are several children’s programs. Women’s programs include support groups, English, health education, and small business training to learn and market such handcrafts as jewelry and embroidered traditional clothing. The mental health program cooperates with local agencies, although first-generation men are reluctant to participate.
Afghanistan has two national languages: Dari, a dialect of Persian (50%), and Pashto (35%). Other languages are Turkmen and Uzbek (11%) and 30 minor languages (primarily Balochi and Pashai) (4%), and there is considerable bilingualism ( ). Both Dari and Pashto are derived from Persian and are part of the Indo-Iranian branch of the Indo-European language family, but they are mutually unintelligible. In the United States, most Afghans speak either Dari or Pashto with regional variations, or another local mother tongue, and many speak two or three other languages in addition to English, such as Urdu, Hindi, or German. Many educated Afghans also speak Russian.
Afghans tend to speak in stories rich in context, rather than providing brief answers to specific questions. Generally, people are reluctant to share personal and family issues with people other than family members, including health care professionals, but women may discuss their problems with friends, including non-Afghans. Men do not discuss their personal problems with others.
Afghan women tend to speak loudly. Westerners observing two women engaging in a conversation tend to interpret this as high-volume speech. Afghan women tend to be very affectionate and, in public settings, speak loudly to express their affection. In private settings, the mother’s voice symbolizes power and control of the children at home. Men, on the other hand, tend to speak in soft tones in private or public settings, which denotes being in control of the situation in a relaxed and comfortable manner. Showing aggression or speaking loudly means that men are losing control, and it is seen as disrespectful in public.
There may also be ethnic differences. Those who speak Pashto may sound like they are arguing when they are talking, but this is a style of speech that does not reflect emotional content. Dari speakers tend to speak softly and use polite tones and words, even when they feel strongly about a topic or issue. In some contexts, particularly when one wants to convey respect, silence may mean disagreement.
Afghans generally call elderly persons by respectful terms, such as uncle, aunt, or mother . Most people have several names: their legal name, which is rarely used, and a familiar name by which family and other Afghans will identify the person. Strangers are never given the legal or familiar name of an adult woman but refer to her by a title, such as Bibi or auntie . Because of the U.S. system of demanding the legal name on documents, this pattern is changing, and health care providers can call a woman by her legal name without causing insult. But Afghans value politeness, and an honorific or title should also be used.
Determinants of touch are family relationships and gender. Among extended family members and close friends, people often touch each other on the shoulder or leg when conversing. They greet with a kiss on each cheek, a hug, or both. However, couples do not show affection in public. Traditional men and women who are not related do not touch each other at all. They do not socialize or even remain in the same room. Unrelated men and women who are from urban backgrounds or who are more acculturated mix socially and may even greet each other with a kiss. Children and young adults raised in the United States use touch much like those in the dominant culture, although they may not do so at home in respect of their parents’ values. However, families strongly disapprove of dating and touch in public.
Greetings between people who are not family members or close friends may be a simple nod or a handshake, but a man should wait for a woman to extend her hand first. However, women often greet each other with a kiss on each cheek, alternating three times or more for special friends or family members. Young or older men may accompany a verbal greeting or farewell with placing the right hand over the heart, which is a sign of respect. This is common when men greet women who are not immediate family members. Men will greet other men with hugs and kisses but greet unrelated women without touch or eye contact.
Gestures in younger Afghan Americans tend to be similar to those in the dominant society, except when they are with their family or in Afghan social gatherings, where they use typical Afghan gestures and body language. In general, youth do not look elders directly in the eyes, but stand turned slightly to the side, with their heads slightly down to convey proper respect. A young person should not correct an elder, although this is changing in American society and can vary from family to family. When an elderly person or the head of a family enters the room, people show their respect by standing. People kiss the back of an elderly person’s hand as a sign of respect and acknowledgment of his or her wisdom, which comes with age ( ).
Sustained eye contact varies by acculturation and generation. More traditional unrelated men and women do not sustain eye contact nor do they “insult” someone they perceive to be of higher status by making direct eye contact. In general, health providers should avoid winking at or touching a person of the opposite gender. Winking is seen as flirting and should be avoided.
Implications for Nursing Care
An appropriate interpreter may be needed for patients who speak little or no English. A considerable number of Afghans who speak English may not read or write it; thus, it is important to check for English literacy before asking them to read forms or instructions. Ideally, the interpreter is trained, respected in the community, of the same gender as the patient, and around the same age or older. It is important to translate health education and training materials into both national languages, even though most Afghans read Dari. Be careful not to inadvertently be swept into a political faction, which can be based on language usage. People often insist that Pashto translations are unnecessary, but this plays into the politics of the country and sends a message of favoritism to the whole community. Also, it is important to use Dari or Pashto interpreters and written materials rather than using more available Farsi (Iranian Persian)–written materials (for mental health providers), despite the similarity of Dari and Farsi. The subtle differences in language usage are great enough to create major misunderstandings in treatment and follow-up. The differences between Dari and Farsi are analogous to those between Spanish and Portuguese.
conducted a study of the information needs of Afghan women that resulted in a detailed guide for service providers. She found that Afghan refugee women can more successfully adjust to their new country if they develop a trusting interpersonal relationship with one or more “point persons” as the primary source of information for all their needs, learn to speak English fluently, gain understanding of how they themselves can navigate the U.S. government and social service information systems, and practice asking questions of strangers in public and customer service so they can advocate for themselves and their families. Smith listed the areas of informational needs as family reunification; immigration, migration, and mobility; education and schooling; employment; health; mental health; transportation; human rights; and community information.
In Afghanistan, extended families live in large houses or compounds, and women socialize as they cook and do household chores together. Afghans in the United States miss the daily proximity of other family members. For example, despite having a four-bedroom house, the four teenage children in one family who has lived in the United States for many years often end up in their parents’ bedroom, sleeping on mats on the floor, because “we like to be together.”
As with other cultural characteristics, space varies with relationship, gender, and acculturation. Physical space between close friends and family engaged in conversation is closer than that between those of northern European heritage, often 1 to 1.5 feet. On the other hand, unrelated men and women who are more traditional keep more distance from each other, often socializing in separate rooms or separate areas of one room.
Spatial comfort depends on the activity and relationship of the people involved and on the setting, such as among all Afghans or with others present. Afghans are extremely modest people who are used to thick walls between rooms. In strictly private activities, such as using the toilet and having sexual relations, people may fear that other family members may “hear” such activities through the thin walls of the typical U.S. apartment or house; a couple may avoid sexual relations because a daughter’s or mother’s bedroom is next door.
Implications for Nursing Care
The topics of sexuality, birth control, and vaginal or breast examinations are considered very private and extremely embarrassing for women; older women may have minimal knowledge of how their bodies work. There is no formal education for these women in terms of sexuality, birth control, and the like. Women prefer to be seen by female gynecologists. If only a male is available, the woman’s husband will accompany her to appointments and stay in the room during the examination.
The situation is somewhat different among young adults and teens educated in the United States, although some parents forbid their middle school– and high school–aged children to take sex education classes.
Traditional women avoid being touched by male nurses or physicians. For example, one couple had been promised that their baby would be delivered by a female physician, but when they arrived at the hospital in advanced labor, only a male physician was available. As they were leaving the hospital, an enterprising nurse suggested that she deliver the baby, although by law, the physician had to be in the room; the couple remained for the birth. More acculturated men and women and Afghan Americans are willing to be cared for by nurses of the opposite gender, but they may not be comfortable with the situation.
It is uncommon to leave one’s children with babysitters because of language and custom. When children cannot accompany their parents to appointments, they stay with other family members who do not work. However, children usually accompany their parents to most health appointments and all social activities. Expect children and provide art materials or other diversions.
Numerous family members and friends gather at the bedside of a patient who is hospitalized and remain until asked to leave. Visiting a sick person is a very important value, and the room will seem crowded. If an Afghan is crying, it is important just to sit beside him or her, without touching or hugging or calling further attention to him or her.