V I T A L S T A T I S T I C S C O L L E C T I O N I N A F G H A N I S T A N (A PILOT STUDY) by Faizullah Kakar, PhD RESEARCH AND ADVISORY COUNCIL OF AFGHANISTAN supported by a grant from W.H.O. VITAL STATISTICS COLLECTION IN AFGHANISTAN RESEARCH AND ADVISORY COUNCIL OF AFGHANISTAN March 17, 1991 INTRODUCTION For planners and workers of public health and community medicine, information on prevailing health conditions in a community is of paramount importance. Without such information health projects cannot be properly planned nor can their effects be evaluated. In addition, vital statistics are valuable as a reflection of a variety of conditions in a community. Infant and child mortality statistics, for example, which are derived from vital statistics, reflect the level of nutrition of a population, its sanitation, and its economic and social development. In 1989 when I was assigned to head the Afghan Interim Government (AIG) Department of Preventive Medicineand I began planning preventive health services for over six million people residing in the liberated countryside of Afghanistan, the tremendous need for having vital statistics became apparent to me. Motivated by this need,I sought to propose a method of vital statistics collection in Afghanistan that would be culturally acceptable and simple enough to be duplicated everywhere in the country. Involving the mosque and mullah system in the collection of vital statistics seemed very logical and appropriate. Ninety -nine percent of the families in all parts of Afghanistan have a mullah who leads prayer five times a day and performs services for the family at times of births and deaths. The mullah, in addition to leading prayers, is called to attend funerals, to call adhan in the baby's ear at birth, to preside at weddings, and to perform other services. The mullah is the most trustworthy individual in the community and is also the most likely to be educated enough to read, write, and count. With these attributes we believed he could be trained and trusted to use simple forms to report vital health statistics. He would also fill the position better than a government official who may be suspected by the people of using the statistics against them. For example, it is well known that previously many families would hide their male children from the government in order to avoid the draft. 2 To pilot test a method of vital statistics collection involving the network of mosques and mullahs,a six month study was conducted under a W.H.O. grant (E17/180/2 AFG) at three sites in different provinces in Afghanistan between May and December 1990. This paper reports our findings. OBJECTIVES The specific objectives and their measures were: 1. To assess the feasibility of incorporating the mosque network to obtain vital statistics in Afghanistan. - -To be measured qualitatively by whether the mullahs showed a cooperative attitude in their ,relationship with the officers of the study, evidenced by taped interviews. - -To be measured quantitatively by whether the forms were properly filled out and promptly returned, and by whether the statistics appeared reasonably valid in light of statistics obtained in the refugee camps and by survey methods. 2. To obtain vital statistics including number of births and number of deaths as well as size of population base from a village with stable population in three different provinces. -- Actual birth rate, mortality rate, and cause -specific mortality rate were to be measured at each site and overall. METHODS A. Selection of sites In selecting sites for testing the feasibility of the proposed method of vital statistics collection, we spent a great deal of time searching for the right towns. The stability of the population size and a low emigration and immigration pattern were important considerations at each site. The towns originally selected in Nangarhar, Kunar, and Paktia Provinces did not pass our specified criteria and thus were disqualified. The main problem was the influx and outflux of Afghan refugees to and from Pakistan. The sites finally selected for the study were: 1. Chak in Wardak Province (See Map 1.) 2. Saroza (Sarhawza) in Paktika Province (See Map 2.) 3. GiruDeecy (Giru) in Ghazni Province (See Map 3.). 3 These towns were selected following lengthy interviews with commanders and mujahideen from these areas and after interview information was verified by our visiting team to the actual sites. (Demographic information about each site is given in the section on Results.) B. Selection of Mullahs In each town site there are senior mullahs called Moulavis who preach in the larger mosques. Each of these Moulavis have one or more smaller mosques under them which are manned by one of their students or other junior mullahs. We will separate them for discussion in this paper by referring to the senior mullahs as Moulavis and the junior mullahs as Mullahs with a capital letter. After the sites were selected, we negotiated with the local commanders for permission to approach all the mullahs at each site for the purpose of conducting the study. The P.I. explained the objectives of the study to the various commanders or their representatives in Peshawar. No commander refused permission. After obtaining permission from the commander, the local mujahideen administration helped us perpare a list of all the mullahs at each site and invite them to one of the town mosques where the RACA team explained the studyand its purpose and answered any questions the mullahshad. Again no mullah in any site refused to cooperate. Since never before in Afghan history had the mullahs been asked to undertake such a job, they consistently askedwhy were they selected for thisjob? Our team answered: "Mullahs were selected because we want the truestatistics about deaths and births. It is only on the basis of sound statistics that a nation can make sound judgements for the health of its people. We need the help of people such as you who are constantly calling people to be truthful." The number of Moulavis, Mullahs, and mosques ineach site were as follows: In Chak, Wardak No. Moulavis = 6 No. Mullahs = 16 No. Mosques = 22 In Saroza, Paktika No. Moulavis = 5 No. Mullahs = 6 No. Mosques = 11 4 In GiruDeecy, Ghazni No. Moulavis = 4 No. Mullahs = 9 No. Mosques = 13 For the purpose of this study thevital statistics unit within each site wasa group of mosques under one Moulavi. It was the Moulavi whowas responsible for recording the statistics and forwarding themon to us. Even though we expected cooperation from all theMullahs, too, by making the Moulavi the person responsiblefor the forms, we avoidedsome confusion which might be causedwhen some student Mullahs move from mosque to mosque under thesame Moulavi. The geographical location of eachstatistical unit within the site was usuallya well- defined area called a Kalay (agroup of related families). In a few locations, the boundaries interdigitated, but each Moulavi hada clear idea of which families were part of hismosque "catchment area" and could list the names of the households heserved. C. Compensation to the mullahs Each Moulavi received 500 Pakistanirupees /month and a set of the Holy Quran Tafseer (text, translation,and commentary). The Mullahs also received Tafseer but didnot receive the monthly honorarium. D. Determination of population size ofa statistical unit For the purpose of obtaining denominator datawe obtained copies of the household lists of the constituenciesof each of the mosques. These lists contain the name of the head of each family and the number in each household. The lists are kept and updated by the Moulavi for thepurpose of distributing sacrificial meat during Eid (religious holidays) and on other occasions. The lists are also utilized to plan community events such as weddings and estimate theexpenses. To double check these lists we utilized the help of the village dumm. A village dumm performs a variety of jobs such as shaving heads and beards, circumscision, informing people of wedding invitations, and finding cooking utensils for weddings. Most relevant to our study, the social status of the dumm, unlike other unrelated men, allows him toenter a household and the women folk do not cover their faces from him. For these reasons, the dumm has a great deal of information about the members of each household heserves and any vital event that may take place in his locality. 5 Because dumms were available at every site and were easily employable, we asked the dumms to count the number of families in each statistical unit and then specify the number in each household. Independent information from the dumm in three units at the Chak site agreed well with the mosque lists. In some cases the mosque list was found to somewhat underestimate the population, particularly in respect to newborns. For all our denominator data we used a combination of the mosque lists and the information provided by the dumms, sometimes the mullah and the dumm would work together and sometimes independently. E. Vital Statistics Collection At each site a local officer was hired to coordinate the local activities, to be responsible for the distribution and collection of vital statistics forms, to transfer payments to each Moulavi, to oversee the dumms' work and to report promptly to the Peshawar -based manager any problem in data collection. Initially the RACA team visiting the various sites provided the forms for the collection of mortality and birth statistics (see appendices) to the Moulavis. Subsequently the job of forms distribution was left to the local officers. Moulavis were requested to provide a form for each month, whether a vital event took place in their unit or not.