Professional nurses are taught to pay attention to details, but at the same time not lose sight of the big picture. The awareness of nursing shortages is often part of current reality experienced in many settings worldwide. As technology, science, social media, and world travel transform our world into an ever smaller global village, the awareness of life’s reality for persons initially deemed to be distant and unrelated becomes ever more crucial for global understanding at both a human and professional level. Responding to the health needs of a given population, in a given setting, and in a given country, is part of the detail that professional nurses recognize. Conscious efforts to understand how the inadequate health response to a humanitarian or health crisis in a faraway country may affect one’s own well-being indicate sensitivity to the big picture. Discover more of that world as you discover thirty countries most in need of professional nurses. If you find it challenging to locate any of these countries on a world map, you will note that the first occurrence of name of the country in the ranking provides a link. Clicking on it will take you to a Wikipedia site with additional information as well as a map with the country in the context of the continent on which it is found.
Countries are generally ordered from the greatest shortage to the least, i.e. the less severe the shortage, the higher the ranking number. Finding statistics for a common year is a challenge, as is the reporting for nurses independently of other health workers, so sources for statistics may vary in their numbers. Because less developed countries have less recent data available, in order for commonality in reporting time to be relevant, one needs to use statistics that are over 10 years old. Although those statistics in numbers may not reflect current reality, the trends are still valid. Countries reporting more than 23 health workers (doctors, midwives, and nurses) per 10,000 population are not listed. World Health Organization (WHO) considers that ratio is the minimal number required to provide 80% coverage of basic health needs. The absence of any country on the list does not imply that they have obtained a minimal coverage. As a point of comparison, even with nearly 100 nurses per 10,000 population, the United States continues to report a nursing shortage.
As one of the poorest countries in the world, Haiti is also one of the most in need of professional nurses. Statistically Haiti has barely one percent of the nurses per population that the United States does. With a long history of internal political instability, as well as outside intervention, a prime location for natural disasters, especially hurricanes and earthquakes, a high population density lacking public health provision, and a lack of local industry, Haiti has not been able to provide advanced education for most of its citizens. Infrastructure for basic utilities, including electricity, potable water, and sanitary waste disposal is not available to most of the population. Communicable diseases from both food and water contamination are common. Numerous international aid organizations are options for short term nurses, and easily found with an internet search. French language facility and openness to learning Creole, the trade language, provides options for teaching and education in both formal and informal settings, but poverty often blocks the door to improved health even with awareness of better options.
Although land-locked, Paraguay has the advantage of two major river systems that provide abundant water for energy, industry, and agriculture. Twelve years ago, Paraguay was only slightly less lacking in professional nurses than Haiti, but has the advantage of a growing economy and a very young population eager to become take advantage of educational opportunities. Although the most recent statistics are several years out of date, that number has now risen significantly. A dictatorship that lasted nearly 35 years that intentionally limited educational options ended 25 years ago. Health care provision has improved as more and more professional health care workers are required to do internships in areas that are lacking medical care. Paraguay has two official languages: Spanish and Guarani. The latter is spoken much more frequently than Spanish in rural areas, but basic health care and education can be provided in Spanish, although less effectively. Other ethnic groups, including German, Korean, Japanese, and indigenous groups local to Paraguay provide opportunity for international nurses who want to be able to speak at one language when they arrive. The flora and fauna of Paraguay make it a beautiful country for both short term and longer engagement. Populated with warm and friendly people, it is a good place to make a difference professionally.
For years Bolivia, right in the heart of South America, has sought to regain its former connection to the Pacific Coast as a way of ending its landlocked status. Despite the fact that it has a rich cultural and economic history, as the heart of the Inca Empire, its mineral wealth not has not changed the status of ordinary persons. Even more so than Paraguay, it has a rich indigenous population which continues to produce beautiful artisan works in a variety of media. Political instability and fraud, however have not allowed the country to progress in the provision of health care, and although the country has been declared free of illiteracy, health care does not match education. Life expectancy is limited as is health care. An internet search for information regarding nurses and nursing care in Bolivia results in half a dozen or more “volunteer openings” for nurses ready to travel to Bolivia. Statistically the number of nurses in Bolivia has actually decreased in the past decade. Perhaps this is why international aid organizations are seeking to find volunteer nurses to provide care that otherwise would not be provided.
Located in the so called horn of northeast Africa, Ethiopia has the highest population of any landlocked country in the world. It has the second highest population of all the countries in Africa. Both human history, with evidence of the earliest known presence of Homo sapiens, and a monarchical government dating back about 4000 years, make Ethiopia a treasure chest for history lovers. Unlike other African countries, Ethiopia was never conquered by any European powers and has maintained its status as an independent nation. Dozens of ethnic groups make it a multilingual nation with an equally rich variety of cultural and religious realities. Christians and Islamic religions have the highest percentages of adherents with a history of a large Jewish population which has now diminished with migration to Israel. Historically minority religions held to practices that raised concerns about human rights. Included were such practices as failing to properly bury disabled infants and marriage by abduction (bride kidnapping). The reported ratio of doctors per total population is extremely low even if one uses the highest reported number (2.6/100,000 population). Improper sanitation and contaminated water supplies make for a very high infant mortality rate, and high incidence of communicable disease. The nurse/population ratio is reportedly more critical than that of doctors with about 2.5/10,000 population reported in 2007. Geographical variations make for a varied climate which can be a small measure of comfort for international nurses looking to contribute to the well-being of others. Because English is the language of instruction in secondary schools, English is widely spoken and understood, and that fact also facilitates nurses being able to provide both nursing care and education for a better tomorrow for the persons and organizations they may serve.
5. Dominican Republic
Populated some eight centuries before Columbus landed there in 1492, the Dominican Republic is one of two island nations sharing an island with another country. Haiti makes up the other half of the island of Hispaniola. With about 10,000,000 inhabitants, ten percent of whom live in the capital city, the Dominican Republic is hard pressed to provide a very high standard of living. Services are the economy’s largest provider. Income varies greatly, ranging from extreme wealth to extreme poverty. Immigration to and from the country is constant. Geographically it is provides a marvelous variety of mountains, plains, and coastal areas, as well as a moderate tropical climate, and tourism flourishes; it is among the most visited countries in the Caribbean. In addition to being Christopher Columbus’ first stop in the Americas, it also has other “firsts” including fortresses, castles, and cathedrals. Politically it has been unstable, and has experienced intervention throughout the years from the United States. Mixed races make up the majority of the population, but none-the-less racism abounds and has been and continues to be an issue. Spanish is spoken throughout the country. Statistically HIV/AIDS is lower in the Dominican Republic than some of the other Caribbean countries, but is still a concern. Strict laws restricting abortions without exceptions of any sort may reflect an impact from Christian churches which claim participation of over 85% of the population. One national university offers degrees in allied health professions, including nursing. Statistically the number of nurses has increased in the past decade, but even the most recent statistics from World Health Organization report only a fraction of the minimal considered valid for basic health provision. As in other “poorer” countries, numerous aid organizations provide opportunities for long and short term nursing involvement.
From sea level in Haiti to the towering peaks of Mount Everest, the highest in the world, located in Nepal, this ranking will visit a host of countries. Countries with stable governments seem to be less challenged in providing health care. But even with a stable government, the needs in Nepal are enormous. It has been a kingdom for over two hundred years, but only been a republic in the past ten years. Geographically Nepal has roughly three areas described as mountains, hills, and plains, and due to elevation variations has tropical to temperate climate. Economically Nepal has resources in agriculture, services, and industry with the first two occupying about 85% of the economy. Industry suffers from the lack of skilled laborers, so poverty among those unskilled continues to be reality, although less so than ten years ago. The awesome landscape and rich cultural diversity in way largely unknown to westerners make it an inviting tourist location. Nepal has no known fossil fuels, so cattle dung provides about 8% of the fuel needs. Infrastructure is increasing, especially in communication with technological advances. Education is not readily an option, so that the overall literacy rate is still just over 60 percent. That number is not equally represented across genders as men are much more apt to be literate than women. Secondary, or high school, education has limited participation. Health provision has resulted in a decreased the mortality rate in children less than five years of age, although by international standards it is still very high. Indoor plumbing and potable water is not an option for over half of the population. Diseases due to lack of potable water are common, and often devastating for small children. Other diseases of poverty such as tuberculosis and leprosy are also common. The nurse/population ratio is one of the lowest considered here unless one includes midwives and other health care providers, but even so the ratio is barely 5/10,000.
In mid-2014 Liberia became one of the better known countries in western Africa, a fact that may be good news for truly conscientious and altruistic nurses. As one of the countries experiencing outbreaks of the Ebola virus, with English as the official language, it provides a unique opportunity to use the very best of universal precautions for the spread of disease, and theoretically be safe while caring for persons for whom death seems inevitable. Liberia has the unique history among African nations of being colonized by North Americans who were freed slaves and returning to their ancestral continent. Political instability began as recently as thirty years ago as successive civil wars killed hundreds of thousands of persons. Geographically, flat and rolling plains abound; the climate is hot and tropical. More than a third of the population is concentrated in and around the capital, Monrovia. About 85% of the population identifies as Christian with persons of Islamic faith forming the second highest grouping. Agriculture is the foundation of Liberia’s economy, but this was limited until recently; consequently Liberia is one of the poorest countries in the world. Just over 60% of the population is literate; education is not always free and is poorly regulated. There are several private and public universities. Health care is limited due especially to the destruction of nearly all health care facilities during civil wars. Life expectancy is limited; communicable diseases, including HIV/AIDS, are common. Food shortages contribute to malnutrition and decreased resistance to disease. Figures vary but some reports cite less than a tenth of the minimal required health workers. The challenges to health and a longer life are numerous. Fortunately, there are international aid organizations who are eager to recruit persons willing to provide long and short term engagement in the health and well-being of Liberians.
8. Costa Rica
Costa Rica is one of the most stable countries in Central America, or possibly even beyond there. A civil war about the time of World War II interrupted the stability, but since then it has been a firmly based democracy. Environmental issues are important for Costa Ricans. With coast lines on both the Caribbean as well as the Pacific Ocean, volcanic peaks that stretch over 12,000 ft. above sea level, and lakes and islands, it has justifiably become a tourist attraction with its beautiful flora and fauna in those settings. Temperatures range from low 60s F. to lower 80s F. Infrastructure is lacking for a robust economy, but ecotourism is a strong sector, as is coffee production. The population is racially diversified. Although Costa Rica does have an official religion, Catholic, there is freedom of religion, and other groups are represented. Literacy rate is among the highest in Latin America, almost 95%. Education is free and obligatory at the primary and secondary level. Both private and public universities provide higher education. Life expectancy is higher than that of the United States, and one region is known for its centenarians. Employed persons have guaranteed health care provision and the population is generally very healthy. “Medical tourism” is common because of the care provided, lower costs, and proximity to more developed countries. Statistically is it not clear why the ratio of nurses/population is still only a third of the minimal expectation.
Madagascar, once known as the Malagasy Republic, is an island nation off the east coast of Africa. Settled by settlers from Borneo some 500 years BCE, it was settled by many different peoples over time and so has a rich cultural heritage. It was not united as one kingdom until the early 1800s. Nearly a century later, French colonialism reigned for well over half a century. Madagascar did not become independent until 1960. Since then both constitutional elected leaders and interim military appointees have led the country; at least one experienced a military coup. Early in 2014 a reportedly fair election returned a constitutional government to power. Nearly all of Madagascar’s 22,000,000 people live on less than $(US) 2.00/day. While Christianity is identified as the religion of choice for about half of the population, there is a high degree of syncretism as well with traditional beliefs and practices still very common. Agriculture and ecotourism comprise the main components of the economy. Tropic forests, mountains, plains, and coastal regions make up the geography. Due to the varied geography and exposure to possible typhoons, the amount of rainfall and climate varies a great deal. As happens on other large islands, the flora and fauna of Madagascar are unique and attract large numbers of persons interested in exploring its unique ecology. Malagasy is the official language, there are numerous dialects and variations. The limited infrastructure is a challenge to expansion and development and limits advancement of health care and education. Health care is very limited, but has improved with the use of childhood immunizations; it is still inadequate. The ratio of nurses/population is similar to that of Costa Rica, but with a diverse population, and no central focus on health, many persons do not have basic healthcare provision.
Bordering a much more prosperous Costa Rica on the south, Nicaragua is without a doubt the poorest country in Central America. Although geographically a tropical country, Nicaragua’s exposure to both the Caribbean and Pacific Ocean, plus a widely varied physical geography including lakes and volcanoes, gives it diversity of climates as well. That of course leads to a biodiversity and makes it a welcome spot for tourists. Ethnically it is also diverse; even the name reflects the name of an early indigenous leader. Politically it has been more stable recently, but historically dictatorships supported by the United States left it struggling for many years. A major earthquake in 1972 destroyed most of the capital city, but funds intended for reconstruction were appropriated by the dictator, so development was further delayed. More recently, as indicated above, tourism became an important commodity. Spanish is spoken throughout Nicaragua with regional accents and particularities. With no official religion, and a long experience of outside intervention, Nicaragua has a variety of religious expression. Although the population of nearly 6,000,000 persons is racially mixed (it includes nearly 10% of African descent, and even more of European descent), Nicaragua does not have a history of racial conflict. Higher education is focused in the capital city, Managua, but literacy campaigns throughout the country following the overthrow of the dictatorship (when Nicaragua’s educational system was among the most poor in Latin America) have been highly successful. Health care, or better said, the lack of health care continues to be a concern. Communicable diseases are on the rise, although immunization for childhood diseases is adequate. Maternal and perinatal deaths are too high, and the disparity of health care provision is a major concern for those responding. As recently as the year 2000 the number of nurses was less than one seventh of the minimal WHO requirement. Aid organizations are present in Nicaragua and provide opportunities for nurses who want to respond to these needs.
Tanzania in eastern Africa faces the Indian Ocean. Together with the island of Zanzibar off the east coast of Africa, form the United Republic of Tanzania, their official name. Mount Kilimanjaro, Africa’s highest mountain, is located in Tanzania, and although geographically in the tropics, it is always snow-covered. Humans settled in the region about 10,000 years ago. A prototype of blast furnace capable of producing temperatures over 3000 degrees F. allowed for the production of carbon steel over 1500 years ago. European countries, including Portugal, Germany, and Britain, ruled the region since the early 1600s; Tanzania gained its independence from Britain in 1960. The first multiple party elections were held in 1995. Economically Tanzania is a poor country on par with its neighbors, and bases its economy on agriculture. To a lesser degree industry, tourism, and mining also contribute. Infrastructure is still very limited; one of five Tanzanians had access to electricity as recently as 2008. Geographically there is a great diversity with high mountains, waterfalls, plains, and sea coast; protected areas, as national parks, are a positive initiative. Although the population is about 45,000,000 nearly one half of those persons are under 15 years of age; one percent or less are of non-African descent. Over half of Tanzanians profess to be Christians, and about one third say they are Islamic in their faith. Linguistically Tanzania is very diverse with over 100 languages represented, but communication is facilitated as both English and Swahili are official languages. Primary education is obligatory and about three fourths of Tanzanians are literate. The availability of potable water is limited to about half of the population, and even less have sanitary waste disposal. Communicable diseases, including HIV/AIDS are still too common. Health care workers, including nurses, are very much in short supply, and so opportunities for international nurses are readily available.
12. Sierra Leone
Along with several other West African countries with a coast line on the Atlantic Ocean, Sierra Leone suffers from an acute shortage of nurses. The nurse/population ratio has decreased in recent years and is currently less than one eighth of the minimal suggested by the World Health Organization. As English is the official language, and the language of instruction, one may assume that as in other English speaking developing countries, nurses are being recruited for jobs in the western English speaking countries. While possibly boosting the local economy by sending home dollars earned abroad, those absentee recruited nurses lead to the decimation of local health care provision. Historically Sierra Leone has a very good record for religious tolerance and has not experienced the conflicts that other nations have with a mixture of Islamic and Christian adherents, even though Christianity is in the minority. Mining is an important part of the economy, but the wealth generated by diamonds and other minerals is not distributed throughout the population; consequently about 70% of the population of 6,000,000 lives in poverty. Britain made Sierra Leone one of its colonies in mid 1700s, but did not grant independence until about 1961. Political unrest and a civil war further impeded development. Sierra Leone has high mountains, plains, and low land with coastal regions. The climate is tropical. Although education is obligatory at the primary level, the lack of infrastructure makes enforcement very difficult. During the civil war large numbers of schools were destroyed. There are three universities in Sierra Leone. As might be expected from the severe nursing shortage, infant mortality is among the highest in the world. Communicable diseases abound, including HIV/AIDS and the Ebola virus. Potable water is limited. Sierra Leone is without a doubt a place where professional nurses can make a difference.
Guatemala, a name based in one of the original indigenous languages, is the closest Central American country to the United States. It is also the most populous country with about 14,000,000 inhabitants, and has about one nurse for every 1200 persons, i.e., less than a third of the minimal considered adequate. Civil wars, intervention from the United States, dictatorships, and other conflicts made Guatemala unstable for many years. More recently it has successfully elected governments and is more stable. However, the economic growth is still limited, especially because of the rugged terrain throughout much of the country. Even though large scale farming is not possible, sustainable farming is and does contribute to the economy. Wealth is very unequally divided. Earthquakes and hurricanes have also devastated the country several times. But the ecological diversity also leads to tourism as does the ethnic and cultural richness present in Guatemala. Nearly half of the population is of Mayan descent, and although Spanish is the official languages there are numerous other languages spoken throughout the country. In fact, there are areas where Spanish is not spoken at all; there are 21 languages used which have their roots in the Mayan language. Education is free, but supplies are not, so that although students may go to school they may not necessarily have the basic paper and writing materials they need. For a number of reasons, basic health provision is very challenged, and the infant mortality rate is among the highest throughout Latin America. Non-western medicine continues to be in conflict at times with more modern practices. Persons who can be cultural brokers, and sensitive to alternate health provision could help improve the health generally, and particularly among the very young.
Although located very close to the equator, Rwanda is very mountainous, with some savannahs, so the climate tends to be temperate. In size, it compares to Haiti. Historically, the first known inhabitants lived there as hunters and gathers during the stone and iron age. Surrounded by several much larger and established countries, Rwanda’s population is mainly rural and also young, numbering about 11,500,000. A few years ago Rwanda was in the news because of horrific genocide taking place there, even though the majority of the population is Christian. The number of persons killed then is not clear, but some estimates are as high as 1,000,000 persons. The cause of those conflicts is still debated with ethnic origin being the most often considered cause. Naturally the massive genocide affected all aspects of life in Rwanda, including the economy, which is largely based on agriculture. Tourism is on the rise with mountain gorillas being a prime attraction. Even though the economy is not booming, the elected government has made potable water a priority. The provision of safe water contributes incredibly to the well-being of persons, and especially to infants and children. Education is a priority and school attendance until the 9th grade is compulsory. However as in other poorer countries the lack of means with which to purchase supplies or school uniforms limits participation. There is provision for higher education, and English is the language of instruction. Childhood diseases and infant deaths are common. With a national health insurance covering 90% of the population, and increased spending for health, there is a marked decrease in the infant mortality. Nurse/population ratios have improved in the past ten years, but continue at only about one fourth of the minimal number suggested by the World Health Organization. Naturally there are numerous opportunities for English speaking nurses.
15. Central African Republic
The Central African Republic is located in the heart of Africa, far from any oceans. With a population of about 4,500,000 it is less densely populated than some of the other surrounding countries. Although inhabited for thousands of years, it was ruled as a French colony from the mid-1800s until 1960. In spite of abundant mineral wealth, including diamonds, gold, and uranium, as well as renewable resources in tillable land and hydroelectric power, the Central African Republic is among the 10 poorest countries in the world. Although now independent for over 50 years, the Central African Republic continues to be very unstable politically. Numerous governments have been overthrown violently; war and hostilities between parties and ethnic groups have been frequent. Geographically the land is either flat or rolling and parts are covered with forest. Both a dry and a rainy season provide seasonal variation, but generally the climate is tropical. Over 80% of the population identifies as Christian and there are numerous missions working in Central African Republic which may provide opportunities for nurses who have a working knowledge of French. As in other poor countries, the infrastructure does not readily permit communication or access throughout the country. Although education is officially required for elementary school age children, the illiteracy rate is about 50%. Health provision is very limited; and the ratio of nurses/population has actually decreased in the past ten years. The most recent figures report about 2 nurses/10,000 population, but only 1 doctor/20,000 population. If one is able to confront the reality of conflict and also face the dire need in any one country, Central African Republic is one such place to make a difference.
Located precisely on the equator, Ecuador, literally “equator”, is the most western country in South America. As a democratic republic it has an unusually complex political history with numerous other countries claiming portions of what was once Ecuador until well into the 20th century. Internally there was a seven year period military takeover in the 1970s. Indigenous persons make up about 25% of the population. Human rights violations for failure to provide freedom of expression has been noted by United Nations. Ecuador also includes the famous Galapagos Islands, which are noteworthy because of the unique species found there. In 2008 Ecuador became the first nation in the world to recognize the ecological rights, in part to protect the rich biodiversity found on the Galapagos Islands. Ecuador’s history is also rich and diverse; although the Incan culture and history is marvelously preserved, people who migrated from other regions in the Americas lived there prior to the Incas. Geographically Ecuador has the high Andes Mountains, coastal regions, and Amazonian plains. The geographic variation also leads to a marked variation in climate. A rising economy has lessened extreme poverty; currently oil is one of Ecuador’s main resources, along with agricultural products. The potential for industry because of hydroelectric power options is still not exploited. Christianity is the predominant religion, although it is almost entirely made up of Catholic adherents. The provision of adequate preventative and curative health care has been a successful priority in the past decade and a half, and is available for all persons. The nurse/population ration has improved dramatically during this time, from less than 5/10,000 in about 1998 to 18/10,000 in 2008. Education has not kept up with health and although it is formally required up to about the ninth grade level, supplies and transportation costs still limit access for the majority of the population; very few students continue through high school, and even less attend at the university level.
As the largest country in Latin America, and the fifth largest in the world, with a population of over 200,000,000 Brazil is perhaps best known for its amazing soccer (football) players. But long before soccer players ruled, large and autonomous indigenous tribes also populated what is now Brazil. Portugal laid claim to Brazil for over 300 years, before independence was granted in the mid-1800s. Portuguese is the official language for all purposes of government, education, and trade, but there are believed to be over 65 tribal groups still not contacted, and nearly half of the population self-identifies as being of mixed race. Because of its enormous size, Brazil is incredibly diverse as well in climate, geography, economy, tourism, and the provision of infrastructure. Some regions of the country are very modern, and huge cities sprawl over large areas of land, others have barely changed in the past century. Well over two thirds of the population lives in urban areas. Science and technology seem in many ways to have made Brazil a highly developed nation, but a number of factors, including political instability, have limited Brazil’s advance. There is a government directed public health system, but infant and maternal mortality continues to be an issue. The nurse/population ratio has not improved significantly in the past decade and still hovers at approximately one fourth of the minimal WHO suggested ratio. The efforts to make nursing a higher priority and more professional have met numerous challenges, including governmental resistance. Because of the high concentration of urban dwellers, rural areas are often not a priority either in education or health provision. By law regions, and states, are responsible for education, and so highly developed urban areas report a literacy rate of about 90%, while rural and impoverished areas indicate less than 20% are literate.
18. Democratic Republic of the Congo
Perhaps none of the countries with a marked shortage of professional nurses better exemplifies the paradox of wealth and resources on the one hand, with ongoing need and failure to provide even fundamental needs of its population on the other, than the Democratic Republic of the Congo. Located in the heart of the African continent, and one of the most wealthy countries in the world in regard to natural resources, the DRC’s history of being exploited by external powers, and then in turn being exploited by its own people, seems somehow closely related to its going tragedies. Wars within the country, displaced persons, lack of infrastructure and extreme poverty have taken the lives of nearly 5.5 million persons in the past 15 years. One index, ranking countries on human development, places it next to last out of 187 countries. It has been administered by external powers, including Belgium; forced exploitation of natural resources by locals decimated the population, killing millions early in the 20th century. Local government politics and policies, along with greed and lack of leadership led to numerous name changes of both the country itself and major cities. Straddling the equator, much of the DRC has a tropic climate with jungles, and plains, but it also has high glacier topped mountains. The economy has not boomed despite incredible natural resources, including mineral and natural navigable waterways, probably due to corruption and greed of those in power. Education is neither free nor obligatory. Disparity between the literacy rates of men and women is also demonstrated in the claim by a United Nations committee that women are exploited and do not have basic rights. Health provision is extremely deficient; the DRC has the second highest worldwide infant mortality. Nurse/population ration was reported to be about 5/10,000 at the turn of the century; more recent figures show a significant decrease, probably less than one fifth of the minimal WHO suggestion.
Located on the northwest “corner” of South America, adjacent to Panama in Central America, Colombia has a rich and also tragic history. Conquest of the local population by Spanish explorers began in the last year of the fifteenth century. Spain continued to rule for over three centuries. Colombia as a country was not free and independent until the end of the 19th century. For nearly 40 years a low intensity internal conflict between the army and guerrilla forces, often considered to be related to illicit drug production, hampered growth and the well-being of Colombia’s population. Colombia is marvelously diverse in many ways which can, and do contribute to a growing economy as internal conflict lessens, and political stability improves. Goods and services, agriculture and mining do their part in stability as well. Geographically Colombia is at the northern edge of the Andes Mountains, but it also has plains and steaming jungles. Climate varies with altitude and provides for a rich biodiversity in both flora and fauna. Although nearly 100% of Colombians speak Spanish, there are over 101 languages recognized within the country including 65 Amerindian languages. Religiously Colombia recognized Catholicism as its official language for many years, but since 1991 officially there is freedom of religion. Education is a high priority at all levels; literacy rate is over 98%. Preschool through university is also included, and total spending is over 15% of the gross national product. Health provision is also a priority, and life expectancy reached 79 in 2012. This is amazing given that in 2000 the nurse/population ration was a meager 5.5/10,000. The most recent figures show a slight increase to 6.6/10,000. Because of the quality of health care and proximity to higher priced countries, health tourism also attracts business, as do tropical beaches on San Andres, an island part of Colombia, pictured above.
Argentina, which forms half of the southern “cone” of South America, is easily “discovered” geographically. With a rich and diverse population, on a larger than first appears land mass, (the eight largest country in the world), Argentina has more roots in Europe than many Latin American countries. However, military takeovers and repeated bouts of run-away inflation have also limited growth and unity in the last century. Argentina prospered greatly following its independence from Spain. Following the end of internal wars in the mid-1800s, liberal economic policies encouraged investment and engagement from Europe. Then military coups, with resultant human rights violations and strict controls pushed the country backwards again economically. Only in the past two decades has Argentina once again become strong economically and been able to respond to internal needs for infrastructure, health, and education. With an incredible variety of geographic features, not to mention multiple climate zones, Argentina has options that few smaller countries enjoy. Agricultural and mineral resources, plus growing industrial strength provide the means for education and a highly literate population with science and technology thriving as well. Education is available at all levels, including the university level which has a large number of public options and is entirely in Spanish, although there are still indigenous groups using their own languages. About three-fourths of the population self-identifies as Catholic, other religions preferences include protestants, and agnostics. The current Pope is from Argentina, a fact not lost to his followers there. Health care is both private and public and has reduced infant mortality rates very significantly in the past half century. The most recent figures, from a decade ago, report a nurse/population ratio of about half of what it was when growth was not happening. Migration to more developed countries offering higher salaries is often cited as one of the principle causes of the nursing shortage, and Argentina is not exempt from that reality.
21. Ivory Coast
Although relatively small compared to the larger nations in Africa, Ivory Coast has a population of over 20 million inhabitants. It is located on the southern coast of the “hump” extending toward the west. Sometimes known by its French name of Côte d’Ivoire (it was a French protectorate or colony for nearly 80 years until 1960), Ivory Coast is populated by several ethnic groups, the largest of which comprises nearly half of the population. Political instability followed independence, and unified leadership was not clearly defined until early this century. Politically power continues to reside primarily in the executive branch with French as a language that unifies the multiple language groups represented. During the time of the Roman Empire trading of precious metals and slaves was common. Islamic influence and domination followed this period. Because Ivory Coast lacked the harbors of some of its African neighbors, slave trade was less common there. Geographically, Ivory Coast is sub-Saharan, and has a better per capita income than most of its neighbors. Income is based largely on agricultural production, especially cocoa beans and rubber. Religiously Islam and Christianity and indigenous religions are about equally divided in the number of adherents. Illiteracy is high, and even more so among women as boys are much more apt to be schooled. With a multimillion population, there are only two universities in Ivory Coast. A decade ago life expectancy for both men and women was less than 50 years. The Infant mortality is also very high. Physicians number about one tenths of the number of nurses. The ratio of 6/10,000 has increased slightly in the past years, although the actual number has decreased, again probably due to migration for improved financial benefits in more developed countries.
Located on the western side of the southern cone of South America, because it is so long and narrow Chile has the benefit of nearly all climate zones. In addition, it also has deep natural harbors which facilitate international trade, and because it is six months ahead, or behind, of the northern hemisphere, Chile can provide “in season” produce when it is least available and most expensive in the north. Unfortunately, because the Andes Mountains occupy a large portion of the land mass in Chile, the arable land is not extensive, and the country is also prone to earthquakes. The northern desert region is one of the driest places in the world and because of its altitude is a marvelous place for space exploration via land based instruments (see accompanying photograph). The region is also rich in mineral wealth, and became known with the rescue of 33 trapped miners several years ago. Dominated by Spain for over two centuries, Chile became independent in early in the 1800s and was quite stable until political unrest, which lasted about 30 years from about 1960 until 1990, but since then has been stable and prosperous. The varied geography, flora and fauna, topography, including long coastlines and incredible mountains, make Chile a marvelous place for tourists. With a population of about 15 million persons, and Spanish as an official language, with influence from different indigenous groups, Chile has prospered internally by making infrastructure a priority for its citizens. Education is valued and is an option for all ages. There are both private and public universities available for students who seek a higher education. As recently as a decade and a half ago, the nurse/population ration was a mere one fourth of the WHO recommendation; more current figures are not available. Public health is a priority and is funded via payroll deduction of 7%.
Bordering Chile to the south, Peru shares some of the vast desert as well as the powerful Andes Mountains. But even more than Chile, Peru was home to a marvelously preserved pre-Colombian culture and people. Although some of the most visited sites, like Machu Picchu was only discovered about a century ago, most of the sites were known and pillaged by early Spanish explorers. Despite the greed and “gold fever” which resulted in the deaths and practical termination of the Incas and their culture, there are still large numbers of artifacts and architecture that speak to the grandeur of the Incas. Following independence from Spain, Peru enjoyed moments of prosperity and growth, but for many years, especially in the late 20th century, internal conflict and authoritarian governments stifled growth and prosperity. Unlike Chile, Peru has large land areas with tropical climate on the eastern side of the Andes in addition to mineral wealth, and sea food products, so exports are an important part of the economy. Although recently Peru has had one of the fastest growing economies on a world wide scale, but poverty continues to be a harsh reality. There are large numbers of indigenous people in Peru with many different ethnic groups represented; Quechua speakers make up not quite 15% of the population. The total population is almost 30,000,000 inhabitants. About 80% of the population identifies as Catholic; Protestants make up about 12%. Figures on health are hard to come by, the most recent figures show an improvement but the ratio of nurses/population is still only a fraction of the WHO recommendation.
Uganda borders on several of the countries noted earlier in this ranking. Located close to the center of Africa, it has the natural beauty of other countries in the region. Its history is as old as its geography with people living in the area as hunters and gathers millenniums ago. As some of its neighbors it was also ruled as a British colony from the middle 1800s until the early 1960s. One legacy of colonial rule is the official use of English, although Swahili is also an official language. Severe political unrest was followed with military coups to place persons in power and attempts were made to maintain power through massive genocide. Idi Amin was one of the most infamous among those despots who ruled for about eight years and was responsible for the deaths of hundreds of thousands of Ugandans. Political discord continues, and there is wide spread corruption. In an effort to maintain power both internal and external investment is very controlled. High land plateaus dominate the geography with an average altitude of over 3000 ft. elevation. Natural beauty abounds, but severe human rights violations and rigid controls limit tourism and interest from abroad. Internally torture and rigid laws, for example, about homosexuality, have further curtailed Uganda’s appeal. Although the economy, based on agriculture and other exports, seems to be improving, poverty has not decreased, and is a grim reality for millions. Only one of three Ugandans are literate even though in theory education is obligatory and attempts to follow a British standard. Costs that must be absorbed by parents make education a luxury for many. Life expectancy is just over 50 years; infant mortality rate is high. About the only public health concern showing improvement is the HIV/AIDS infection rate which has dropped significantly in the past three decades. Health care is still not an option for many rural Ugandans, and the nurse/population ration is less than a third of the WHO minimal suggestion.
Generally this ranking has provided information on countries found among those most lacking professional nurses. However there are several countries where the realities may be less harsh in the ratio of nurse/population, Jamaica is one such country. Located in the Caribbean Sea southeast of Florida, and south of Cuba, strangely enough Jamaica was once a British colony also. Britain maintained it as a colony for over three hundred years until granting independence in 1962, However, because of the legacy of the English language, Jamaica too has lost a significant number of nurses (nearly one third from 2003-2008) to more developed and higher paying countries who recruit its English speaking nurses. Nearly three million people populate this island nation slightly smaller than the state of Connecticut. Jamaica did not experience the political upheavals that other former British Colony nations experienced. That stability has contributed to its well-being and a nurse/population ratio that is more than double that of other countries with a history of British rule. With a tropical climate and abundant rainfall, Jamaica has beautiful scenery and a wealth natural flora and fauna both on land and in the surrounding ocean, including water falls as noted in the photo above. Black Jamaicans make up about 90% of the population. Although Jamaica has not experienced political unrest, the crime and violence rate is very high, especially in the capital city, Kingston. The economy has both private and government sectors and exports provide most of the power to the economy by way of agriculture, mining, and industry. The majority of Jamaicans self-identify as Protestant in religion, although ethnic religions also have their adherents. Education is free through secondary (high school) level, and there are numerous universities for those who can afford them.
Located in central Africa, Zambia is one of the more stable countries in the region, and several years ago was named as one of the fastest growing economically. Although inhabited and settled for centuries, from the mid-1800s it was under British control until its independence in 1964 when it ceased to be Northern Rhodesia and became Zambia. Geographically Zambia has mountains and high plateaus as well as plains and broad river valleys. Generally the climate is tropical, although because of altitude variations, this is also varied. Nearly half of Zambia’s 14 million plus inhabitants live in urban areas. Employment opportunities are limited and create their own challenges. Although English is the official language, there are over 70 different ethnic groups, as well as Europeans, and Asians. Refugees from unstable and strife ridden neighbors also add to the multicultural mix and create linguistic challenges for communication and economic growth. There are a variety of expressions of Christianity; according to the 1996 constitution Zambia is a Christian nation. There are other religious traditions as well but they make up only about two percent of the population. Zambia has struggled economically during its history, but recently has improved and exports (including hydroelectric power, mining, mineral, and especially agricultural products) are a major source of income. Based on the British system, educational efforts (with free education through primary school) have achieved an 80% literacy rate. Higher education, via universities and technical schools, are an option for those who can afford it. Unfortunately, health provision has not been a priority and life expectancy is just over 50 years. There are numerous hospitals, including at least one teaching hospital; at one point the nurse/population ratio came closer to the minimal suggestion of any countries considered in this ranking, but tragically, for Zambians, the most recent number reported by WHO (2010) was less than half of what it was only five years before: about 7/10,000. Undoubtedly that decrease is due to recruitment from more developed English speaking countries.
Persons who knew Asian countries about 50 years ago remember Bangladesh as a country with incredible human suffering. Bordering India on its west, Bangladesh was formed as a separate country from India in 1947. Political unrest, and military coups lead to breakdown of basic services and famine and poverty become wide spread. Since becoming a democracy in the early 1990’s, it has stabilized, although as one of the most densely populated countries in the world it still faces major challenges. Geographically it has large deltas loaded with very fertile soil following flooding of the rivers and higher plains. By blocking silt so that it is deposited instead of washed to the sea, new land is being formed. The climate is tropical and winters are not severe, but its location makes it vulnerable to cyclones and other storms. With a growing economy based on exports of clothing and textiles, as well as sea food, agricultural products, and science and technology, Bangladesh has greater hope for the future than just a few years ago. English is used as a secondary language, but most of the population speaks Bengali. Muslims make up over 90% of the population, Hinduism, and Buddhism, have much fewer adherents, and less than one percent of the population is Christian. Education is funded largely by the government; nearly 40 of the population is illiterate. Health care provision is a low priority, and reportedly large numbers of persons trained as medical providers actually know very little about health care. The state of health of many Bengals is precarious, in a large part due to the minimal attention paid to the provision of health care generally. The nurse/population ratio continues very low and is far from the minimal requirement as per WHO. Supportive care, as provided by community health workers, see photo above, and nurses are very much in short supply.
Tucked between China and India, Bhutan has less than three-fourth of a million inhabitants. Early 1600s its identity as a unified nation became a reality. According to some indicators it is the happiest nation in Asia. Although not a part of the British empire, it was influenced by India, and less than ten years ago became a constitutional monarchy. Bordering on the Himalayas, it has peaks that are well over 20,000 feet in attitude, but also has subtropical climate. Much of the country is mountainous with steep inclines, but there are large areas that are forested and filled with wildlife. Other areas are flatter and provide soil that is appropriate for agricultural production. Agricultural produce is a major source of income for the economy, as is hydroelectric power. Conservation of natural resources is a challenge, but there are movements that seek to maintain the abundance of resources naturally present. As a nation, Bhutan is primarily Buddhist in religion; there are persons who identify as Hindus as well. Less than twenty years ago major ethnic strife resulted in large numbers of persons being forced to leave, and that has continued. At one point over 100,000 refugees were living in camps; many refugees were later settled in western countries. Bhutan has only one international airport, and has very limited infrastructure, with no rails and few developed highways due in part to the very rugged terrain. Educationally only about 60% of the population is literate. There is only one national university. There are dozens of tribal languages, but only one national language, Bhutanese. Health care provision is also limited as evidenced by the limited life expectancy of only about 60 years. Over the past decade the nurse/population ratio has almost doubled, but even so is less than half of the recommended minimum suggested by the World Health Organization.
Although a long way from being the largest country in the world, India has the second highest most inhabitants. Easily identified as a triangular-shaped area of land east of Africa, India has a population of over 1.2 billion persons. Major world religions originated there, and Judaism and Christianity were present within the first hundred years of our CE. Neolithic groups are believed to have been present nearly 9,000 years ago. Commerce with Britain began in the early 1700s and gradually became British rule. With its huge population, India currently has a rapidly growing powerful economy, industry, and major armed forces, including nuclear weapons, but it also has crime, corruption, poverty, challenges in providing health and education. Even though English is not the official language (Hindi is), since independence from the British Empire in 1947 English continues to be widely used at many levels. Large numbers of ethnic groups, languages, and cultures provide a challenge for mutual understanding. Family values are considered to be important, but cultural interpretations vary. For example, childhood brides are still common. Culturally women are less valued; apparent infanticide has resulted in a mismatch of potential brides of 50 million less than marriageable men as recently as 10 years ago. Geographically, India has a full-range of topography. In the north the Himalayas reach skyward, although not the highest in the world, they influence much of the surrounding area. Industry, agriculture, and commerce all can take advantage of the varied possibilities the varied geography provides. Education and health are based on the British system, but there are severe shortages in both areas. As in other countries which use English professionally, Indian nurses are recruited, and respond, to work in more developed countries for a better wage. Though the population has been growing steadily, between 2001 and 2004, the number of professional nurses dropped by more than a third. Since then the ratio has improved and most recently was about 17/10,000–not the desired number but much closer than most of the countries in this ranking.
Unlike the many landlocked countries we have explored, Indonesia is a long chain of islands, about fifteen thousand, in fact. It does actually have some physical borders shared with other countries, but generally it is surrounded on all sides by the Pacific Ocean. As early as 600 CE it was already a trading center. Hundreds of different ethnic and language groups are represented in the largely Muslim population. Some time after 1850 it became known as the Dutch East Indies, but the current name, Indonesia, has been recognized for about 100 years. There is archeological evidence of civilizations settled there over 40,000 years ago. The Dutch influence and control began about 1600. World War II ended the Dutch rule when Indonesia was occupied by Japan. During that time millions of persons died; within days of the end of the war, Indonesian survivors proclaimed the islands independent. Currently it is governed by a presidential system with power concentrated in the president, although there is a representative body as well. Geographically Indonesia straddles the equator giving it a tropical climate. Because it lies in an area with numerous volcanoes there are advantages in the form of rich and fertile soil for agricultural purposes; moderate and stable temperatures provide an added benefit. Biodiversity abounds providing ready tourist trade, but rapid population and growth industry are a challenge to natural resources and beauty. With a population of hundreds of millions, providing education and health services in the context of hundreds of language groups is a challenge. Twelve years of schooling are required of all citizens. Both public and private schools and universities are options; thankfully the concern about literacy has increased the rate to 90% in the past two decades. Health care provision is available at all levels, but the ratio of health workers/population is still far below the minimal suggested. Since the mid-1990s, the ratio has almost doubled, the most recent being 9/10,000 population.