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Country Study: Turkmenistan

CPT Scott J. Stokoe

HCA 5312, Issues in International Health

12 March 2004

Turkmenistan

Whether it’s from the daily headlines regarding Operation Enduring Freedom or articles focusing on diplomatic discussions, countries like Afghanistan, Uzbekistan, Iran, Kazakhstan, and Turkey have become well known since September 11, 2001. Strategically positioned and hidden between these countries lies another country that is not so well known. This country is Turkmenistan. Formerly known as the isolated Turkmen Soviet Socialist Republic (SSR), it has emerged as a developing nation committed to bettering economic relations and building stability and peace (Embassy of Turkmenistan, 2003).

The history of Turkmenistan is spattered with the influences many popular historical figures. It begins with Alexander the Great in 330 B.C. and follows on with Genghis Khan in 1221, Peter the Great in 1716, Joseph Stalin in 1930, Mikhail Gorbachev in 1985, and today’s president, Saparmurat Niyazov. For many years, the Soviet Union maintained the Turkmen SSR as an isolated republic refusing to allow the Turkmen to travel beyond its borders. Its isolation; however, did not slow the country’s economic development and in 1990, the Turkmen fell in line with the other republics in the Soviet Union to gain independence. Their first step was to elect Saparmurat Niyazov as the first president of the Turkmen SSR. After gaining complete independence in 1991, he was again elected as president under the country’s new constitution (Embassy of Turkmenistan, 2003).

Peer Nations in the Region

Turkmenistan is located in central Asia near the Caspian Sea. It shares its northern border with Kazakhstan (379 km), its north to northeastern border with Uzbekistan (1,621 km), and its southern border with Afghanistan (744km) and Iran (992 km). The western border of the country is its coastline with the Caspian Sea (CIA World Factbook, 2003). The Caspian Sea and its actual boundaries are still a source of dispute among the nations in the region (Country Watch, 2004). Turkmenistan is broken down into five administrative districts: Ahal, Balkan, Dasoguz, Lebap, and Mary. It is slightly larger than California and measures 188,456 square miles (Population Reference Bureau, 2003). The Garagum desert stretches across 80% of the country, leaving roughly 3.5% as arable land. The desert and flat to rolling sandy desert dunes produce the country’s subtropical desert climate. The southern region of the country has some mountainous terrain, which traces the Turkmenistan-Iranian border (CIA World Factbook 2003).

Demographics

The country’s ethnic makeup is 77% Turkmen, 9.2% Uzbek, 6.7% Russian, 2% Kazakh, and 5.1% other. The primary languages spoken are Turkmen, Russian, Uzbek, and other. Strict government intervention limits religion to Sunni Muslim and Eastern Orthodox. In 2003, 89% of the population was practicing Muslims and 9% were Eastern Orthodox (CIA World Factbook, 2003). According to the Human Rights Watch (2004), followers of other religions face criminal persecution, police beating, deportation, and sometimes have their houses of worship destroyed. Literacy throughout the country is relatively high with 98% of the total population over the age of 15 able to read and write. The population age structure of the country is considered young with a median age of 21.1 years (CIA World Factbook, 2003). As with other Middle East countries, gender discrimination, backed by social and religious norms, exists against women. Discrimination limits their freedom and affects all aspects of their social life (U.S. Department of State, 2003).

Immigrants and Refugees

The net migration rate for Turkmenistan was -0.9 migrants per 1000 people in 2003, which indicates that people desire to leave the country (CIA World Factbook, 2003). Those seeking refuge and asylum in Turkmenistan are primarily from Tajikistan and Afghanistan. At the end of 2002, Turkmenistan hosted 13,700 refugee and asylum seekers, 13,200 from Tajikistan and 500 from Afghanistan. No formal national structure exists in the country to assess refugee claims; therefore the United Nations High Commissioner for Refugees (UNHCR) conducts all refugee status determinations. Turkmenistan recognizes and accepts approval certificates issued by the UNHCR (U.S. Committee for Refugees, 2003).

Population Pyramid

In mid 2003, the population of Turkmenistan reached 5.7 million with 44% of it being urbanized. It is projected that by 2025 the population will reach 7.7 million and by 2050 it will reach 8.8 million. This is a 55% change from 2003 to 2050 (Population Reference Bureau, 2003). The population pyramids indicate that the population structure, as a whole, will remain fairly consistent throughout the next 47 years. The bell curve distribution will fatten and the population, but will continue to be classified as a young (U.S. Census Bureau, 2004). A fertility rate of 2.2 babies per woman is probably the most significant contributor to the country’s young age structure. The country’s birth rate is 19 per 1000 people and its death rate is 5 per 1000 people (Population Reference Bureau, 2003). The average life expectancy is 61 years and the probability that someone will not reach the age of 60 is 27.6%. Compared to other populations throughout the world, Turkmenistan’s is ranked number 114 (U.S. Census Bureau, 2004).

Energy Resources

The primary natural resources found in Turkmenistan are petroleum, natural gas, coal, and sulfur. The country’s large abundance of natural gas make it the world’s fifth largest holder of natural gas reserves. In 2001, the country produced 162,500 bbl per day of oil and consumed roughly 63,000 bbl per day. In regards to electricity, in 2001, the country produced 10.8 billion kilowatts and consumed 8.5 billion kilowatts (CIA World Factbook, 2003).

Economy

It is difficult to assess Turkmenistan’s actual economic condition because its economic statistics and GDP are held as state secrets (CIA World Factbook, 2003). This is readily apparent in the information available about the country. Few data sources have consolidated or continuous data for each consecutive year.

Turkmenistan’s strong roots with the former Soviet Union have resulted in its current soviet-style government control over almost all aspects of the economy. Government or government owned agencies provide the majority of the country’s industries and services and the agriculture program remains state run (U.S. Department of State, 2003). Basic commodities, like water, wheat, and bread, are free and heavily subsidized. All transactions for these commodities must be registered with the State Exchange Commodity and the sale of all cotton or wheat must be done through the state order system (World Bank, 2003). Continued governmental influences have resulted in Turkmenistan’s label of “repressed” by the Index of Economic Freedom (2004). On a scale of one to five, five being the worst, it scored a 4.3, which place it at number 150 in the world rankings. Individual categories of trade policy, government intervention, banking/finance, and informal market ranked the worst with a score of five. Monetary policy, foreign investment, wages/prices, property rights, and regulation each scored one point better to earn a score of four. The best of all categories, fiscal burden of the government, scored a three. Since 1998, Turkmenistan has continually scored in the range between 4.2 and 4.5.

In 2001, Turkmenistan’s gross domestic product (GDP) was estimated at $21.5 billion (Nationmaster, 2003). In 2002, its GDP growth was estimated at 21.1% and its inflation was estimated at 5%. (CIA World Factbook, 2003). The Economist Intelligence Unit (2003) predicts that a combination of an overuse of agricultural resources and a lack of restructuring in 2004-2005 will significantly slow Turkmenistan’s economic growth. They believe that the actual GDP growth will be roughly 10%, but will probably be overstated at 20%. The country’s primary import products consist of machinery and equipment, and foodstuffs from Russia, Turkey, Ukraine, United Arab Emirates, U.S., China, Germany, and Iran. It exports gas, oil, cotton fiber, and textiles to the Ukraine, Italy, Iran, and Turkey. Cotton fiber is important to note because Turkmenistan is the world’s tenth largest producer of cotton (CIA World Factbook, 2003).

Few natural disasters have challenged the economy. In 1998, 40 people were killed in a transport accident; in 1999, a flood affected 420 people; and in 2000, an earthquake killed 11 people. Prior to 1991, Turkmenistan was part of the Soviet Union and all natural disasters were classified under the Soviet Union (OFDA/CRED International Database, n.d.).

Politics and Elections

The government of Turkmenistan is a republic with its capital city located in Ashgabat. It maintains one political party, the Democratic Party of Turkmenistan. All other political parties, such as the Gundogar Party and the Erkin Party, are officially outlawed (CIA World Factbook, 2003). There are two parliamentary bodies within the government, the Halk Maslahaty, or People’s Council, and the Mejlis, or Assembly. The People’s Council’s job is to adopt constitutional amendments, treaties, and referenda. It consists of both cabinet members and regional/district/city parliamentary members (Country Watch, 2004). Despite the country’s discrimination against women, 17.5% of its ministers and 26% its parliamentarians have been female. The first female to work in the parliament occurred in 1990 (Nationmaster, 2003).

As mentioned earlier, the president of Turkmenistan is Saparmurat Niyazov. In 1992 he ran unopposed and was elected president. Elections were slated to occur every five year, but in 1994, a referendum named him president until 2002. In 1999, parliament made him president for life. Under his reign, the government is one of the most repressive in the world. The government tolerates no opposition, allows no free media, limits access to the internet, and has banned the opera, ballet, circus, philharmonic orchestra, and all non-Turkmen cultural associations (Human Rights Watch, 2004). President Niyazov has proclaimed himself Turkmenbashi, the “father” of Turkmen, and has introduced his personal Rukhnama or Book of Soul. This book has been dubbed the center of his personality cult. Everyone employed by the state must know passages of the Rukhnama by heart and students are not admitted into the university unless they successfully pass a test on the book. Prisoners who refuse to swear an oath to the book face beatings and have been denied release when their sentences are complete. In 2003, the United Nations commission on human rights expressed concern about the status of human rights in Turkmenistan. However, to date, the country has made no political changes or movements toward implementing recommendations from the international community (Amnesty International, 2003).

External Debt

The World Bank assesses Turkmenistan as a lower, middle-income country. The bank has assisted Turkmenistan with three loans and 10 policies, but has received little in return. It is unable to provide new loans to the country because Turkmenistan has failed to report its external debt and has not met minimum resource management standards. The majority the country’s revenues are reinvested into the public infrastructure, which has little or no economic return (World Bank, 2003). In 2003, Turkmenistan’s revenues hit $288.8 million and its expenses hit $658.2 million. Its current debt is estimated somewhere between $2.3 to $5 billion (Nationmaster, 2003).

Corruption

There are no formal controls to stop corruption and little is done to persecute corrupt government officials in Turkmenistan (U.S. Department of State, 2003). The Index of Economic Freedom (2004) has characterized the country as “rampant with corruption.” Investors rely heavily on bribes to officials to ensure there is support for their projects. Though, not directly assessed on the Transparency International Corruption Perceptions Index, Turkmenistan’s neighbors of Uzbekistan and Kazakhstan scored a 2.4 on the 10-point scale (10 being the cleanest or best) (Transparency International, 2003). This indicates that corruption from these countries could continue to influence corruption levels in Turkmenistan.

Health Status

The Human Development Index ranking, which measures quality of life by looking at longevity, knowledge, and education, for Turkmenistan was 87 out of 175 in 2003 (Country Watch 2004). Its world health status is ranked number 153 out of 190 (www.geographic.org, 2004). According to the Population Reference Bureau (2003), in 1999, 58% of the population used improved water sources and 100% had access to adequate sanitation. In the rural population, 31% of the population used improved water sources and 100% had access to adequate sanitation. One noted water deficiency was that although most of the rural population had access to piped water systems, they only received low pressure, unpurified water three or four times a day (Worldbank, 2003).

To counter disease within the country, the government funds the vaccination program. As of 2003, 99% of the population had received their immunizations for tuberculosis and 97% had for measles. In regards to disease, the Armed Forces Medical Intelligence Center (2002) assessed Turkmenistan as an intermediate risk country. Diseases of concern are food/waterborne diseases (diarrhea, hepatitis A, and typhoid fever), vector borne diseases (Crimean-Congo hemorrhagic fever, sand flies, and sporadic malaria), and sexually transmitted diseases (hepatitis B and HIV). Travelers should be aware and take the appropriate precautions before visiting the country (Armed Forces Medical Intelligence Center, 2002).

Morbidity / Mortality

The primary cause of death in Turkmenistan is from diseases of the circulatory system, such as cardiovascular disease, and the secondary cause is respiratory disease. Death from infectious disease, respiratory disease, chronic liver disease, and cirrhosis in Turkmenistan are among the highest found in the European region. In fact, the World Health Organization, (2000), estimates the proportion of deaths attributable to respiratory, infectious, and parasitic diseases is 2.5 times higher than the regional average. Another concern is the increasing incidence of viral hepatitis. It too, is the one of the highest among the European region. Cancer is one area that Turkmenistan ranks lower than others in the European region. There are no significant features about the country’s smoking or drinking; however, Turkmenistan has seen an increase in the amount of illicit drug use (World Health Organization, 2000).

Infant mortality in Turkmenistan is 25 deaths per 1000 births (Population Reference Bureau, 2003). According to the World Health Organization (2000), the primary causes of infant death in 1996 were acute respiratory disease, diarrheal disease, perinatal conditions, and congenital disorders. With a death rate of 251.6%, respiratory disease appears to be the number one concern for infant mortality (Nationmaster, 2003).

HIV / AIDS

The HIV and AIDS rate in Turkmenistan is considerable low. In 2002, there were only two reported cases of HIV. The country may experience a rise in the future due to its increase in sexually transmitted diseases and drug use. Syphilis, for example, increased tenfold in the last five years with the current prevalence rate of 50 out of 100,000 people (UNICEF, n.d.).

National Health Services System and Structure

Little information could be found regarding the structure of the Turkmenistan health services system. Information that is available is from the World Health Organization and is a little dated. As with the economic structure, the health service system is also a byproduct of the former Soviet Union and many of its health resources cannot meet current medical demands (World Health Organization, 2000). For example, basic medical supplies, including disposable needles, anesthetics, and antibiotics are often in short supply (U.S. Department of State, 2004). According to the U.S. Library of Congress (2002), the government of Turkmenistan maintains a near monopoly on its financially bankrupt heath care system. The result is poorly trained physicians who provide primitive treatment using outdated medical technology. Recent health reform has started to allow medical professionals to offer private medical care.

Healthcare is primarily funded by the government through state revenues raised from taxes and the sale of natural resources. State funding accounts for 90% of the health budget and voluntary insurance accounts for 7%. Veterans, some disabled persons, people affected by the Chernobyl explosion, and a few other special categories have free access to all health services. Access is considered good for most of the population, especially in urban areas. Rural hospitals are rather small with 25 beds. They are often in poor physical and sanitary conditions, have limited capability, and can generally only provide primary care. Citizens in urban areas are assigned a family physician and often have access to freestanding outpatient clinics. To receive care in a hospital, physicians must refer patients. Patients without a referral will not be admitted directly to a hospital (European Observatory on Health Care Systems, 2000). In 1997, there were 710.7 beds per 100,000 people and the average length of stay was 13.4 days (World Health Organization, 2000).

The Ministry of Health and Medical Industry is responsible for the actual operations of health services and it provides oversight and direction to regional health authorities. Management of the health system remains bureaucratic and hierarchical and regional authorities have limited control over improving local health care delivery (European Observatory on Health Care Systems, 2000).

Health Reform

Within Turkmenistan’s government, health policy is made by the Cabinet of Ministers, which is overseen by the President. The country’s overall poor health conditions resulted in its first health reform initiative in 1995. This initiative was called the president’s “State Health Program.” The intent was to improve health and health life expectancy. To do so, one initiative called for an increase in the share of GDP allocated for health. A budget shift also provided more funds to states that had higher numbers of women, children, and mortality ratios. Some of the major aims of the program were to carry out effective preventative measures, develop a family based primary care service, rationalization of hospital beds, and development of the private sector (European Observatory on Health Care Systems, 2000). In 1996, family medicine, voluntary medical insurance, and mandatory government licensure were introduced into the health system (World Health Organization, 2000). Since 1995, the major health policy reform initiatives have focused on improving health and accomplishing the aims outlined in the state health program.

Health Providers

According to the World Health Organization (1998), in 1997, Turkmenistan had 300 physicians, 507 nurses, 78.4 midwives, 33.5 pharmacists, and 21.6 dentists per 100,000 people. In 1998, there were 3015 family physicians that were capable of providing 75% of the services needed. To meet the demand, health reform initiatives also focused on reclassifying doctors as family physicians. Shortage in rural areas led to setting up 833 family clinics that were staffed with auxiliary military medical personnel (feldshers).

Costs and Financing of Health Care

In March 1998, the State Fund for Health Development was established to further develop the health sector and improve the supply of pharmaceuticals. Sources from the fund are generated through insurance premiums, fee-for-service providers, fees for product certification, and penalties for sanitary violations. Health care itself is rather expensive and medical professionals are not paid very well. One study noted that roughly 50% of the people it had interviewed paid for medical care with “under-the-table” payments. Such a practice prevented money from being re-invested in the health care system, but did provide needed supplements to physician salaries. In 1998, 5.2% of the GDP was spent on healthcare (4.1% for public spending and 1.1% for private spending). The per capita spending was estimated at $30 (Nationmaster, 2003). The exact amount spent on health care was difficult to find or ascertain due to the close hold the country has on its exact GDP figures and amounts.

Utilization of Technology Promoting Health Care

Other than a modern cardiology hospital equipped with sophisticated equipment from Germany, Japan, and the U.S., there was little information on the utilization of technology to promote health care. The literature indicates that Turkmenistan is still working on the basics to transform its rudimentary health care system into one that is capable of providing basic primary care for its citizens (European Observatory on Health Care Systems, 2000).

Telecommunications

The government heavily regulates media in Turkmenistan. The two newspapers in the country, for example, are subject to pre-publication censorship (Human Rights Watch, 2004). The telephone system is poorly developed and an estimated 363,000 lines were in use in 1997. The estimated number of cell phones in 1998 was 4,300. Compared with the number of people in the country, these numbers are very small. In 1997, there were only three television broadcast stations to serve 820,000 televisions throughout the country. Internet use is practically nonexistent with only 0.3 Internet hosts and 2,000 Internet users (Nationmaster, 2003).

Military / Armed Forces

Turkmenistan ranks 20th out of the 26 Middle East nations for military strength. It Ministry of Defense consists of an army, air and air defense force, navy, border troops, and internal troops. As of 2004, the military strength was 17,000 men, 2,100 armored fighting vehicle, and 80 combat aircraft. Compared to its peer nations, Turkmenistan has the smallest military force (CIA, Factbook, 2003; Strategypage, 2004). In 2000, the country spent an estimated $176 million of its budget, or 4% of its GDP, on defense. Low pay, low morale, corruption, and poor discipline characterize the military and plans are in place to replace its conscript army with a professional one in 2005 (Economist Intelligence Unit, 2003).

Military Health Services System

Turkmenistan’s army has only one corps headquarters and its breakdown makes no reference to the military health system as a whole or its health component (U.S. Library of Congress, 2002).

Implications for Military Health Services System

Due to the limited information available on Turkmenistan’s military health care system and the potential to make false assumptions, no implications are drawn.

Implications for Military Planners

Turkmenistan’s location is of considerable importance for military planners. With the global war on terrorism and operations ongoing in Afghanistan, Turkmenistan is strategically located in Central Asia. If U.S. presence expands in the region, its location could be of great importance. Although Turkmenistan played the least active role in the military campaign in Afghanistan, President Niyazov did grant over-flight permissions to U.S. during Operation Enduring Freedom for humanitarian aid purposes. The president’s unpredictable behavior is a key factor to keep in mind should future support be needed (Country Watch, 2004). The U.S. should also remember that until September 11, 2001, Turkmenistan had a close working relationship with the Taliban (U.S. Department of State, 2003). An additional security concern for the future is the hostility that may arise from the Caspian Sea boundary disputes.

For the next 20 to 50 years, the population in Turkmenistan will continue to grow and remain a relatively young. Continued economic reform will significantly improve Turkmenistan’s economy and international commerce opportunities. It will also provide needed jobs for the country’s citizens. Despite the socially accepted discrimination against women, the 26% that has served in parliament provides hope to other aspiring women throughout the country. The country may still continue to receive small number of immigrants and refugees; however, if human rights violations continue, the may seek refuge elsewhere.

The fact that Turkmenistan is so secretive about its economic figures and that there is a belief that the country inflates its statistics could inhibit future support, aid, loans, and trade or business agreements. Disagreements over the alleged human rights violations and the country’s unwillingness to implement suggested corrective measures also works against the country. The country has lots of opportunity for growth and has great potential to be an ally in the central Asian region. However, until President Niyazov implements change, both growth and future opportunities will remain limited.

Lessons Learned for U.S. Health Care System

As an undeveloped country, the lessons learned for the U.S. health care system are somewhat limited. One important lesson is the importance of preventative medicine. Turkmenistan’s health system follows a curative approach rather than a preventative approach. The result is its high number of respiratory, infectious, and parasitic diseases and deaths. Their approach to health has also made it difficult for them to make significant advances in medicine. Much of their efforts are spent trying to maintain and fix the problems they currently have. The U.S. system also uses narrow, curative approach, but has the capability to spend larger amounts of money on preventative medicine. The result is the U.S.’s capability to control its disease outbreak. Using lessons learned from Turkmenistan and by placing a continued emphasis on preventative medicine, the U.S. can further improve its health system and control costs.

It is also important for the U.S. health care system to monitor health progress in Turkmenistan. Often the U.S. becomes the backer of large donations to fund medical and humanitarian support. Close monitoring of health in Turkmenistan will help the U.S. prepare and provide the correct support when needed. As business opportunities expand in Turkmenistan, there is also a potential for U.S. citizens to increase travel back and forth from the country. Continuous exposure to the health concerns of an undeveloped country could lead to an increased prevalence or incidence of disease in the U.S. Close monitoring and support will help prevent this and benefit both countries.

Conclusion

Turkmenistan has only been an independent country since 1991. As a young country, it has great potential to become a great state. If needed, it can remain guarded, but it should seek the assistance of other countries that have had similar experience with economic, health, and growth issues. Continued human rights violations in Turkmenistan will also cause additional world attention that may further inhibit its growth and development. Early action by President Niyazov can positively change the momentum of Turkmenistan and help it establish a foothold in the world community.

References

Armed Forces Medical Intelligence Center. (2002). Turkmenistan. Retrieved February 24, 2004, from http://mic.afmic.detrick.army.mil/

Amnesty International. (2003). Turkmenistan: clampdown on dissent, a background briefing. Retrieved February 27, 2004, from http:web.amnesty.org/library/print/ENGEUR610152003

CIA World Factbook. (2003, December 18). Retrieved January 12, 2004, from http://www.odci.gov/coa/publications/factbook/print/tx/html

Country Watch. (2004). Turkmenistan: 2004 country review. Retrieved January 11, 2004, from http://www.countrywatch.com

Economist Intelligence Unit. (2003). ViewsWire Turkmenistan. Retrieved February 24, 2004, from http://www.viewswire.com/index.asp?layout=oneclick&pubcode=VW&country_id=TM

Embassy of Turkmenistan (2003). Turkmenistan. Retrieved January 12, 2004, from http://www.turkmenistanembassy.org

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Human Rights Watch. (2004). Turkmenistan. Retrieved January 24, 2004, from http://hrw.org.english/docs/2003/12/31/turkme7274_txt.htm

Index of Economic Freedom. (2004). Turkmenistan. Retrieved January 11, 2004, from http://www.cf.heritage.org

Nationmaster. (2003). Asia: Turkmenistan. Retrieved February 23, 2004, from http://www.nationmaster.com/country/tx

OFDA/CRED International Database. (n.d.). Disaster profiles: Turkmenistan. Retrieved February 24, 2004, from http://www.cred.be/emdat/profiles/natural/turkmeni.htm

Population Reference Bureau. (2003). Turkmenistan. Retrieved February 23, 2004, from http://www.prb.org/datafind/prjprbdata/wcprbdata.asp?DW=DR&SL

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Transparency International. (2003). Transparency International Corruption Perceptions Index 2003. Retrieved January 15, 2003, from http://www.transparency.org

U.S. Department of State. (2003, November). Background note: Turkmenistan. Retrieved February 23, 2004, from http://www.state.gov/r/pa/ei/bgn/2866pf.htm

U.S. Committee for Refugees. (2003). Turkmenistan: world refugee survey 2003 country report. Retrieved February 23, 2004, from http://www.refugees.org/world/countryindex/turkmenistan.cfm

UNICEF. (n.d.). At a glance: Turkmenistan. Retrieved January 12, 2004, from http://www.unicef.org

U.S Census Bureau. (2004). IDB population pyramids. Retrieved January 11, 2004, from http://www.census.gov/ipc/www/idbpyr.html

U.S. Library of Congress. (2002). Retrieved March 02, 2004, from http://countrystudies.us/turkmenistan/

World Bank. (2000). Turkmenistan. Retrieved January 11, 2004, from http://www.devdata.worldbank.org

World Health Organization. (1998). WHO estimates of Health Personnel. Retrieved February 27, 2004, from http://www3.who.int/whois/health_personnel/health_personnel.cfm

World Health Organization. (2000). Highlights on health in Turkmenistan. Retrieved January 11, 2004, from http://www.who.int

www.geographic.org. (2004). World health organization’s rankings of world’s health systems. Retrieved January 11, 2004, from http://www.photius.com/rankings/healthranks.html

Appendix

Comparison of the United States and Turkmenistan