Int J Emerg Med (2009) 2:77–82 reasonable standard of living, forcing physicians to practice at hospitals or public clinics in the morning and spend the afternoon in private clinics. The few residency training programs that exist provide minimal guidance in terms of lectures, clinical practice, or supervision [23]. Because there are two dominant languages in Afghanistan, courses must be offered in both Dari and Pashto. Upon completion of the programs, few health care workers desire to work in rural areas due to the poor living and working conditions, lack of education for their children, security issues, and poor transportation [3]. Although the immediate future for health care worker education is improving, there will be many struggles ahead as 60% of primary school aged children still do not receive an education. The illiteracy rate among women is 78% and among men 48% [13, 24]. Role of women While the number of overall health care workers is improving, the focus must be on women. Afghan societal norms dictate that only women can provide medical care for women. During the Taliban regime, women were forbidden from going to school; thus, virtually no female doctors or nurses were trained during this period. In 2002, only 21% of health care facilities had at least one female health care provider. Today nearly 60% of facilities have at least one woman to provide care. Access to health care for women is improving, but there are still many obstacles to overcome to decrease the health disparities between men and women [18, 22]. The future of health care in Afghanistan The challenges of establishing a functional health care system in Afghanistan include those of a developing nation, post-conflict nation, and a combat zone. The long-term goal of quality health care for all citizens will only be met by a combination of specific goal-oriented projects, foreign aid, and domestic responsibility. Health care in Afghanistan is improving as evidenced by improved access to care, enhanced quality of patient care, and more knowledgeable health care workers in rural areas. These improvements show the effects of streamlined cooperation between the Afghan military, civilian government, and NGOs. Unfortu- nately, the country’s health care system still needs signif- icant improvement before it meets basic and higher-level health care needs. The focus on primary care is appropriate; primary care is the first line of defense and yields large dividends. Currently, the future of the US military’s humanitarian role in the continued rebuilding of medical systems in Afghanistan is uncertain as both the local military leader- 81 ship in Afghanistan and the administration of the USA is in transition. While it is likely that the military will continue to be the driving force for this project, future plans are unclear at this time. President Obama is calling for a greater military presence in Afghanistan, making the future of humanitarian assistance in that country difficult to predict. The emergency training of the military should proliferate throughout the civilian health care systems. Civilian ambulance programs should be established in urban areas to begin emergency care. The WHO Essential Trauma Care Project can be used as a model to teach first responders with minimal training how to perform simple, inexpensive, and life-saving maneuvers such as airway management and hemorrhage control. Hospitals should be adequately stocked and staffed to ensure a patient with an emergency can be treated. Once emergency departments are properly staffed and stocked, more extensive prehospital training can be developed. A tertiary care system for the sickest patients should be established. With time, emergency medicine will develop to meet the specific needs of the people of Afghanistan. All of these future goals will require the continued involvement of foreign aid in Afghanistan as well as aggressive domestic economic development. The health care situation in Afghanistan today is dire, but improving. Time and commitment will ensure a brighter, healthier future for the nation of Afghanistan and its people. Acknowledgment The authors would like to thank C. James Holliman, M.D. for his help providing background information on the state of emergency medicine in Afghanistan and final review of this paper. Conflicts of interest None. References 1. World Health Organization. Country profile, Afghanistan. Available via http://www.who.int/countries/afg/en/. Accessed 5 Nov 2008 2. Saguil A, McCormack MT (2008) Preparing for Afghanistan’s medical future. CMAJ 178(8):990 3. World Health Organization. Country cooperation strategy for WHO and Afghanistan, 2006–2009. Available at http://www.who. int/countryfocus/cooperation_strategy/ccs_afg_en.pdf. Accessed 7 Nov 2008 4. 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