The Taliban have been waging a particularly bloody offensive this year now that Afghan government forces are in charge of security. The result: Afghan army and police are suffering record numbers of casualties — far more than NATO ever did at the height of its troop presence in Afghanistan.
So even as NATO forces are preparing to leave, they are working to bolster the medical capabilities of Afghan forces at hospitals, clinics and training centers across the country.
At Forward Operating Base Nolay, a joint U.S.-Afghan base in Helmand province's restive Sangin district, American forces are mentoring Afghan medics who get plenty of opportunities to practice emergency field medicine.
The Sangin district in southern part of the country is still one of the most violent places in Afghanistan. Afghan forces clash with the Taliban and other militants there on a daily basis.
On a recent afternoon, an Afghan police convoy came under fire as it passed the base, and two Afghan officers were wounded.
They were brought to the Afghan Army's new medical clinic at the base, which is little more than a prefabricated barn. There are several triage beds made out of two-by-fours, and blue bed sheets with patterns of frolicking dolphins lining the plywood walls. Still, it's a big improvement from the old clinic on the base.
Afghan medical staff treated the police officers under the supervision of U.S. medics, led by Navy Hospital Corpsman 1st Class Frederico Sanchez.
"Does your chest still hurt?" Sanchez asked one of the wounded officers. The officer indicated he was breathing a little better, and several Afghan staff helped him across the room to a bed in the ward.
One of the two wounded officers had received a deep graze across his back from a bullet.
"They stitched it up, gave him antibiotics," Sanchez says. "The other guy got shot in the left shoulder, might have jarred his clavicle. I think it's broken. They're not urgent, they were treated correctly."
A Need For More Doctors
U.S. Gen. Joseph Dunford, the NATO commander in Afghanistan, told Britain's Guardian newspaper in September that casualties among the Afghan forces were often reaching 100 per week.
"I view it as serious, and so do all the commanders," Dunford told the paper. "I'm not assuming that those casualties are sustainable."
Abdul Haq Ghanizada is the Afghan physician assistant in charge of the clinic at the base in Sangin. He had six years of experience in various clinics in Afghanistan and India prior to joining the army a few months ago — over his family's objections.
The Afghan army has just about reached its quota of physician assistants, but the quality isn't always up to par. It's still actively trying to recruit and train doctors.
"It's getting better," says Sanchez. "Day by day, I see the difference of how they are better than the past Afghan physician assistants."
Ghanizada says that he treated the patient shot in the shoulder by doing the basics of field triage — stop the bleeding, provide pain relief and prevent infection.
"We want to transfer the patient to the big hospital, because here we don't have X-rays," he says.
The Afghan army has one national hospital in Kabul, four regional hospitals and two more under construction. The hospitals have modern equipment provided by NATO. But transporting casualties to these facilities is one of the challenges for Afghan forces.
"They're trying to get me to medevac them," says Sanchez.
But he says the wounded policemen don't need urgent care. Sanchez says this is all part of the process of making the Afghans self-sufficient.
"They called us after they treated him. They just had a question so we just came down," he says. "It was more for reassurance, and they'll do that every now and then, which is fine for me."
Sanchez says that when he arrived eight months ago, the Afghan medical staff called him for help constantly, even for things like sprained ankles. Now, they only call him for advice on complicated cases.
One patient recuperating in the small ward is 19-year-old Norullah, who like many Afghans goes by one name. His army patrol was attacked a few days earlier, and he was shot in the hand.
"They have good medicine, and they gave me good treatment," says Norullah, who had a tourniquet on his wound by the time he arrived at the clinic.
Afghan combat medics are now receiving training in things like applying tourniquets, which often make the difference between life and death for a wounded soldier. But they are still losing a lot of soldiers who would likely be saved by Western militaries.
"They are close to reaching where they need to be at, working within their means and capabilities," says Sanchez. "Now if we talk about comparing it to Western-style medicine, it's still a long road to go."
And as NATO troops continue to draw down, it's a road the Afghans will be traveling more and more on their own.