MilMed NovDec 2006.qxp - SA Military Health Service

VOLUME 22 NO 3 - 2006

“The Surgeon General says...”2Lt Gen V.I. Ramlakan DMG, MMS, MMB, OStJ“...respect for women and childrenmust start at home with partners,parents, relatives and friends...”On Friday 11 August 2006, the Pretoria MilitarySports Club in Thaba Tshwane was host to fourhundredand fifty female soldiers from theSANDF who formed part of the Women’s DayCelebrations Parade.During his keynote address at the parade, Defence Minister,Mr Mosiuoa Lekota, highlighted that the Department ofDefence has developed plans and strategies to ensure equalopportunities for all women in the organisation. Against thisbackdrop, women in the SANDF have a definite and criticalrole to play. Outside our organisation, women have equallyimportant roles to play, amongst which are domesticresponsibilities. For them to play these multiple roles to thefullest, a secure home environment needs to be created forthem.The 16 Days of Activisim Campaign of No Violence AgainstWomen and Children is therefore a useful tool to ensuresuch a secure environment. Its launch therefore marks thebeginning of a process of generating awareness aboutviolence directed at women and children, how it manifestsitself in our society, and the negative impact it has on thedevelopment of these vulnerable groups.It is fitting that the SAMHS, after hosting the successfulWomen’s Day Celebrations, now focuses on protecting themost vulnerable in our society. The 16 Days of ActivismCampaign of No Violence Against Women and Children,which took place from 25 November to 10 December,seeks to achieve just that.I wish to remind everyone in the SAMHS that the Bill ofRights affirms women’s rights. It reads, “Everyone is equalbefore the law and has the right to equal protection andbenefit of the law”. It further states that “everyone hasinherent dignity and the right to have their dignity respectedand protected, to be free from all forms of violence fromeither public or private sources; not to be tortured in anyway”. Clearly, the safety of our citizens and the respect ofhuman dignity are enshrined in our Bill of Rights.Our government has as a result put in place mechanismsto enable the realisation of these rights, but the responsibilityof ensuring the safety of women and children in our homes,on the playing fields and at schools, indeed everywhere, isour joint responsibility as citizens.Therefore, respect for women and children must start athome with partners, parents, relatives and friends whoshould not be perpetrators of such violence.The safety of our citizens and the respect of human dignityare enshrined in our Bill of Rights. Our government hastherefore put in place mechanisms to enable the realisationof these rights but the responsibility of ensuring the safety ofwomen and children in our homes and our bedrooms, inour playing fields and schools, indeed everywhere is ourjoint responsibility as citizens.We also know government alone cannot succeed on thisone. Given the fact that most abuse takes place at home,families and communities should help expose offenders. Aswe sit in our homes when we read this message, let us maketoday the day we stand up and report abuse in our homes.Tell somebody today; if you do not, you are slowly killingthose who are facing abuse. If you are facing abuse, speaknow.During the 16 Days Campaign let us all move in onedirection to ensure that the silence is broken and the cycleof violence against the vulnerable groups is broken.I therefore call upon all members of the SAMHS to rallybehind government’s efforts to regenerate the moral valuesinherent in our rich cultures. All our different cultures teachus to respect women and protect the weak.We also need to get men involved on all fronts and be inthe forefront of beginning to change men’s behaviour. Wealso need to provide support to women and children so asto break the silence and act against any form of violenceperpetuated against women and children.Let us, as members of the SAMHS, heed the call of theDeputy President when she asked us not to stop at the 16Days of Activism, but to continuously raise the much-neededawareness and to make this campaign an everydaycampaign.

contentsmilmed@mweb.co.zaRegulars“The Surgeon General says...”Inside CoverEditor’s Column 5News Clips 6FeaturesTurberculosis, a curable disease 7The Prevention and Eradication of Gender Violence 8-94th Annual Phidisa Conference 10-11Anti-retroviral (ARV) Rollout 12-13HIV Kap Study 2006 14-151 Military Hospital to receive upgrade 16-17Exercise LANCET 18-1920Front Cover Photo: A landmine detonationtakes place under a Casspir vehicle during ademonstration at the International Blast andBallistic Trauma Congress.(Photograph by Lt Col Sally Buckton (AMHF HQ)16International Blast and Ballistic Trauma Congress 20-22Trauma Nursing 23DOD/Denel Programme develops latent talent 243 Med Bn Gp deploys first Reserve Force members 25SportsIt’s Volleyball in the Western Cape 26GeneralLetters 26SAMHS Fund News 2718MILMED is the official magazine of the SA Military Health Service. It is an authorised publication.Opinions expressed are not necessarily those of the Editor, the SAMHS or the SANDF.The Editor reserves the right to alter any contribution or advertisement.3

Editor‘sColumnSAMHS hosts InternationalBlast and Ballistic TraumaCongressLand mines claim one victim every twenty minutes and an estimated 110 millionland mines exist in 65 countries.Seventy percent of their victims are killed, resulting in about 10 000 deaths everyyear. Of the survivors, half are severely injured with many needing amputations.Beyond the physical damage there are many other consequences of landmines.With a region or village perimeter heavily laden with landmines, access to thearea by much-needed medical teams or aid workers is affected. In addition, bymining farms or water sources, the risks of malnutrition and disease often increasegreatly. Landmines not only kill or maim victims; they also affect nearbycommunities.Mines are found throughout the world. The continent most laden with landminesis Africa with 26 countries facing this risk. Little progress is being made in dealingwith the problem.In the Americas, landmines are mostly found around remote border areas incountries such as Chile, Ecuador and Peru. Some Eastern European, Central Asianand Asian-Pacific countries also have landmine situations. Many afflicted countriessuch as Turkey, Albania, India, and North and South Korea have not made indepthassessments of the problem. Many of the poorer mine-infested countriescannot afford de-mining programmes.Some countries have indicated financial and technical problems in destroyingantipersonnel mines.Bearing this in mind, two hundred and fifty local and foreign delegates recentlyattended the Armscor/SAMHS International Blast and Ballistic Trauma Congressheld at the Armscor conference facility in Pretoria. Countries represented includedAustralia, Bosnia-Herzegovina, Canada, Egypt, Germany, the United States ofAmerica, the United Kingdom and the Russian Federation.The purpose of the congress was to afford delegates the opportunity to interactwith one another and to discuss on an international level the impact, treatmentand prevention of blast and ballistic trauma in terms of both military and civiliancasualties who are caught up in conflict situations throughout the world today.During his address at the Congress, the Surgeon General, Lt Gen V.I. Ramlakan,said, “The motto of the South African Military Health Service summarises thepurpose of this congress - We save the Brave. As medical personnel or engineerswe are all here because we believe that we can contribute to saving the brave -be it an innocent bystander or weathered soldiers”.Enjoy reading your MILMED.Lt John SverdloffLt John Sverdloff (Editor, MILMED)EDITORIAL COMMITTEECol T. ReynoldsLt Col M. SibanyoniLt Col W. KrugerLt Col V. PillayDr I. BuxLt J. SverdloffCOVER DESIGNDOD Visual CommunicationsMAGAZINE DESIGN & LAYOUTLt J. SverdloffJOURNALISTSLt M. Pretorius2Lt S. SegoneLANGUAGE EDITINGSAMHS Language SupportCORRESPONDENCEThe EditorMILMEDPrivate Bag X102Centurion0046E-mail: milmed@mweb.co.zaTEL: 012-671 5066FAX: 012-671 5278REPRODUCTION AND PRINTINGSAN Publications Unit021-787 32425

NEWS CLIPSNEWSNEWS CLIPSNEWS CLIPS6South African doctors who practisein New ZealandThe New Zealand Herald\News:“South African doctors fast-track route to NZ blocked”A short note saying the New Zealand Medical Council plansto close the fast-track route many South African doctors useto qualify to practise in New Zealand. The Council plans totake South Africa off its list of countries deemed to have a“health environment” similar to New Zealand. Notes thatSouth Africans will still be able to practise in this country, butwill face a longer route to qualification.New strains of TuberculosisThe Guardian\News\Sarah Boseley:“Global alert over deadly new TB strains”World health officials put out an unprecedented warningthat deadly new strains of tuberculosis, virtually un-treatableusing the drugs currentlyavailable, appear to bespreading across the globe.The new strains are known asextreme drug-resistant TB, orXDR-TB. They have beenidentified and have killedpeople in several countries,including the United Statesand Eastern Europe, andhave recently been found inAfrica, where they couldswiftly put an end to all hope of containing the Aidspandemic through treatment. Paul Nunn, who heads theWorld Health Organisation’s TB resistance team, said thesituation was very serious and added that there are 9 millioncases of TB in the world and the WHO estimates that 2% ofthem - or 180 000 - could be XDR-TB.The spectre of a new untreatable plague has concentratedminds because of the identification of a cluster of cases inKwaZulu-Natal, in South Africa. Scientists ran tests onpeople with tuberculosis in a rural part of the region. Theystudied 544 patients and found that 221 had TB strainsagainst which the two common drugs, rifampicin andisoniazid, had no effect. But the swift deaths of all but oneof the study group in KwaZulu-Natal have huge implicationsfor the antiretroviral (ARV) drug treatment programme beingrolled out across Africa in the hope of keeping millions ofpeople with HIV alive and well, pending a cure. The XDR-TBcases in South Africa were discovered only because Harvardscientists embarked on a study to gauge the extent of drugresistance. In other parts of Africa, there are no researchersor facilities to make the diagnosis, let alone monitor thenumbers. Most African countries either do not have anational reference laboratory for TB or they do not haveenough. Kenya has one, he said, but it should have four orfive. WHO officials and international TB experts will takepart in an emergency two-day meeting in Johannesburg,South Africa, to decide what action must be taken toaddress the crisis. They are expected to make recommendationsthat will include the importance of ensuring all TBpatients take their full six-month course of drugs to try toprevent resistance developing. In much of the world, thathas proved difficult.Global alliance for vaccines and immunisationThe Independent\News: “Bond to raise $4bn for vaccines”An innovative bond to raise up to $4bn (£2.13bn) to savethe lives of five million children through vaccinations will belaunched during October, funded by the UK and sevenother countries. The scheme, proposed by Gordon Brown,seeks to front-load aid commitments by governments to ineffect underwrite the long-term loans to fund immunisationsover a decade. The Treasury said the first tranche of thebonds, which will be managed by the World Bank, will belaunched on 12 October and aims to raise $750m to $1bndepending on demand. Goldman Sachs and DeutscheBank are currently marketing the bond. The Treasury hadhoped to issue the first tranche in April but the launch wasdelayed to seek commitments from governments. Mr Brownsaid seven other countries - France, Italy, Spain, Sweden,Norway, Brazil and South Africa - had pledged also to makepayments to fund the repayment. The Chancellor hopes thatshould the bond be taken by investors at a reasonableinterest rate, it will open the door for other similar projects,known as advance market commitments. He said theywould accelerate the development and availability of prioritynew vaccines against diseases such as malaria, TB, Aidsand pneumococcus that kill millions of people in developingcountries each year.

TUBERCULOSISCompiled by Brig Gen F. Meyer (Director Medicine)Tuberculosis (TB) is a curable disease that is spreadthrough the air and is inhaled when someone withTB coughs, spits or sneezes. Depending on howstrong your immune system is, the TB germ attacksthe lungs and can even spread to other parts of the body.The following signs and symptoms will be present if youhave TB:* coughing for more than two weeks; coughing up blood* not wanting to eat; pains in the chest* losing weight; lumps or swellings* tiredness or weakness of the whole body; sweating at nightwhen it is cold; a fever that comes and goes; easily becomingshort of breathIf you present with the above-mentioned signs and symptoms,you need to report to your nearest sickbay, clinic ormedical practitioner. The medical surveillance will includelaboratory testing and chest X-rays. If you are diagnosedwith TB it will also be necessary to identify and assess thepeople you live or work with to see if they have TB too.The treatment of TB takes up to 6 months and must becompleted to prevent recurrence of the disease or the developmentof resistance to treatment. Compliance to the dailytreatment will help to ensure the prevention of medicineresistantTB (or multi-drug resistant TB). Members presentingwith this resistant type of TB need to be isolated in a militaryhospital for treatment to ensure optimal treatment results.IT IS IMPORTANT TO NOTE THAT TB CAN BE CUREDWITH DAILY TREATMENT AND THAT THE DISEASE IS NOTINFECTIOUS WHEN YOU ARE ON TREATMENT.MANAGING MULTI-DRUG RESISTANTTUBERCULOSISMulti-drug resistant TB (MDR-TB) emerges in the majority ofcases when a TB patient receives inappropriate or ineffectivetreatment, which allows naturally-occurring resistant TBbacteria to survive and multiply. It makes up 2.9% of TBcases in South Africa and is very contagious in activelycoughing patients with positive sputum smears for TB.When people with strong immune systems are exposed toMDR-TB they can become infected, but will not normallybecome sick. However, once an infected person’s immunesystem is compromised due to illness, a poor diet, stress orHIV, that person can develop active MDR-TB. At a moreadvanced stage of the disease, that is when sputum testsdetect organisms under the microscope, and once a patientdevelops a cough, they can infect others in their immediateenvironment.Normal drug-susceptible TB requires at least six months oftreatment, but MDR-TB takes up to 24 months to treat successfullyand patients need to be hospitalised for 4 to 6months during this period. Laboratory investigations arealso extensive and include monthly bacteriological cultures.The toxicity of the drugs used also necessitates additionallaboratory screening, including liver and kidney functions,as well as audiometric tests to determine hearing loss.Both normal drug-susceptible TB and MDR-TB patients mustbe counselled at the onset of treatment on their responsibilityto adhere to the treatment regimen and the consequencesof interruption and/or default. Limited drug availabilityand the best use of scarce resources need to be takeninto account when decisions on restarting MDR-TB treatmentafter interruption or default are taken.TB (and MDR-TB) is classified as an occupational diseasefor health care workers. They have the legal right to a safeworking environment where adequate protection must beprovided against TB infection. Infection control must beensured in all military health facilities by means of protectivemasks and protective clothing during the treatment ofpatients with TB. This rule also applies to visitors of thesepatients. However, as soon as the sputum smears of thesepatients are negative for TB, they can be treated at homeand can even go back to administrative work without anyproblems.Monthly bacteriological cultures will be required for theduration of the treatment and follow-up period. The implicationis that members with MDR-TB will not be allowed todeploy for operational duties during the 24-month period oftreatment.Capt Nomsa Maseko (1 Military Hospital), microscopicallyexamining slides for acid fast bacilli.7

The PREVENTIONand ERADICATIONof GENDER VIOLENCEExcerpts from DOD Policy on gender-based violenceGender-based violence (GBV) is a serious evilthroughout the world, even within the SouthAfrican society. There is also a high incidence ofdomestic violence especially violence againstwomen and children. Domestic violence is howevercommitted in a wide range of domestic relationships andnot only against women and children by men, but also bywomen on men and amongst same-sex partners.The Department of Defence (DOD), being a microcosm ofthe broader South African society, declares that it shall takeall possible measures to ensure that violence and abuse isnot committed by any of its members on DOD property,during the deployment of SANDF members both inside andoutside the borders of South Africa and also in domesticcircumstances, which includes Defence Force housing andofficial quarters.It is the duty of the DOD to instill high moral valuesamongst all its employees. Even if violence or abuse takesplace in the home, which may be viewed as a private arena,the DOD will intervene. If any action by a DOD memberbrings the department into disrepute, the DOD membermay be liable for disciplinary action. The emphasis of thispolicy is however to educate all DOD members about thenegative effects of gender-based violence, rather thannarrowly focusing on punishment.The DOD and Public Service Codes of Conduct that havebeen signed by every member of the DOD underpin theintent of the DOD GBV policy. DOD members who live outthese values will always treat all others with dignity andrespect especially the most vulnerable members of society,namely women and children. Commanding Officers,managers and supervisors at all levels will also live out thesevalues by ensuring equitable leadership when dealing withall cases of violence reported to them and shall themselvesnot be guilty of such conduct.The South African Constitution clearly states in the Bill ofRights that violence against another person is prohibited inat least four sections, namely, equality, human dignity, theright to life and freedom and security of the person.With respect to violence against children, the Constitutionstates in the Bill of Rights in Section 28 that inter alia, “everychild has the right to be protected from maltreatment,neglect, abuse or degradation”.South Africa is a signatory to the World Declaration on theSurvival, Protection and Development of Children(December 1993) and ratified the Convention on the Rightsof the Cild on 16 June 1995, a date that is celebrated asYouth Day in South Africa.The Domestic Violence Act No. 116 of 1998 prohibitsdomestic violence and sets out legal measures to affordvictims of domestic violence the maximum protection fromdomestic abuse.The DOD publicly made five commitments to prevent andeliminate violence against women and children inNovember 1998 and the action plan was approved in July1999. These commitments emanate from the SADCDeclaration on the Prevention and Eradication of Violencein March 1998 hosted by the South African Department ofJustice. Subsequently the SADC Heads of State adopted thedeclaration on 14 September 1998 in Mauritius. Every year,during the campaign of 16 days of activism on no violenceagainst women, the DOD is required to publicly reportprogress being made on these commitments.GBV can be distinguished from other kinds of violence inthe sense that GBV is rooted in prescribed norms,behaviours and attitudes that are based on gender. GBV isviolence that attempts to establish or enforce genderhierarchies and perpetuate gender inequalities.GBV does not only occur in the family but also in theworkplace and in the general community, it can alsosometimes be condoned or perpetuated by the statethrough a variety pf polisies and actions.GBV includes, but is not limited to physical, sexual andpsychological violence such as wife beating, burning and8

Posed photograph taken by 5 ASUacid throwing. Sexual abuse includes rape and incest byfamily members, female genital mutilation, female feticideand infanticide, whilst emotional abuse includes actionssuch as coercion and abusive language.For the majority of women persistent insults, abuse,confinement, harassment, and financial and physicalresourse deprivation are even more than physical attacks.Such women live in a permanent state of fear and as a resultsuffer from sub-standard, mental as well as physical health.The World Health Organisation states that women havereported that the mental torture and living in fear and terroris undoubtedly the most profound and long-lasting effect ofGBV.Research shows that women who experience domesticviolence are more likely to visit a health worker with healthproblems related to abuse than they are likely to access anyother statutory service provider. Good medical evidence isvery important in obtaining convictions of perpetrators ofgender-based violence. Health workers must therefore beprovided with appropriate training and organizationalsupport because they play a vital role in the prevention ofgender-based violence.There are set procedures to follow in the DOD should anindividual be a victim of domestic violence or other acts ofviolence.In as far as domestic violence is concerned, it is importantfor DOD members to understand that all victims, includingchildren, have recourse to report the crime to the SAPS andthat they may apply for a protection order in the case ofphysical abuse in accordance with the Domestic ViolenceAct No. 116 of 1998.In as far as internal DOD procedures are concerned withrespect to domestic violence and other acts of violence thefollowing must be done:The victim must write a letter or phone the employer of theperpetrator or his/her immediate Manager/Commanderdetailing the kind of violence being perpetrated againsthim/her.If the victim is a minor, a neighbour or any concernedcitizen may contact the DOD on behalf of the victim. Anyhealth professional, teacher or any person who examines,attends to or deals with any child in circumstances givingraise to the suspicion that such child suffers from any injurymust report such suspicion.The victim must get an undertaking from the employer ormanager/commander in writing that the matter will beinvestigated promptly.If the domestic abuse takes place in any state ownedhouse/residence, the victim has the right to request that theMilitary Police should intervene if the life of the victim is indanger.The victim has the right to request a protection order fromthe military police if deemed appropriate.All cases or suspicion of domestic violence, rape andviolence against children must be reported to the socialwork officer who will initiate a multi-disciplinary interventionplan.9

The 4th Annual Phidisa Conference took place atthe Protea Edward Hotel, Port Elizabeth (otherwiseknown as the Friendly City) from 24 to 28 July2006. The conference was well attended, with over150 delegates from more than 19 different countries takingpart.The aim of the conference was to provide an opportunityfor Phidisa personnel and international delegates to meet,discuss, network and share experiences on the progressachieved so far at Phidisa, thereby assisting in futureplanning of the research programme.The theme of the conference was “The Optimal Conduct ofa Clinical Research Programme within a Military Context inthe Republic of South Africa”. To this end, delegates fromvarious armed forces highlighted best practices and futurestrategies in presentations on the challenges of HIV andAIDS prevention and care in the military setting at plenarysessions. Breakaway sessions into various “theme” groups(based on specialist expertise and clinical practice)addressed the progress made so far, and identified thechallenges faced at the various sites and new goals to bemet in the next year.The United States DOD HIV/AIDS Prevention Programme(US DHAPP) conducted concurrent sessions for Africandelegates from the various armed forces in a workshopmode, sharing knowledge and building capacity onsurveillance, opportunistic infections prophylaxis, motivatingbehaviour and approaches to anti-retroviral (ARV)management.Phidisa is a collaborative partnership between the USNational Institutes of Health (NIH), the SA DOD and theAustralian University of New South Wales. There are tworesearch protocols, viz Phidisa I and Phidisa II. Phidisa Ideals with patients who are HIV negative and positive andwho do not require ARV treatment; this includes children.Phidisa II is an ongoing randomised control trial (RCT)comparing the safety and efficacy of different combinationsof anti-retroviral treatment as provided to (“HIV positive,treatment-naïve, research-qualifying”) SANDF members andtheir dependants at six research sites in a military setting.There are three urban research sites, viz 1 Military Hospital(Pretoria, Gauteng), 2 Military Hospital (Cape Town,Western Cape) and 3 Military Hospital (Bloemfontein, FreeState); and three rural sites, viz AMHU EC (Mthatha, EasternCape), AMHU KZN (Mtubatuba, KwaZulu-Natal) and theproposed site at AMHU LP to open on 1 December 2006 atBa-Phalaborwa, Limpopo Province. Patients that do notqualify for the provision of ARVs in a research study receivetheir treatment at an “ARV rollout” site within the SAMHS.Valuable lessons are thus being learned from Phidisa interms of the provision of ARVs at these sites, particularlyrelating to deployments.The Surgeon General (SG), Lt Gen Vejaynand Ramlakan,officially opened the “Africa Day” at the Conference onThursday, 27 July 2006. In his opening address, he4th AnnualWritten by Dr Dhesi Achary (SSO Medical Services) Photographs by Lt John Shighlighted the partnership as signed in the bilateralagreement on 26 April 2005 between the US and SAgovernments with a projected programme schedule until 26April 2010, “… just two months before we host the 2010World Cup of Soccer, which is expected to be won byBafana Bafana”. He emphasised the value of sharedleadership and collective wisdom, which in the past sawSouth Africa being unshackled from the chains of apartheidand colonialism.The SG formally extended an apology for the nonattendanceof the Deputy Minister of Defence, Mr MlulekiGeorge, due to other political commitments, but remindeddelegates that Mr George is the identified politicalchampion of the project. He went on to reiterate the fact that10

Phidisa ConferenceverdloffCol Andrew Ratsela (National PI) is interviewed by themedia on various aspects pertaining to Phidisa II.The Surgeon General, Lt Gen Vejaynand Ramlakan, andCol Andrew Ratsela in duscussion during the Phidisa pressconference.Phidisa, as a research project, is very important not only tothe SAMHS but also to the wider Southern Africancommunity and, as such, the commitment and pledge madeby the various stakeholders hold testimony to this fact. TheSG highlighted the release of preliminary data and results asbeing a very significant milestone in the history of theproject. He congratulated the project on all the gainsachieved despite the numerous challenges it faced.Lt Gen Ramlakan then conceptualised the Phidisa project interms of the “Age of Hope”, the theme of hope as espousedby our Commander in Chief and President, President ThaboMbeki, in his State of the Nation Address earlier this year.However, he pertinently reminded delegates not to forgetthat the yardstick measure of any such research is the impactit has on the lives of ordinary Africans and the hope itprovides for them.The SG stated that Phidisa, being an integral part of thenewly established HIV/AIDS Directorate, was one of thebuilding blocks towards the establishment of the envisagedSAMHS Research Institute and must therefore be fullyaligned and integrated into the normal SAMHS structuresand systems. This will ensure both sustainability andcontinuity and assist in preparing for a “Life after Phidisa” asthe taking of ARVs is a lifelong commitment.Dr Cliff Lane, Director of Clinical Research at NIAID, NIHand a US Phidisa Executive Committee member, stated thatresearch is as robust as the supporting health care servicethat serves it. He reiterated that research is an integral partof the overall health care delivery system affording thepatient an option of voluntarily taking part in research asstandard of care after informed consent has been obtained.Careful thought must be given to all moral and ethicalconsiderations, as well as established standards inconducting such research. Recruiting and retaining patientson the research for the full duration are critical to thesuccess of the research, and he expressed that the Phidisaproject and the “ARV rollout” project complement eachother.The Gala Evening on Thursday, 27 July 2006 at the PrinceAlfred’s Guard Hotel provided delegates with anextravagant exposure to local cultural items, which wasperformed in a brilliant array of dances, poems and musicemphasising the prevention and treatment messages of HIVand AIDS.In his closing remarks on Friday, the SG highlighted thenecessity to communicate the research results as far as ispossible to all stakeholders, that patient care must beprioritised irrespective of bureaucracy, and that the successof research projects depend ultimately on the impact wehave on lives. The big question that remains to be answeredis, “Does the research impact on the behaviour modificationof our soldiers?” He finally quoted a Chinese proverb, “Thatthe journey of a thousand miles begins with one step”, andthis leaves a long road ahead to be traversed.Thanks and appreciation for the success of this conferenceare extended to the acting OC AMHU Eastern Cape andher staff for the professional way in which they supported theconference organisers and delegates, the Henry JacksonFoundation and the Phidisa Executive Committee.11

Written by Dr Dhesi Achary (SSO Medical Services)Photograph by 5 ASUA nti-retroviral(ARV)RolloutOver the last 25 years, the HIV and AIDS (HumanImmunodeficiency Virus and AcquiredImmunodeficiency Syndrome) epidemic hasescalated worldwide to pandemic proportions.This pandemic has continued to highlight obstacles toprogress in the global development agenda. Of the eightkey areas covered by the Millennium Development Goals,six, namely reduced poverty and child mortality, increasedaccess to education, gender equality, improved maternalhealth and efforts to combat major infectious diseases; arebeing undermined by high rates of HIV in many low- andmiddle-income countries. Sub-Saharan Africa and inparticular, South Africa has experienced the mostdevastating impact of this epidemic.Since the cause of AIDS was identified in the early 1980s,standards of treatment and care have evolved considerably,primarily in high-income countries. Yet, the humanimmunodeficiency virus has spread across political, socialand economic boundaries much more quickly than have theclinical and public health responses that help curb theepidemic and its impact. Until recently, anti-retroviraltherapy (ART) was accessible only to the fortunate few, whilemillions were denied their fundamental right to benefit fromthe advances of science.In recent years an international consensus has emerged onthe need to fight HIV/AIDS with a comprehensive response,including treatment, care, prevention and impact mitigation.There has been a sharp increase in available funding forHIV/AIDS in low and middle-income countries, which hasmarked a new era in international public health, focussedon providing access to treatment, care and prevention forthe people most in need, despite poverty and other dauntingobstacles. The collective efforts of many countries and theirinternational partners have generated real momentum inscaling up HIV treatment and prevention.In South Africa, HIV and AIDS remains a major health riskand as such, is also a major health risk to the SA DOD. Ifthe HIV epidemic were allowed to continue unabated in themilitary, it would inevitably have a negative impact onnational security and the operational capability of the SouthAfrican National Defence Force (SANDF). The DOD wouldDifferent kinds of anti-retroviral drugs. Treatment is administered in theform of highly active anti-retroviral medication, as a triple combinationtherapy.thus not be able to fulfil its mandate towards the Republic ofSouth Africa.The SA DOD, having realised this impact, developed acomprehensive approach to the management of HIV andAIDS including the provision of ART. The approach, morecommonly known as Masibambisane, is based on the sevengeneric disease processes of prevention, promotion,diagnostics, treatment, rehabilitation, palliative care andresearch and development. It is important to note thatprevention interventions remain the foundation of HIVmanagement in the workplace and that prevention andhealth promotion should be integrated with treatment andcare to ensure a disease management continuum that startswith prevention and ends with terminal/palliative care.There are various enabling and/or crosscutting processes ofgovernance, communication, stigma and gender, riskmanagement, capacity building, monitoring and evaluationand cooperation and coordination that complete the12

strategic approach of the DOD towards HIV and AIDSmanagement.The vision of the DOD in this regard is to achieve a“Healthy and HIV – free” military community. The mission ofthe DOD in this regard is to provide a comprehensive,multi-professional, multi-layered, military specific responseto reduce the impact of HIV and AIDS on the operationalcapability of the DOD and all its officials, dependants andapproved clientele. So in terms of equality, and to ensure anon-discriminatory environment free of stigmatisation,officials in the DOD living with HIV and AIDS must betreated the same as any other official with a chronic,debilitating and life-threatening illness/disease.The Cabinet instructed the Minister of Health on 8 August2003 to plan for the rollout of ARV’s in the Public Sector.The South African Military Health Service (SAMHS), beingthe health care arm of the Department of Defence (DOD),had to follow suit. The Comprehensive HIV and AIDS Care,Management and Treatment Plan for South Africa is asignificant milestone both as a health sector intervention aswell as a socioeconomic enhancement strategy. TheNational Department of Health (NDOH) has establishedextensive minimum guidelines towards the achievement ofcomprehensive management of HIV and AIDS which formedthe basis of the program and plan for the provision of ARTin the DOD.The Comprehensive HIV and AIDS Care, Management andTreatment Plan (CCMT) for the DOD is therefore in line withthat of the NDOH plan. An important paradigm withinwhich the plan is conceived and developed is the reality thatsingular problems, including HIV and AIDS, can only beaddressed successfully in a context where the entire healthsystem is simultaneously being strengthened and developedto adequately sustain equitable and quality care whilepromoting healthy lifestyles. The plan envisions significantinvestments to ensure that the highest available quality ofcare is provided to approved clientele of the SANDF in linewith international and local norms and standards. The careand treatment protocols are thus based on internationalbest practice.The primary goal of ARV treatment is to decrease HIVrelatedmorbidity and mortality. ARV treatment aims toensure fewer opportunistic diseases and other HIV-relatedillnesses, to increase the immune function as measured bythe CD-4 count and to reduce the viral load to undetectableamounts.ARV treatment is offered to any individual that qualifies forsuch medication according to current policy. Theinfrastructure, human resource availability and capabilitiesof the Military Health Units may limit the availability offacilities that can provide such treatment, but it is envisagedthat the SAMHS will maintain at least one such facility inevery region.Accreditation of ARV treatment facilities according to theminimum standards set by NDOH is crucial to ensurequality of care within the DOD. These standards include thefollowing components:* Standard facilities (Physical) that is accessible andadequate with reliable electricity and safe waste disposal* Standard data reporting and management informationsystems* Standard clinical services with regard to the capacity offacilities for diagnosis and treatment as well as referralsystems* Standard human resource capacity with regard to the onsiteavailability of particular categories of health careprofessionals (multidisciplinary approach)* Standard human resource competency of on-sitepersonnel to provide ARV care, management and treatmenttherefore specialist training in this regard is essential* Standard diagnostic services available* Standard pharmacy capacity to manage HIV treatmentprotocols* Standard care and support services, including linkages tocommunity support structures* Standard access requirements to ensure patientaccessibility and transport of patients, laboratory specimensand drugs/consumablesGeographical considerations have guided theestablishment of ART facilities to ensure that all members ofthe Department of Defence can access ART that qualify fortreatment. The DOD provides ART through research andnon-research sites. Six ART research sites through ProjectPhidisa have been established at 1, 2, and 3 Militaryhospitals; Mthatha, Mtubatuba and Ba-Phalaborwa that willbe opening on 01 December 2006 co-inciding with WorldAIDS DAY. In addition, six other ARV rollout sites have beenaccredited in partnership with the NDOH at 1, 2, and 3Military hospitals, Nelspruit, Potchefstroom and Durban. Tenmore sites are envisaged to be accredited in the next year toensure wider access to treatment sites.Healthcare professionals involved in the management ofARV’s have received accredited training, as sponsored bydonor funding from DFID (British Government), inpartnership with the University of Pretoria. To date,approximately 150 HCP’s, have been trained from thevarious sites. Further hands-on practical training, updatesand refresher courses form part of the ongoing professionaldevelopment.The objectives addressing the acquisition of medicationnecessary to provide anti-retroviral treatment to membersand their dependants, as well as the cost of diagnosticinvestigations is currently supported through donor fundingfrom the US President’s Emergency Plan for HIV and AIDSRelief (PEPFAR). However, funding allocated as aConditional Grant by the SA DOD to combat HIV and AIDSis an indication of sustained commitment to fight HIV andAIDS and that the accumulated cost in this regard will betransferred soon to the departmental budget.All members are encouraged to visit their nearest MHUsickbay, PHIDISA clinic or ARV clinic to get tested and knowtheir status in order to access comprehensive treatment andsupport, including the provision of ARV treatment.It must be noted that, ARV treatment is not a cure forHIV/AIDS but does improve the quality of life of an HIVinfectedperson making HIV/AIDS, a chronic manageabledisease.13

14On 1 September 2006 the report on the fifth HIVKAP study in the South African Department ofDefence (DOD) was released to the SurgeonGeneral. The KAP study measures changes in theKnowledge, Attitudes and Practices of DOD officials inrespect of HIV and AIDS. The focus of the KAP study is theprevention of HIV infections. The first study was conductedin 2001, making this the longest running replicated healthsurvey in the DOD. The results of the 2004 HIV KAP studywere published in the previous issue of MILMED (Van Breda,2006).MethodologyA cross-sectional research design was followed todetermine the knowledge, attitudes and practices of thepopulation at specific points in time. This allows forcomparisons to be made of the population over time. Thismethodology, often termed BSS (behavioural surveillancesurvey) methodology (Family Health International, 2000), is“based on classic HIV and sexually transmitted disease(STD) serologic surveillance methods” (Utomo &Dharmaputra, 2001, p. 6). This is the methodology used byour Department of Health, for example, in the antenatalclinic HIV and syphilis prevalence surveys (NDOH, 2005).Surveillance survey research does not evaluate a specificintervention/programme (Family Health International,2000, 2001). Rather it is able merely to track changes overtime in various constructs that are relevant to theprogramme. It is not possible to attribute such changes, withcertainty, to the specific programme. The role of a specificprogramme, such as Masibambisane, in causing suchchange can, however, be suggested by the sequencing ofindicators. If there is evidence of programme rollout, ofincreased knowledge and attitudinal change and of reducedrisk behaviour, then there is reason to believe that areduction in seroprevalence may, at least in part, beattributable to that specific programme.SampleIn the 2006 KAP study, a five percent sample of the DODwas drawn, using quota sampling. Service, region, genderand rank were used to construct a proportional sampleframe. A total of 3 652 questionnaires were sent out, ofwhich 2 721 were returned adequately (ie at least two thirds)completed, giving a 74.5% national return rate and a 3.7%sample of the DOD. This sample meets the criteria ofrepresentivity and the results of the KAP study can, withconfidence, be generalised to the DOD population.This excellent return rate is a tribute to the HIV Nodal Pointsin SAMHS units. They have taken ownership of the KAP studyand worked tirelessly and assertively to collect the requireddata. Four units, AMHU EC, AMHU NW, AMHU NC and 2Mil Hosp, returned 100% of their questionnaires, whileAMHU KZN, 3 Mil Hosp and IMM returned 90% or more.HIVWritten by Lt Col Adrian van Breda(Military Psychological Institute)Photograph by Military Psychological InstituteCongratulations to these seven units for their excellentparticipation in data collection!Key FindingsAlthough in 2006 statistically significant improvements (atp < .01, using the Mantel-Haenszel chi-square test) wereseen in 18 of the 30 indicators (60%), this is less than in2004, where 21 of 31 indicators showed improvements(68%). Furthermore, in the 2006 study three indicatorssignificantly deteriorated, whereas in 2004 no indicatorshad deteriorated.Overall, this suggests that the HIV prevention programme,while still showing improvements over time, is in need ofrevitalisation and refocusing. This finding is consistent withthe impressions obtained through site visits, discussions withHIV Nodal Points and reviews of reported HIV projects.These data in combination point towards a great need for areview of the HIV prevention programme of the SA DOD.RecommendationsBased on the findings of the KAP study, the following sevenrecommendations were supported by the Surgeon General:Programme Implementation. The comprehensive rollout ofthe HIV programme remains low – only 49% reportexposure to workplace programmes in the previous 12months and 57% report exposure to HIV training in theprevious 24 months. HIV workplace programmes must beestablished in every DOD unit. These programmes shouldbe managed by the unit’s Military Community DevelopmentCommittee (MCDC), which should be chaired by the unitofficer commanding, with SAMHS personnel in an advisoryrole.HIV Prevention Training. The increase in exposure to HIVtraining found in the KAP study contradicts the reduction inreported HIV training found in the HIV Projects Database.This suggests that KAP participants have a broaderdefinition of ‘HIV training’ than we do. The quantity, typeand quality of HIV prevention training provided to DODmembers should thus be urgently improved. Brief, largescale,information sessions (mass awareness programmes)

KAP Studyshould be avoided. HIV prevention training should be runwith small groups of approximately 10-20 participants overat least ten hours, with periodic refresher training thereafter.Risk Behaviour. Sexual risk behaviour remains high (32%),with clear indications that it is associated with higher risk forSTIs and HIV. HIV prevention programmes need to targetrisk behaviour more aggressively, with stronger emphasis onthe reduction of the number of sex partners. Faithfulnessremains a crucial component of HIV prevention.Condom Use. Knowledge of condom use remains verypoor, with no sign of improvement in five years. Forinstance, a third (35%) of respondents in 2006 still believethat an oil-based lubricant (eg baby oil) can be used oncondoms. This poor knowledge is compounded by lowlevels of condom use among those engaging in riskbehaviour (31%). Furthermore, almost half (47%) therespondents in 2006 report negative attitudes towardscondom use. In light of these findings, training in thecorrect use of condoms, combined with training in condomnegotiation within a sexual relationship, is essential.OHS Training. Knowledge of self-protection when assistingan injured person who is bleeding remains low (50%), withno sign of improvement over the five years since 2001.Such knowledge should be addressed through training andmass awareness.Stigma and Discrimination. There appear to be concerninglevels of stigmatising attitudes towards people living withHIV and AIDS (ranging from 37% to 55%). A subprogrammeon the prevention of stigma and discriminationin the workplace should be established and qualitative dataobtained to provide further clarity on how to address thisissue. Units that have developed programmes addressingstigma and discrimination are encouraged to report these tothe Director HIV.Young Privates. Young privates (under the age of 25)remain an extremely vulnerable group – 40% of these youngpeople engage in sexual risk behaviour, compared with 32%of the entire sample. A concerted effort to reduce riskbehaviour among young privates, as early in their career aspossible, is an essential part of reducing the HIV prevalenceof the DOD as a whole.ReferencesFamily Health International. (2000). Behavioral surveillancesurveys (BSS): Guidelines for repeated behavioral surveys inpopulations at risk of HIV. Arlington, VA: FHI. Available:http://www.fhi.org/en/aids/wwdo/wwd12a.html#anchor545312 [2004, May 25]Family Health International. (2001). Evaluating programsfor HIV/AIDS prevention and care in developing countries:A handbook for program managers and decision makers.Arlington, VA: FHI.Available:http://www.fhi.org/en/aids/impact/impactpdfs/evaluationhandbook.pdf [2004, May 25].NDOH. (2005). National HIV and syphilis prevalencesurvey: South Africa: 2005. Pretoria, RSA: NationalDepartment of Health. Available: http://www.doh.gov.za/docs/hiv-syphilis-f.html [2006, August 11].Utomo, B. & Dharmaputra, N.G. (2001). Findings of theBehavioral Surveillance Survey (BSS 1996-2000) on femalecommercial sex workers and adult male respondents (FCO# 87530 BSS V). Indonesia: Centre for Health Research,University of Indonesia.Available:http://www.fhi.org/en/HIVAIDS/pub/Archive/bss/index.htm [2006, September 27]Van Breda, A. D. (2006). HIV KAP Study: Key findings for theSAMHS. Milmed, 22(3), 15.Left to right: Mrs Susan Brummer (research assistant), Lt Col Adrianvan Breda (study leader), S Sgt Geoffrey Poley (study administrator).15

1 Military Hospital toCompiled by Lt John SverdloffPhotographs by 5 ASU161Military Hospital is to under go a repair andmaintenance programme (RAMP) early in 2007. Thepurpose of RAMP is to repair government-ownedfacilities to a fully functional state and to maintainthem for a period of three years. The National Departmentof Public Works (NDPW) project manager, Mr Johann de Witfrom NDPW Head Office in Pretoria, will manage the RAMPprogramme for 1 Military Hospital.Consultants are appointed to design, document andmanage individual facilities. In the case of 1 MilitaryHospital the appointed consultant for the mechanical andelectrical infrastructure, as well as for the building structuraland wet services, is Stewart Scott International. The hospitalmanagement, headed by the Officer Commanding, BrigGen Zola Dabula, was a crucial component in themanagement of the RAMP contracts at 1 Military Hospital.The external project manager is Multi-Pro Cost Engineering.Devereaux Pienaar and Nelius Louw from Multi-Pro will beinvolved in the management of the project.The procurement process for 1 Military Hospital has beencompleted. Superway (Pty) Ltd was appointed on 5 October2006 for the building structural and wet services, andFastmove Electrical cc was appointed on 12 October 2006for the mechanical and electrical infrastructure. Theduration of each contract is three years, with maintenanceof the facility starting on day one of the three-year period.The repair period also starts on day one, with repair periodsof 24 months and 18 months respectively. Maintenance ofthe facilities starts from day one and consists ofmaintenance prior to completion of repair, andmaintenance after completion of repair. Maintenance priorto completion of repairs entails maintenance of allequipment that is in working condition, and is not includedin the repair scope of work. Once all the repair work hasbeen completed the total maintenance of all the equipmentand installations becomes applicable.The purpose of the repair phase is to reinstate the facility toa fully functional state that can be easily maintained. 1Military Hospital is approximately 30 years old and many ofthe mechanical, electrical, wet services and other systemsare past their economic lifetime and must be repaired, orreplaced in instances where repair is not possible. All thewet services will be replaced, fittings will be replaced orrepaired as required, cracks will be repaired, all buildingswill be cleaned and painted, roofs will be repaired andwaterproofed, etc. Work on the mechanical and electricalservices will, inter alia, include the replacement of thecentral heating system and the steam and condensate pipereticulation systems, and repairs to the air conditioningsystem as well as to all other mechanical systems, includingthe kitchens, laundry, swimming pool, medical gas systems,refrigeration systems, etc. The security and access control

eceive Upgradesystem will be repaired and reinstated, electrical systemssuch as the emergency diesel generators, transformers, HTand LT systems, lights and light fittings, switch socket outlets,electrical distribution panels, etc, will be repaired andserviced. In short, the entire envelope of all the buildings at1 Military Hospital, as well as all the associated mechanicaland electrical services, will be repaired, serviced andmaintained during the next three years.All breakdowns will be reported at a central point in 1Military Hospital, from where it will be logged at a 24-hourcall centre. The call centre logs the breakdown with therelevant engineer, who will inform Superway or Fastmove,who will in turn be responsible for rectifying the breakdownwithin the specified time. There is control mechanisms inplace based on a points and penalty system, whereby acontractor will be penalised if repairs are not done within aspecified period.Construction activities in an occupied environment aredifficult and disruptive, even more so at health careinstitutions. It will therefore be of utmost importance that allactivities at 1 Military Hospital be carefully managed,controlled and coordinated between all stakeholders.A number of planning meetings were held with Gen Dabulaand his staff, where it was decided that the best approachwould be to make an entire floor of the hospital availablefor repairs. Once repaired, the floor will be handed back tothe hospital and the contractors will move to the next floor.A similar approach will be followed with the single quarters,flats and houses. Progress, planning, coordination andtechnical meetings will be held on a continuous basis tomanage and control this enormous repair process.The fire safety upgrade will be running concurrently with therepair and 36-month maintenance programme (RAMP) andboth will be coordinated by a common project managementconsultant appointed by the Department of Public Works.The post-maintenance period will be carried out by theDepartment of Public Works after the fire safety upgradeand/or RAMP cycle has been completed.1 Military Hospital will make available one full floor or workarea at a time so that both fire safety & RAMP contractorscan work together to minimise disruptions to the hospital.The work area will be cordoned off against dust andtrespassing. There will be a dedicated access corridor andlift for contract personnel.Considerable understanding and patience will be requiredby all parties during the next two years. The end result will,however, be a functional, neat and clean facility without theproblems it currently experiences.FIRE SAFETYKhatima Engineering Services, who will be responsible forthe fire safety upgrade of 1 Military Hospital, started theirplanning process in February 2005, with the tender beingawarded at the end of November 2006. Completion of thefire safety upgrade is scheduled for the end of November2008, with maintenance guarantees until the end ofOctober 2009.The rectification programme will include the servicing of firehose reels, extinguishers and sprinklers; the replacement ofkitchen canopies in the kitchen (found in recorded history tobe the main source of fires in the kitchen); the installation ofan electronic system controlling the zoning of emergencyareas, including communications; the upgrading of firedetection and controlled smoke extraction measures; andthe installation of emergency illumination in passage waysand staircases.The rectification programme will include the servicing of the sprinklersystem at 1 Military Hospital.Roofs will be repaired and waterproofed.17

Exercise LANCETMass Casualty ExerciseWritten and photographed by 2Lt Sello SegoneThe mass evacuation exercise component ofExercise LANCET took place in scorching heat atthe Combat Training Centre in Lohatlha on 24October 2006. Witnessing the spectacle were theDirector Military Health Force Preparation, Maj Gen A.J.Landman, the Chief Director Military Health Force Support,Maj Gen L.Z. Make, Maj Gen M. Radebe from theDepartment of Health, and senior members from the Officeof the Presidency and the Department of Health, especiallythose responsible for the 2010 Soccer World Cup, as invitedguests. The exercise was aimed at preparing the SouthAfrican Military Health Service for their training in themanagement of mass casualties if called upon to supportany eventuality during the 2010 Soccer World Cup.The management of the exercise was carried out by way ofa pre-exercise training programme conducted by theUniversity of Cape Town. This also served as a catalyst toenhance the training of health professionals in theevacuation of patients. One of the unique features of theexercise was the use of rail as opposed to air and roadevacuations.The scenario of the exercise involved a war simulationbetween South Africa and the fictional nation of Kabana.Kabana was attempting to occupy the mineral-rich area ofthe Northern Cape. 43 SA Bde was situated in Lohatlha,where a level 1 medical post was deployed next to theDippies runway as a stabilisation facility for all evacuationscoming in by rotor craft. Trying to counter all military actionsof 43 SA Bde was the Kabana Defence Force, situated onthe Pomfret-Kuruman-Barkly West axis.A C130 aircraft took off from a gravel runway atAasvoëlkop carrying 64 parabat soldiers from 44 ParaRegiment. During take-off, at an altitude of approximately100 m, the aircraft was involved in a midair collision withanother C130 carrying 72 troops from 9 SAI Bn and 5 crewmembers. Both aircraft had exploded upon impact, whichresulted in burning pieces of aircraft plummeting to earthonto the airfield. On the airfield two infantry platoons from9 SAI Bn had been formed up, waiting to depart with theincoming C130.The impact of the collision ripped the total fuselage of theC130 troop carrier apart just before landing, scattering thepassengers over a large area. The troops on the groundwere hit by flying debris, burning fuel and falling bodies.The level 2 field hospital, as part of the medical teamsupporting 46 SA Bde, was moving through the area fordeployment, but was not yet ready to receive casualties. Amedical train envisaged to transport casualties to a level 3specialist hospital in Kimberley accompanied the hospitaland was stationary at Bulkop station.The medical task force commander (MTC) made a decisionto task the level 2 field hospital commander in support of 46SA Bde, to assume command of the situation, appoint ascene commander and send the total staff component of thefield hospital into the scene to assist with casualties. He alsodetached a task team from the medical battalion groupsupporting 43 SA Bde under his operational control.The field hospital had with them a platoon of first aidersfrom the St John Ambulance Brigade, who had been calledin as part of the national reserve of the Surgeon General toact as first aiders taking care of civilians injured in battle.They were also tasked to deploy to the scene.The medical task group commander instructed his taskteam deployed in the area to support the emergency by reroutingall available Mfezi ambulances with personnel to thescene. The task team commanders waited for guidelinesfrom the level 2 field hospital commander as to where theambulances had to assemble.18

The medical task group commander ordered the level 1medical post and the task team on the perimeter of theairfield to prepare with utmost urgency to receive casualtiesand to stabilise them prior to evacuation. He placed thelevel 1 medical post and all ambulances under operationalcontrol of the level 2 field hospital commander for thepurpose of addressing the crisis.Due to the field hospital not yet being deployed, thedecision was made by the commander to evacuate allcritical casualties by air directly to the closest level 3specialist hospital ready to receive casualties, 300 km awayin Kimberley. The priority 2 and 3 casualties were evacuatedto the level 2 field hospital of 43 SA Bde at Hotazel.The medical train, set-up on the nearby Bulkop station, wasmade available for evacuations, as was a fixed-wingaircraft. As the airfield was blocked by debris, the closestlanding area was the Sishen airfield.A C130 troop carrier was re-routed to wait at the airfield atSishen to transport casualties to the level 3 specialisthospital in Kimberley. The aircraft had no medical personnelonboard, but was rigged to receive stretchers.The medical train had the capability of transporting 56patients by stretcher, 39 lying patients in sleeper coaches,and 74 sitting patients.Due to road conditions and enemy action by forwardelements of 23 Bde of the Kabana Defence Force, themedical task group commander made the decision not touse road evacuation further back than the Sishen airfield.The railway line to Hotazel had, however, been secured by43 SA Bde and was functional.The exercise had 40 mentors who assisted staff members incarrying out various functions. Approximately 180 membersfrom different units in the SAMHS took part and wereaccompanied by support elements from the SA Army, the SAAir Force and the St John Ambulance Brigade.Assistant Brigade Manager of the St John AmbulanceBrigade, Ms Jozelle Steenkamp, said that brigade memberswho had taken part in the exercise were responsible for theinitial treatment of priority 3 patients on the scene; helpingto extract the injured from the scene to the secondary triagepost; and helping in the loading of patients into thehelicopter. She further mentioned that their interaction withmembers of the SAMHS had gone well as they had had theopportunity to learn and also exchange ideas.Col Theo Ligthelm, Officer Commanding the School forMilitary Health Training, described the whole exercise as auseful learning process as it contributed to the testing andfinalisation of a doctrine aimed at addressing mass casualtyevacuation in the SAMHS and South Africa as a whole.At the end of the exercise the Surgeon General thanked theExecutive Manager of Spoornet and all support staff, theChief of the SA Army, the Chief of the SA Air Force and allsupporting units, the Manager of the Kimberley Airport and,most importantly, all personnel who took part in theexercise. He mentioned that such exercises are contributingfactors in striving to make the SAMHS a world-classorganisation.19

IBBT Congressplaces emphasis on battlefield traumaCompiled by Lt John Sverdloff Photographs by Lt Col Sally Buckton (AMHF HQ)Two hundred and fifty local and foreign delegatesrecently attended the Armscor/SAMHSInternational Blast and Ballistic Trauma Congressheld at the Armscor conference facility in Pretoria.Countries represented included Australia, Bosnia-Herzegovina, Canada, Egypt, Germany, the United States ofAmerica, the United Kingdom and the Russian Federation.The purpose of the congress was to afford delegates theopportunity to interact with one another and to discuss onan international level the impact, treatment and preventionof blast and ballistic trauma in terms of both military andcivilian casualties who are caught up in conflict situationsthroughout the world today. It furthermore allowedengineers, scientists, medical professionals and projectofficers an opportunity to learn how the rest of the world isprogressing in this technological area.More than thirty scientific presentations were made duringthe congress, which included Blast and Ballisticsmechanisms of Injury, Blast Trauma of the Abdomen, Pre-Hospital Management, Robotic Combat Casualty Extractionand Evacuation, Tactical Combat Casualty Care andExtremity Trauma Management of War Wounds.During his opening address the Surgeon General, Lt GenV.I. Ramlakan said, “Fortunately, South Africa has not beeninvolved in any mine or non-accidental blast situationsduring the last 14 years. This, however, emphasises theimportance of learning from our colleagues who areinvolved in these incidents more recently to keep our skillscompetent.“Mine and IED (improvised explosive device) awarenesstraining is the activity that can have the most immediateimpact on reducing the suffering caused by such weapons.Such training, coupled with education in self-aid and buddyaid for victims, has been shown to greatly reduce the injuryand death rate.“This needs to be followed by competent emergency care20

within the proverbial golden hour and effective evacuationprocesses. The need for proficient medical and nursingpersonnel receiving the casualty, maintaining control overbleeding and implementing definitive care cannot beoveremphasised. I hope that this congress will benefit all themilitary medical services present, to achieve this.“During the past decade South Africa has established awell-defined national arms control and non-proliferationpolicy and control system that is embedded in legislation;for example the National Conventional Arms Control Actand the Non-Proliferation of Weapons of Mass DestructionAct.“As a responsible member of the international communitySouth Africa has also acceded to a number of internationalarms control and non-proliferation agreements, such as theNuclear Non-Proliferation Treaty, the Chemical andBiological Weapons Conventions, the Missile TechnologyControl Regime and the Nuclear Suppliers Group.“To limit these horrendous injuries South Africa is party tothe Conventional Weapons Convention, which controls orprohibits the use of weapons with non-detectable fragments;mines and booby traps; incendiary weapons and blindinglaser weapons.“South Africa is also a state-party member to the OttawaConvention, also referred to as the Mine Ban Treaty, whichprohibits the use, stockpiling, production and transfer ofanti-personnel mines. This Convention also requires statepartiesto destroy all stockpiled anti-personnel mines,including mines currently planted in the soil, within aspecified period of time.“The South African National Defence Force (SANDF)strategy and concept of operations, which are aligned withgovernment intent and policy, are clear - we will deploy andserve in Africa to promote peace and stability in our region.The much spoken about ‘African battle space’ must now beanalysed and defined so that it can guide our doctrine anddevelopment of our weapons systems, our treatmentregimes and our evacuation resources. We need Africansolutions and we must work towards interoperability ofarmies in our regions. Since 2003, the SANDF has becomeinvolved in central Africa on a significant scale. I am surethat this fact not only creates unique opportunities for ourlocal industry but also holds serious challenges in optimalcombat casualty care.“When users, like ourselves, specify our vehiclerequirements for wheeled armoured vehicles, we tend to laydown stringent specification to meet our firepower, mobilityand survivability requirements. Furthermore, we want thisequipment to cost as little as possible and we always needit urgently.“This is always a challenge to engineers and scientists andit is up to them to come forward with an affordable solutionthat is well balanced. By affordable I mean it is affordablethroughout the lifecycle of the weapons system.“The tools available to scientists and engineers today aremuch more advanced than 30 years ago and vehicles aremore optimised. The man-machine interface is bettermanaged and soldiers experience better all-roundprotection in vehicles.“When I look back into history at the South African vehicledesigns, I realise that we have come a long way in thedevelopment of mine-protected vehicles. South Africa isdelivering vehicles to various foreign countries, including theUSA, Sweden and the United Nations. These products havecontributed to the saving of many soldiers’ lives.“The SANDF is mindful and appreciative of the work doneon its behalf by Armscor and the industry. It is throughdesign and a systems approach that acquisition andtechnology development for the SA Army was entrusted tothe said parties as part of the transformation of the DOD.“The motto of the South African Military Health Servicesummarises the purpose of this congress - We save theBrave. As medical personnel or engineers we are all herebecause we believe that we can contribute to saving thebrave - be it an innocent bystander or weathered soldiers.”Over the last 60 years, anti-personnel mines have causedmore deaths and injuries than nuclear, biological andchemical weapons combined.The International Committee of the Red Cross estimatesthat 800 people are killed by mines every month, andanother 1 200 are maimed: a total of 2 000 victims amonth. This means that one person is either maimed orkilled by a mine every 20 minutes. Most of these victims arecivilians killed or injured after hostilities have come to anend.Anti-personnel (AP) blast mines shatter the foot and lower leg portion of a victim. This usually results in the amputation of the lower leg or foot,depending on the size of the mine.Left photograph - the effects of a 100 g test on a mine-protected boot (boot in top right hand side of picture).Right photograph - the after-effects of a 100 g test on a standard boot (left) and a mine-protected boot (right).21

22IBBTCNearly a third of mine victims have at least one limbamputated. In the United States of America, there is onaverage one amputee per 22 000 inhabitants. InCambodia, one of the countries worst affected by mines,there is one amputee per 384 inhabitants. Angola, with oneamputee per 334 inhabitants, has the highest rate ofamputees per inhabitant in the world; about 1,5% of thepopulation has been injured in mine or unexplodedordnance incidents.Increasingly, mines have shifted from being primarily adefensive, tactical battlefield weapon, to being an offensive,strategic weapon. It is often aimed deliberately at civilians inorder to empty territory, destroy food sources and createrefugee flows, or simply to spread terror. Such use has beenespecially prevalent in internal conflicts involving insurgentsor other types of unconventional forces. This is partlybecause of the limited financial and material resources ofinsurgent forces (mines are cheap), and partly becausemines are particularly effective in terrorising civilianpopulations for political gain. However, governments andconventional armies have also practised mine use againstcivilian populations. Targeting civilians in this way is ablatant violation of international humanitarian law, whichexplicitly bans such practices.Mines are, however, not the only form of blast trauma. InIraq, the United States has experienced severe casualties,specifically from the new weapon of the day, improvisedexplosive devices or so-called IEDs. These devices vary froma liquid petroleum gas cylinder with artillery shells tiedaround it and detonated from a distance, to massive truckbombs constructed of tons of explosives. The United Stateshas already lost 2 400 soldiers and almost 18 000 havebeen injured in this conflict, mainly due to blast and ballistictrauma.These devices cause unspeakable suffering as they inflictappalling physical injuries, which often lead to amputation,severe disability and psychological trauma. Dirt, debris,metal or plastic fragments from the casing, vehicle andenvironment may be driven deep into the bodies of victims.Treatment is needed urgently, with surgical intervention farforward and close to injury often the only lifesaving optionto control bleeding.Surgeons who treat such injuries daily consider them to beamong the most horrendous of war injuries and haveexpressed profound abhorrence for the effects andcontinued use of IEDs.Suicide attacks, where the blast is caused by detonatingexplosives often wrapped around the body, have even moreunique challenges. Shrapnel and bony fragments from theattacker intermix to penetrate deep into often-innocentbystanders.MARITIMEEMERGENCY CARETRAININGWritten by Maj Ezra Peterson (OIC MECTS) Photograph by MECTSThe Maritime Emergency Care Training Satellite(MECTS) is a subunit of the School for MilitaryHealth Training (SMHT) in Pretoria. The OfficerCommanding SMHT is Col Theo Ligthelm.The MECTS is situated in the Red Hill Mountains in Simon’sTown, and overlooks the picturesque False Bay and theNaval Dockyard.The satellite was established in November 2001 to servethe Western Cape and the SA Navy with maritimeemergency care training programmes. Since the inceptionof the MECTS we have trained approximately 3 000members in the fields of Maritime First Aid level 1 & 2;Industrial First Aid level 1, 2 & 3; Military Basic AmbulanceAssistant (MBAA); and Maritime Vocational Orientationtraining for operational emergency care practitioners(OECPs). We presented our second MBAA learningopportunity during 2006.The following learning opportunities are presented:* Military Basic Ambulance Assistant* Maritime Vocational Orientation* Maritime First Aid level 1, 2 & 3* Industrial First Aid level 1, 2 & 3* Cardiopulmonary Resuscitation (CPR)There is a joint training relationship with SAS Simonsberg,especially with the Nuclear Biological Chemical Defence(NBCD) section.“We have a joint training relationship with SAS Simonsberg,especially with the Nuclear Biological Chemical Defence(NBCD) section on board the vessel, and we utilise theirsimulators for outcomes-based training.“We are very proud to belong to the MECTS and theSAMHS. The staff is very dedicated and loyal to theorganisation”, said the officer in charge, Maj Ezra Peterson.

TRAUMA NURSINGCore CourseWritten by Maj Grobbelaar (SMHT) Photographs by SMHTIn an analysis of the lessons learned during variousoperations and joint exercises it has become apparentthat the nursing officers of the SAMHS are generally notprepared to fulfil their operational health support role inmanaging trauma victims and man the casualtydepartments of a level 2 field hospital.To address the issue, the School for Military Health Trainingnegotiated with the Emergency Nurses Association (ENA) ofthe US to rollout the Trauma Nursing Core Course (TNCC)in the SAMHS in order to prepare the nursing officers fortheir role in manning the facilities of a level 2 field hospital.The TNCC is at present used by the US Defence Force inpreparing their nursing officers for combat casualty care. Itis also presented in the UK, Australia, the Netherlands,Canada and Sweden for both civilian and military nursetraining. With the approval of the Surgeon General thiscourse rolled out in the SAMHS during August 2006. Ateam of four lecturers from the ENA visited the School forMilitary Health Training over the period 11 to 26 August2006, under the leadership of Vicky Patrick from theUniversity of Texas at Arlington.Currently the SAMHS has the sole mandate for the next twoyears to present the TNCC in South Africa for the SAMHS aswell as members of the SADC countries.Learners attending the course need to obtain an 80% passrate in their written examination and be successful in theirskill station evaluations to be competent as TNCCproviders. In order to be invited as an instructor for theTNCC Provider Course a learner needs to obtain 90% in thewritten examination, be successful in his/her skill stationevaluations and meet the criteria to be invited as aninstructor.The first TNCC Provider Course was presented over theperiod 14 to 16 August and the first Instructor Course waspresented over the period 17 to 18 August. There arecurrently 17 competent TNCC providers and five TNCCinstructors. The first five SAMHS instructors presented theTNCC Provider Course over the period 21 to 23 August.Another six instructors were identified during this course andare currently being verified as TNCC instructors.The course qualification is only valid for a period of fouryears and the students need to then be re-verified. Thecourse is also internationally recognised as it falls under theauspices of the ENA, an international organisation.In future this course will form part of the Combat CasualtyCare Course, which will be presented by the School forMilitary Health Training prior to all deployments of medicalofficers, nursing officers and operational emergency carepractitioners.Susan Douglas, an instructor of the ENA, presenting the first TNCCProvider Course at the School for Military Health Training.Maj A. Mpooane and Capt B. Sibande, students on the first TNCCProvider Course, practising airway and ventilation intervention in thesimulation laboratory of the School for Military Health Training.Sally Snow, an instructor of the ENA, training students in spinalimmobilisation in the simulation laboratory of the School for MilitaryHealth Training.23

DOD/Denel programmedevelops latent talentWritten by Lt Maahir Pretorius Photographs supplied by DenelThe Department of Defence (DOD)/Denel YouthFoundation Training Programme (YFTP) aims tofully develop the potential of all the candidates thatpass through its doors. This programme will meetthe client requirements for the enhancement of theeducational qualifications of previously disadvantagedapplicants who apply for appointment in highly specialisedcombat, technical, health or financial occupations. Thisapplies mainly to Grade 12 mathematics, physical science,biology and accountancy symbols.Programme role players or stakeholders include the fourservices of the DOD, as well as the DOD FinanceDepartment, CMI and Denel.According to YFTP Manager, Col S.M. Pienaar, a strongemphasis is placed specifically on the academics and thepersonal development of each participant in theprogramme. This includes the development of leadership,confidence and self-fulfilment. The enrolment criteriastipulate that candidates must be between 18 and 21 yearsof age, must be SA citizens, must be in or have alreadywritten Grade 12, must have applied for or expressed aninterest in a career with the DOD, and must be medically fit.Furthermore, they must have had mathematics and science(biology or accounting) in their previous attempt at Grade12 and preferably be single with no dependants.Sponsorship to the programme includes tuition fees,accommodation (with meals), all books and equipment anda monthly allowance. However, the sponsorship does NOTinclude medical cover, private travel or clothing.Even though the focus is stronger on marginalised provincessuch as the Limpopo Province, the Northern Cape and theEastern Cape, this does not exclude candidates comingMaj Gen Ntshinga (GOC Training Command) receives a token ofappreciation from the Student Management Team Leader.from other rural parts of the country. However, the successrate of the programme determines its effectiveness. As from2001 the YFTP has seen the following achievements:· In April 2001 the first DOD YFTP started with 167 studentsfor the SAAF, the SA Navy and the SAMHS.· In January 2002 the YFTP prepared 187 students for theSAAF, the SA Navy, the SAMHS and SA Army. During Aprilanother 25 students for the DOD Finance Departmentjoined the YFTP, bringing the total to 212.· In January 2003 and 2004 the YFTP opened with 250students for the DOD.· In February 2005 and 2006 the YFTP opened with 250students for the DOD.Many of the achievers are currently serving in the DOD asmildents, therapists and nursing staff. Most of them arecurrently serving as military officers.Maj Gen Ntshinga (GOC Training Command) and Dr Brian Chinsami(CEO DCLD) interacting with physics learners.Prospective Naval learners “strutting their stuff” in front of their display.24

“A ge of Hope”dawns on 3 Med Bn GpWritten and phtographed Lt Maahir PretoriousDuring his speech at the official Opening ofParliament in Cape Town, our Head of State,President Thabo Mbeki, announced 2006parliamentary theme as the “Age of Hope”. Thesethree meaningful words became reality as 3 MedicalBattallion Group recently deployed their first Reserve Force(ResF) members outside the borders of the Republic of SouthAfrica.As South Africa’s involvement grows within the Africancommunity, so does the need for deployment and theadditional support of the ResF. According to the SAMHSSenior Staff Officer Reserve Forces, Col J.H. Lourens, this isa prime example of the one-force concept within theSANDF. The core function of the SAMHS is to providemedical support to the other services and divisions, andResF formations are frequently being called upon asadditions to the Regular Force during internal and externaldeployment.3 Med Bn Gp is currently the biggest ResF unit in the MobileMilitary Health Formation. This unit strives to continuouslytrain and develop its members throughout the widespectrum of its leadership. It is composed mainly ofvolunteer citizen-soldiers with a strong passion for thediscipline of the military culture. The Battalion HQ and atask group are situated in Goodwood, Cape Town, with agrouping of this task group stationed in Port Elizabeth, whilea second task group is situated in Potchefstroom.The Acting Officer Commanding 3 Med Bn Gp, Lt Col J.A.Fabricius, says the call to duty came as no surprise. “Thebattalion is rigorous in its approach to constantly prepareand train its members to be contingent ready and forcedeployable. Our pride and well wishes go out to S Sgt C.Mohammed, S Sgt E. Williams, L Cpl L.M. Gorekoang andPte S.G.S. Shinchunge (all operational emergency careorderlies). My sincerest gratitude, however, must go to thefamilies who so unselfishly and with great sacrifice allowthemselves to be separated from their loved ones.”3 Med Bn Gp is constant in the synergy of its members.Human resources officer, Maj N.A. Hanekom, states that,“We encourage a culture of continuous learning within ourranks. Our members are being developed through inservicetraining sessions, detached duties, functional andpromotional courses, military exercises, etc. As a leadergroup we have learned not to focus on the quantity of thebattalion only, but on the quality of our members. Inresponse to this paradigm shift we frequently receive positivefeedback on all our endeavours”.Beyond the normal daily tasks, the effectiveness of thebattalion is evident as it still reaches most of the set goals.S Sgt C. Mohammed stated before departing to Burundi,“What comes natural to the norm is considered honourableand a privilege to us. The distant promise and expectationsof external deployment have finally become a reality for us”.25

It’s all Volleyball in theWestern CapeWritten by Maj Amora Taljaard (2 Mil Hosp)Photograph by Capt D. BrandtThe Officer Commanding Area Military Health UnitWestern Cape, Col F.J. Matthee, opened theSAMHS Volleyball Tournament at the WynbergIndoor Sport Complex in Cape Town recently. Theunit played host to teams from Area Military Health UnitsGauteng, Free State, KwaZulu-Natal, Limpopo and theWestern Cape.This tournament afforded members of SAMHS volleyballteams the opportunity to be selected for further participationagainst an invitational volleyball team from Western CapeDefence, and also for participation in inter-armschampionships or tournaments.The guest of honour, Brig Gen J.A. Jansen, who is theSAMHS Volleyball Patron, handed over trophies and medalsto deserving members during the prize-giving ceremony atColenso, GSB Youngsfield. The SAMHS volleyball team wasalso announced.The overall winner was AMHU Gauteng, who boasted firstposition in the ladies and men’s team categories. Thecombined team of 2 Military Hospital and AMHU WC tooksecond place in both categories, with AMHU Limpopoplacing third in the men’s category and the AMHU KwaZulu-Natal ladies taking third place.It was once again proven that volleyball is truly a wonderfulsport that transcends all barriers of language, religion andrace and brings all players together in true friendship andDefence Force camaraderie.Brig Gen J.A. Jansen, SAMHS Volleyball Patron, handsover trophy to WO1 F. Roos as best Blocker.26LETTERSAddressed to the Surgeon GeneralDear Sir,Visits to hospitals tend to be most people’s least likedappointments. Once in a while a patient comes into contactwith professionals who make these visit a little lessunpleasant.I would like to commend the Physiotherapy Department at1 Military Hospital, and specifically Monique, one of thetherapists serving there, for the excellent quality of servicethey deliver.I have been in their care for a number of weeks and cantherefore personally attest to their absolute professionalism.Despite working in an environment in the hospital that is notparticularly physically appealing, the physiotherapists bringa sense of humanity and support, not to mention humour,which has a reassuring effect on patients.Monique, who was responsible for my series of treatments,in particular exudes a confidence and professionalism thatbelie her relative youth and left me with the feeling that I wasin very capable hands with nothing to worry about.She explained to me in terms I could understand what shewas going to do and why she was going to do it, and thendid it with expertise and understanding.All the people I met in the Physiotherapy Department addedvalue to the team and showed great “people skills,” bearingin mind that most patients probably tend to be emotionalfrom the outset because of the reason for the visit there.All the people serving there, especially Monique, are acredit to their profession, to the department they representat the hospital, the SAMHS and the DOD as a whole.It would be sincerely appreciated if you would pass thesesentiments on to the GOC of the hospital and thePhysiotherapy Department.Over the years it has been my experience generally thatpatients tend to voice their criticisms far easier than theirpraises. My family and I have only good things to say aboutthe care we have received from the “medics” over manyyears.Yours sincerelyCol John RoltSSO Projects, Defence Corporate Communication

Fund NewsSAMHS Fund NewsBANANA BEACH HOLIDAY RESORTMost members will be aware that this Resort, situated on thecoast approximately 100 km south of Durban midwaybetween Hibberdene and Port Shepstone, is wholly ownedby the Fund and has as its prime objective the provision ofaffordable holidays to Fund contributors who enjoysubstantial discounts throughout the year and preferentialbooking rights for the Christmas and Easter school holidays.In the 2005/6 financial year, the discount to contributorstotalled R980 000. This is the difference between actualincome and potential income if all units had been chargedat non-contributors’ tariff.The Fund was established in January 1980 and just overthree years later on 26 August 1983 it purchased NelsrusHoliday Resort at a cost of R500 000, which was amammoth transaction for the fledgling Fund. At that time theResort comprised the former owner’s house and 14thatched rondavels. On 16 February 1985 the Fundpurchased the adjoining caravan park at a cost of R560000, on which were erected 26 units of Swiss-chalet designplus an administrative block; manager’s flat; recreationhall; bar; staff quarters; stores and swimming pool at a totalcost of R4,8 million.When the Fund acquired Nelsrus the name was changed tothe SAMS Holiday Resort, which in turn was changed in1999 to the Banana Beach Holiday Resort. This latter namechange was made following our affiliation to RCI, as someof its civilian members were reluctant to visit the Resort asthey were under the mistaken impression that the SAMSHoliday Resort was a military camp!Left to Right Mr Petros Mquadi, Best Staff Member 2006(Gardens and Maintenance), Mr Kenneth Mzobe, BestStaff Member 2006 (Security), Ms Eunice Majola, TopEmployee of the Year 2006, Ms Witness Mzelemu, BestStaff Member 2006 (Housekeeping).Contributors can feel justifiably proud of being owners ofthis beautiful debt-free Resort, which is probablyconservatively worth in excess of R14 million since, forcapital gains tax purposes, the Resort was valued at R8,975million as at 1 October 2001. The valuer has, however,stated that in his opinion the current value is 50%-100%higher.It is with deepest regret that we must record the recentuntimely deaths of Mr Henry Bhengu and Ms EvidenceDuma, both of whom had been promoted to the managerialcadre as part of the Fund’s ongoing transformationprogramme. In 2004 Evidence was promoted tohousekeeper, where she made valuable contributions to theraising of standards. Henry joined the staff initially as a parttimebarman, was later appointed as a full-time securityguard and, until the time of his untimely death, wasChairman of the Workers’ Forum, which not only plays animportant role in maintaining good industrial relations at theResort but also regularly makes constructive suggestions onimprovements in the running of the Resort itself. In May2006 it was decided to promote Henry and Ms LucilleMoodley to the newly-created posts of trainee manager andto pay for their studies towards a resort managementcertificate. Regrettably Henry passed away before he couldtake up his new appointment but Lucille is continuing withher studies.The second Annual Staff Member of the Year awards tookplace during August. The choice of the Top Employee of theYear was difficult due to overall high standards maintainedby staff during the year, but it was eventually decided to givethe award to Eunice Majola, with the following personsbeing chosen as the best staff member in their respectivedivisions: -* Housekeeping: Witness Mzelemu* Garden and Maintenance: Petros Mquadi* Security: Kenneth Mzobe* Administration and Supervision: The late Evidence DumaStaff training courses presented to all staff by IndigoTraining have resulted in a general raising of standardsthroughout the Resort. All staff have also undergone Level1 First Aid Training and this course will be offered to newstaff members early in 2007. Four staff members have beenidentified to undergo Level 2 Training in this financial year.27

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