Special Hearings — Health Sector Hearings — 1997-06-17

GEN M KNOBEL: Thank you Madam Chairlady.  May I also say on behalf of the Medical Service that we appreciate the opportunity to be able to take part in the process of truth and reconciliation and to be allowed to make a presentation also at this meeting today.
 Before starting on the presentation I would just like to make the following remark and it pertains to some of the other presentations that you have already listened to.  The Medical Service has undergone a process of transformation which really started in 1979, and it will come out in my presentation why I refer to this specifically.
 In the period under discussion we have had four Surgeons General.  The original Surgeon General that was in the office from 1960 to 1969 was a General Raymond who is still alive but not in very good health at the moment.  His successor was General Cockroft who was the Surgeon General from 1970 to 1978.  He died some years ago.  His successor was my predecessor, General Niewoudt, he was the Surgeon General from 1978 until 1988.  I took over as Surgeon General in March 1988 and I will be retiring in December this year when General Masuko on my right, who is the Surgeon General designate, will take over the office of Surgeon General.
 Now why I refer to the process of transformation is that it actually deals with the period in which General Niewoudt became Surgeon General in 1978 and was continued by myself from 1988.  
 It is also important to note that all the Surgeons General that I have mentioned were all members of the Medical Council, not in terms of the office that they occupied, but as appointees of the Minister of Health, and likewise I also served on the Medical Council from 1988 onwards.  And you will see how our functioning intertwines closely with the functions of the Medical Council.  Hopefully when the new Act is promulgated that Mr Prinsloo referred to, the new Surgeon General will be a member of the Council in an ex officio capacity.
 I would like to call my presentation, "The South African Medical Service as a Unique Health Provider".  Internationally it is a standard principle that members of defence forces who risk physical exposure, injuries, disablement or death in the service of their country can depend on a dedicated health service that is professional, comprehensive, self-supporting and available anywhere and at all times.
 This international norm places a moral obligation on a country to make provision in its Department of Defence, for a Surgeon General, and a unique uniformed health service that can render military health support as its primary function.  This military health capability must be trained and fully incorporated into the doctrine and standing operational procedures of combatant forces.
 This implies military command and control, communications and logistics within the health capability that is unique in its own right and is markedly different from that of civilian health capabilities.
 Furthermore, this capability must be retained between conflicts since if this is not done, it will be impossible to provide the necessary health support to armed forces when required.  At the same time it is then available to the State in national health objectives and during other man-made or natural disasters.  
 The whole concept of a military health service is further aimed at the fact that no medical fund can or will be able to cover the casualties that might occur in an armed conflict, neither will it be able to act with the same discipline, efficiency, cost of activity and mobility required in a combat situation or during natural disasters.
 The South African Medical Service, through its diversity of health professions and infrastructure developed to render a comprehensive health service in support of forces in the field has a far broader capability than any medical aid scheme and this implies that although the organisation may be placed on a comparable hierarchial level the organisation cannot be compared directly with any medical aid scheme.
 This above introduction can be summarised as follows.  It is a unique strategic capability which is there firstly to ensure a healthy security environment, and secondly, to ensure a secure health environment. 
 The history of the Medical Service can be traced back to 1913 with the founding of the South African Medical Corp of the South African Army.  In the same year provision was made for the employment of volunteer nurses which system fell away in 1921 with the establishment of the South African Military Nursing Corp.  This created a second military health service.  Each had their own executive.
 The following year 1922 saw the creation of yet another military health service in the South African Air Force.  There were then three services and this endured until 1960 when the South African Navy also established a Medical Corp.  Now clearly we were on our way to having four different medical services within the Military. 
 1970 saw the first rationalisation with the amalgamation of the South African Medical Corp of the army and the South African Military Nursing Corp as the South African Medical Corp under one Surgeon General.  The other two arms of service remained, or the corps of service remained with their own medical services.  
 During 1979, and this is the period that I was referring to earlier on, the South African Medical Service came into existence under General Niewoudt fusing together the three military health services into a separate, independent arm of service of the National Defence Force, the so-called "fourth arm" of service.
 Now over the years of this transformation process the mandate of the Medical Service became clear and this is as it stands today.  It is derived from the following sources.  First of all the Constitution of the Republic of South Africa; secondly, the Defence Act; thirdly, supplementary legislation of which you can see the examples on the screen there, all of which impacts on all the statutory professions that are embodied in the South African Medical Service. Finally, also from the defence strategy of the Department of Defence, which in itself is derived from the Defence Review and the White Paper on Defence which is currently much in the news.
 The mission of the South African Medical Service is to provide and to ensure as part of the South African Government's Southern African strategy a military health service that is complete, comprehensive, self-supporting and available at all relevant times and places within the boundaries of our country and even outside if required, all of which to ensure the physical, the psychological and the social well-being of the entire military community, as well as other approved clients.  
 This mission is accomplished by a management philosophy which is based on the following principles.  Efficiency, cost-effectiveness, participative management, standards in keeping with international norms, professionalism, ethics in keeping with internationally accepted declarations and practice, future orientated and innovative, client-orientated, with equal opportunities with merit as basis, non-discriminatory in respect of race, gender, religion, culture and creed, enabling human resources development, and finally with an affirmative action programme towards a more equitable system.
 The guiding values within this management philosophy are, the fostering of all religions and religious tolerance; improvement of self-image and the promotion of a healthy and stable family life; better understanding of others and respect for values entrenched in the Bill of Rights and the National Defence Force Code of Conduct; a healthy social life; improvement of the quality of the working environment; promotion of nobleness of the professions; promotion of discipline and the maintenance of physical and mental well-being.
 Within that framework the functions of the Military Medical Service of the SAMS are the following - Primarily medical support to the South African National Defence Force and previous to the National Defence Force to the South African Defence Force. Further, Military Medical cooperation and assistance as and when required and as instructed by the Government.  Thirdly, Medical support to the South African Police Service and the Department of Correctional Service.  Fourthly, in the preservation of life, health and property.  Furthermore diplomatic assistance operations, disaster relief operations.  Support to other State departments resulting from the unique capabilities that are found in the Medical Service.  Support to any State department in socio-economic upliftment programmes.  Finally, provision and maintenance of essential health services.
 A word about the clients.  Primarily, clearly the South African National Defence Force and all their dependents.  But in the State dispensation, Central government, other governmental departments, all the provincial authorities and the local authorities.  Thirdly, secondary to the above primary clients any private sector patient as approved by Treasury and according to the regulations of the Auditor General.
 The technologies used to maintain or to attain the mission are medical expertise covering the entire spectrum of health disciplines particularly in the fields of evaluative, preventative, promotive, diagnostic, curative and rehabilitation services.
 I am not going to say much about the structure of the service, but just to sum it up, all these capabilities are deployed in the Medical Service in static medical force structures, in mobile medical force structures and in specialist medical units.
 The origin of an independent arm of service in 1979 was of great importance because it provided the Medical Service with an autonomy which had the following characteristics.  I am sure this will be the subject for discussion later on.   In the first place it had to have an identity, with its own uniform and clearly recognisable within its deployments.   Secondly, the SAMS has an image of being a reliable source of medical proficiency in times of need.
 Thirdly, it has to be able to perform independently, to perform delegated tasks.  And also in such a way that it is independent by means of its various staff systems.
 Furthermore it has to be professional, high standard and professional and proficiency is well documented.  It must have its own command and control system with the Surgeon General as its commander.  It must be self-supporting, because of the unique capabilities that are in the Medical Service of the Defence Force, it is important that it should be fully self-supporting.  
 It must have mobility.   The medical rapid deployment force has great mobility and is air, sea and land transportable and capable of maintaining all functions rendered within a static medical infrastructure.
 It must have clear and efficient line of communication and a high degree of participative management.  
 All analyses show that the Medical Service is cost-effective and it's capable of supporting its primary and secondary tasks.  
 The numerous occasions on which the units or directorates of the Medical Service have received high accolades from the National Productivity Institute reflect the level of productivity that is maintained.
 It must be ready to be deployed at any time at short notice.
 It must show that it is, as an independent arm of Service, impartial to all parties concerned and it is there to serve those who are in need, as indeed stated in its motto, "We Support the Brave".
 The existence of the Medical Service as a single independent health service for the National Defence Force results in a single medical standard for all arms of service.  
 The existence of the Medical Service as an independent dedicated centralised health service leads to a unity of effort. 
 Finally joint planning between the arms of Service is facilitated by an independent arm of Service.
 It is clear from the above that where the Medical Service has a primary operational responsibility to the National Defence Force and also the other security services in the Republic of South Africa, it does, at the same time, commit itself to making available its collateral capabilities to the State and to the population at large as a secondary responsibility.
 I want to talk about these two major responsibilities briefly.  It is the doctrine of the golden hour that determines that a combatant who is wounded or injured immediately becomes the responsibility of the South African Medical Service.  This principle equally to members of own forces and to members of enemy forces.  
 It entails that the patient be cared for by a medical orderly within 20 minutes and by a medical officer within 40 minutes of injury.  Immediate medical care in terms of resuscitation, stabilisation and preparation for evacuation of patients from the battlefield or on board ship is necessary.  This also implies medical officers and medical orderlies trained to be air dropped with special forces and with paratroopers.
 Evacuation takes place to a military medical mobile or static structure where life-saving surgery can be performed and/or patients treated.  This is followed by transportation to military hospitals where combatants will get the necessary comprehensive health care and where necessary patients will be moved to a rehabilitation centre.
 To achieve this it is necessary to have specialised services like maritime medical services, aviation medical services, trauma, psychology and psycho-strategy services in place and measures for the detection of radiation and chemical and biological warfare agents and the treatment of injuries caused by such agents, as well as the ability to acquire and to stockpile and to distribute medical supplies and to have a medical management information system which supports this entire service.
 The Medical Service is unique in the Republic of South Africa and even internationally since it encompasses the whole spectrum of professional health services within the above multi-disciplinary operation.
 With regards to its secondary function.  During peace time the secondary functions of the South African Medical Service becomes more prominent than the primary function.  Through the creation of this unique military operational health support system the SAMS has become a national asset with unique capabilities and a large collateral utility capability which can be utilised to the best possible advantage in promoting national, non-military health interests.  
 It possesses the inherent organisation, the skills, the mobility, the equipment, the discipline and the working procedures to perform a number of health-related tasks more efficiently and on shorter notice than any other comparable State or private organisation.
 To maximise return on investment within the SAMS by the State its unique capabilities in collateral utility are used by the following means.
 Firstly, acting as a medical rapid deployment force for the State in disastrous situations.  Examples of these are the Oceanos disaster, the Merryspruit sludge dam disaster, the Delmas typhoid epidemic and the nurses strike that occurred a number of years ago.
 Secondly, acting as an agent of the State in respect of its unique capabilities in the fields of aviation medicine, maritime medicine and chemical, biological and radiation defence.
 It uses its unique capabilities and collateral utility to the best interest and advantage of national non-military health interest.  This, inter alia, implies support to the departments of Health, Foreign Affairs, Transport, the Police Service and Correctional Service. 
 Support to these departments consist of the following:
 Firstly, the responsibility of health care to the President, the Deputy President, Cabinet Ministers and Members of Parliament;
 Secondly, immunisation campaigns;  rendering of essential services during labour unrest and strikes; disaster relief operations; the training of primary health care personnel for the health authorities of the country; medical examinations of dignitaries, flight crew, divers and personnel on duty in South African Research bases in the Arctic Circle.  Treatment of Police Service and Correctional Service personnel and animals.  Social upliftment programmes through certain RDP project.  Provision of medical supplies and specialist advice and services in the unique capabilities within the service.
 By virtue of its organisation it is the only medical rapid deployment force for disaster relief at large or national scale which is available to the State.
 An amplifying factor is that of the spectrum of professional health functions in the SAMS; the highly integrated multi-disciplinary team concept and single command.
 In essence it utilises the faith and the capital investment provided by the taxpayer, not only for military gain, but to ensure health services for the nation in times of need.
 I need to say something about the reconstruction and development programme.  Within the RDP policy framework it is stated that one of the first priorities is to draw all the different role players and services into the national health system.  This must include both public and private providers of goods and service and must be organised at national, provincial and community levels.  
 The RDP further states that all policy decisions affecting health must take into consideration the fact that South Africa is an integral part of the Southern Africa region and has regional responsibilities to prevent and contain the spread of disease.  Since its introduction the Medical Service has become involved in no less than 27 areas of reconstruction and development in the RSA as is shown on that transparency.
 In particular I would like to refer to three unique projects which were already functioning in the SAMS before the RDP was announced.  
 First of all Project Harmonia.  The influence of music and song on individuals and groups is no secret and can be traced back to very early days.  There are numerous examples of how music and song were used during religious ceremonies, battles, community activities and prestige occasions ...(intervention)