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Introduction
After the Second World War, medical care of the Royal Netherlands Armed Forces was to a large extent focused on the troops deployed in the Northern German Plain, in a NATO Alliance framework, in preparation for a large-scale conflict with the Soviet Union and Warsaw Pact partners.
Since the early nineties of the last century, after the fall of the Berlin Wall and the disintegration of the Soviet Union and in line with the new political vision in Western countries of global stabilization of conflicts, Dutch military units have been deployed globally in peace-enforcing, peacekeeping and humanitarian relief operations as part of a larger international military unit or in a self-supporting role. These usually take place outside Western Europe. In this cadre, the first operation in which the Dutch were involved was UNTAC in Cambodia (1992-1993). Later on, substantial operations followed in East Congo (Goma), Eritrea, Iraq, and Afghanistan (2001-2014). Currently, Mali is the main focus.
This new scenario demanded from the military doctor a profound knowledge of epidemiology and management of infectious diseases in different situations with challenging climates and infrastructures. Moreover, military health care is not limited to the troops, as its extension to the local population is a logical and frequently occurring consequence. A knowledge of healthcare systems in low-income countries and an understanding of specific health problems in their populations are essential for success in such a mission.
In 1993, the Dutch Ministry of Defence requested the Department of Tropical and Travel Medicine of the Academic Medical Centre (AMC) in Amsterdam, the Netherlands, to develop an educational programme to provide this knowledge to military doctors.
The training programme that was developed for military medical officers (in Dutch: ‘Algemeen Militair Arts’ (AMA)) is part of their basic two-year training and consists of 3 courses (BIUPAMA, HPGAMA and GOLAMA).
Military nurses follow a similar training, adjusted to their level of education and focused on practical skills, e.g. malaria diagnostics.
It’s worth mentioning that before a medical team of doctors, nurses and troopers (military medical managers) is deployed, a pre-deployment briefing and refresher course of laboratory skills are provided in a one-day session at the AMC.
Training programme
The BIUPAMA and HPGAMA are related courses in the AMA training programme, covering infectious and tropical diseases and Force Health Protection respectively. These two courses share specific issues with the GOLAMA, a simulated deployment exercise from a public health perspective.
Biupama: course on infectious diseases and tropical pathology for the military medical officer
The BIUPAMA is a two-week course on infectious and tropical diseases, focusing on epidemiology, clinical presentation, diagnosis and treatment. It is organized and hosted by the department of Infectious Diseases (ID) of the AMC. A clinical (symptom-based) approach is used that aims to cover all essential knowledge and skills in a two-week programme. The participants are also introduced to the laboratory diagnostics of parasitology, bacteriology and virology (content: see box 1). The faculty of the course consists of staff members from the AMC’s Infectious Disease Department and invited national and international experts. Obviously, the course is not only of great interest to the operational military doctors but also to medical officers of the barracks in the Netherlands, enabling them to recognize tropical disease in returning military patients.
The BIUPAMA is held twice yearly: in March a Dutch spoken course and a second English spoken one in October. The latter course is open to military doctors from NATO countries but also welcomes participants from Eastern Europe as well as from African and Asian countries (see Figure 1 and 2).
Hpgama: course on hygiene and preventive measures for the military medical officer
HPGAMA is a course on Force Health Protection. Many aspects of disease prevention are dealt with in groups, an educational form similar to the GOLAMA. Hygienic measures in a military camp, vector-control and prevention in connection with venomous and poisonous animals, prevention of high-altitude disease and medicine in extreme climatological circumstances, and health hazards caused by radiation and chemical agents are all part of this course.
It is a one-week course, hosted twice per year by the Military Institute for Medical Training (DGOTC) in Hilversum, the Netherlands. Several military and civilian experts contribute to the HPGAMA, including AMC staff from the Department of Tropical and Travel Medicine.
Golama: course on health in fragile environment for the military medical officer
The GOLAMA is a one-week course, including evening classes, on public health systems and their management in developing countries. It is co-hosted by the AMC and the Royal Tropical Institute (KIT) in its historic building in the centre of Amsterdam. The GOLAMA focuses on planning and implementation of humanitarian and medical aid as part of an international military operation. It covers outbreak detection and control, setting up and managing a refugee camp, cooperation with local authorities and NGOs, and intercultural communication. In particular, ethical and legal aspects of military presence are also discussed and practiced. Additional tools are presented, such as health care assessment methodologies and problem prioritization. Participants work in groups of four to five persons, covering a diversity of issues arising in theatre. Each group is coached by a medical professional with extensive international experience and a civilian or military background (objectives and teaching methods: see box 2).
In the educational timeline, the GOLAMA is positioned in the final semester of the AMA training programme, shortly after BIUPAMA and HPGAMA. The course also welcomes medical logistic officers/medical planners (‘troopers’) and staff nurses, as efficient cooperation between these different disciplines is very welcome. Due to the success of the English spoken BIUPAMA, starting in 2017, one of the two yearly GOLAMA courses will be held in English and will be open to NATO partners.
Pre-deployment briefing
Before medical personnel are deployed, a work-up period is generally scheduled in preparation of the mission. This programme includes a briefing by the AMC’s Department of Tropical and Travel Medicine. Combining aspects from BIUPAMA, HPGAMA and GOLAMA, this briefing aims to present an updated situation report. Based on the epidemiology of the locally most prevalent health problems, a discussion is held of preventive measures, disease management, and possible scenarios for humanitarian military-medical deployment, the latter depending on the mission’s mandate. A laboratory refreshment course in parasitology is scheduled separately. During the mission, 24/7 consultation is provided by the ID physician of the Ministry of Defence, based in the AMC.
Outbreak response teams (ort)
Infectious disease outbreaks during deployment affecting the troops and/or the local population cannot always be managed by the medical personnel at the deployment site, despite the adequate training programme they have gone through. Therefore, specific military units with expertise in managing outbreaks are trained and held on ‘standby’ in the Netherlands, who can be brought into the area of an outbreak within 24 hours. The forerunner of the ORT was a team sent in 2005 to the camp near Mazar e Sharif, in northern Afghanistan, assisting the medics in an outbreak of cutaneous leishmaniasis that affected nearly 20% of the Dutch contingent of 938 military personnel.
Epilogue
In the past two decades, the training programme resulted in an effective approach to medical care for the military and for the local population during deployment in several turbulent regions. So far, the BIUPAMA has trained a total of 1005 Dutch and international participants (see Figure 1 and 2). The courses are evaluated separately and adjusted to the needs of the participants and changing operational military demands. An example of questions and an outcome of the evaluation (BIUPAMA) is shown in Figure 3. The present Dutch political point of view requires flexible military deployment in a wide range of activities worldwide. Military doctors are increasingly deployed abroad in an early stage of their career. The courses, therefore, have become a vital part of preparation of military medical personnel.
NETHERLANDS 740
EUROPE 198
OUTSIDE EUROPE 67
| Box 1 The following clinical problems in tropical pathology, imported diseases, and infectious diseases of temperate climates are dealt with: Assessment of fever Fever and respiratory tract infections Fever and neurological diseases Fever and diseases with mononucleosis Fever and lymphadenopathy Fever and skin disorders Fever and jaundice Hepatosplenomegaly Eosinophilia Diarrhoea Tropical dermatology Attention is also paid to specific clinical diseases: Malaria Tuberculosis Enteric fever Sexually transmitted diseases HIV disease/AIDS The following subjects are also covered: Overview of immune system Principles of antibiotic treatment Virology in daily practice (diagnostics, antiviral agents) Immunizations and malaria prevention Post-tropical screening Biological weapons Practicals are given in: Bacteriology Parasitology (malaria and intestinal parasites) After an introduction to epidemiology and control of infectious diseases, two case histories are presented to the trainees to be worked out in groups. |
| Box 2 GOLAMA course: training objective, teaching methods and content OBJECTIVE The training objective is formulated based on the tasks that the General Military Doctor (AMA) is performing in the context of peacekeeping operations in a fragile country. These tasks are translated into skills necessary during a deployment mission and include : Preparing the delivery of the necessary medical care for the unit during deployment Assessing the medical situation on the ground after arrival and acting in accordance with the findings Setting and maintaining military medical service delivery system Administering management information system at the level of the primary care Managing medical information system at the level of the primary care Attending and advising on all medical problems Selecting medical aid intervention for the local population appropriate for local setting Organizing termination of the health post and transfer of materials Organizing redeployment Providing debriefing sessions Organizing post-mission medical care for the unit TEACHING METHODS The elements of the GOLAMA training are imbedded in a simulation exercise that continues through the whole course. The structure of each session is as follows: Introduction session by a specialist in this field An assignment to the group (max. 5 people per group with 1 leader) Summary made by the specialist or the group leader |
References
- Coldren RL, Brett-Major DM, Hickey PW et al. Tropical medicine training in the Department of Defense. Military Medicine 2012, 177: 361-363
- Humphery TJ. Training the physician for deployment. Australian Defence Force (AFD) Health 2002, 3: 9-12
- Ryan JM, Hopperus Buma APCC, Beadling CW, Mozumder A (Ed.). Conflict and Catastrophe Medicine. A practical guide. 2014, 3rd Edition, Springer Verlag London
- Van Thiel PPAM, Leenstra T, de Vries HJ et al. Cutaneous leishmaniasis (L. major infection) in Dutch troops deployed in northern Afghanistan. Epidemiology, clinical aspects and treatment. Am J Trop Med Hyg 2010, 83(6): 1295-300
