Based on the presentation given by Connor Hartnady, Lecturer – Emergency Medical Care
Insights shared at the recent HEMS Symposium highlighted that South Africa’s Helicopter Emergency Medical Services sector is largely built around structured dispatch systems, regulated airframes and defined clinical protocols. Yet a growing number of extreme weather events across the region is exposing the limits of that model.
Real-world flood responses in Mozambique and Malawi demonstrated that helicopter operations in large-scale humanitarian crises require a very different mindset from traditional HEMS. These environments challenge assumptions about dispatch, communication, patient preparation, safety and inter-agency coordination, offering lessons that could strengthen domestic readiness in South Africa.
Operations during Cyclone Idai in Mozambique in 2019 and Cyclone Freddy in southern Malawi in 2023 illustrate the scale and complexity of these events. Idai alone created a 120-kilometre floodplain, displaced over 146,000 people and affected millions across Mozambique, Malawi and Zimbabwe. When responders arrived in Beira, almost every aircraft had been damaged, with a single squirrel helicopter remaining serviceable. Environmental conditions were harsh. Roads, bridges and power infrastructure were destroyed. Cellular networks had collapsed. GPS coordinates were often unavailable, and communities arrived at the airport on foot to report emergencies. None of the formal, structured HEMS activation pathways that would normally be used existed.
The absence of formal command structures in the early hours of the response created duplication, inefficiencies and safety concerns. Military aircraft, private operators, NGOs and volunteer teams all began flying without a unified frequency or coordinated tasking. Refuelling cycles were inconsistent, and opportunities to move patients were lost.
Despite these constraints, aircraft had to support simultaneous missions: rescuing stranded individuals, transporting medical supplies, delivering food and water, moving clinic staff and evacuating patients. These realities highlight the extraordinary value of helicopters – a journey that normally takes ten minutes may take six hours or become impossible when bridges are destroyed. Helicopters become the sole means of access for humanitarian relief, clinical evacuation and reconnaissance.
Clinical realities in these environments differ markedly from routine HEMS missions. Patients are often unpackaged, untriaged and delivered to landing zones by community members using doors, wheelbarrows or makeshift stretchers. Multi-patient loads are common and space inside the aircraft must be improvised. Helicopters may arrive after carrying food, bodies or contaminated materials, introducing significant biohazard risk. Contamination from sewage, pesticides, animal carcasses and flood debris is widespread. Rapid turnaround times mean aircraft cannot be fully decontaminated between missions, placing crews at heightened risk of infection.
Equipment selection and bag configuration become critical. Flood-response aircraft require rugged, waterproof, minimalist medical kits, as clinicians must adapt to confined spaces, unstable floors and the absence of tie-down systems. Every unsecured item becomes a projectile hazard.
The growing frequency of flood operations in South Africa raises an important question: should HEMS training incorporate environmental medicine, hazardous contamination and multi-patient evacuation competencies more formally?
Legal and ethical considerations add another layer of complexity. Clinicians often operate outside their licensing jurisdiction and may be unable to use certain medications due to local regulations. Documentation is limited and overwhelmed hospitals cannot provide structured patient handovers. Large-scale malaria outbreaks, crush injuries, waterborne diseases and prolonged entrapments introduce unfamiliar clinical burdens that differ significantly from urban trauma-focused HEMS work.
The broader value of aviation assets in such settings extends beyond patient transport. Aircrews become the eyes of the response. Photographs with geolocation data provide critical intelligence on washed-out bridges, destroyed clinics and isolated communities. This information shapes relief priorities and operational planning, bridging the information gaps created by collapsed communication networks.
These experiences underscore a key message: flood HEMS is not routine HEMS. Yet the principles developed in these disaster environments offer valuable insights for South Africa’s domestic systems. Fast, low-information activation models used in the early phases of a disaster have parallels in more responsive dispatch protocols. Coordination tools developed in austere conditions can strengthen inter-agency collaboration. Equipment discipline, contamination awareness, landing zone risk management and multi-patient adaptability could all enhance the resilience of current HEMS practice.
As climate volatility increases, the likelihood of large-scale flood responses within South Africa grows. Preparing the country’s HEMS workforce for such operations requires more than aircraft and clinical capability. It demands flexible protocols, austere-environment training, enhanced safety awareness and the ability to adapt standard HEMS principles to unconventional, rapidly evolving contexts. The lessons drawn from Idai and Freddy highlight not only the indispensability of helicopters in humanitarian crises but also the importance of evolving South Africa’s HEMS training and operational doctrine to meet the challenges of a changing environment.
