Proceedings of the Subcommittee on Veterans Affairs
Issue 2 - Evidence - Meeting of November 22, 2006
OTTAWA, Wednesday, November 22, 2006
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 12:05 p.m. to study on the services and benefits provided to members of the Canadian Forces, veterans of war and peacekeeping missions and members of their families in recognition of their services to Canada.
Senator Michael A. Meighen (Chairman) in the chair.
[English]
The Chairman: Good afternoon. It is my pleasure to welcome you to the Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence. Over the next months, our committee will be examining the services and benefits provided to members of the Canadian Forces, veterans of war in peacekeeping missions and members of their families. The subcommittee will begin to focus in on the range of services and programs offered to soldiers and their families as they return from duty in Afghanistan and until such time as they become veterans.
Appearing before us today on behalf of the Department of National Defence is Rear-Admiral Tyrone H.W. Pile, CD, Chief Military Personnel; Lieutenant-Colonel Gerry Blais, Director, Casualty Support and Administration; and Brigadier-General H.F. Jaeger, Surgeon General. My name is Senator Meighen and I have the honour to chair the subcommittee.
Before I begin, I would like to briefly introduce the senators present here today.
Senator Kenny should arrive any moment and he is chair of the Standing Senate Committee on National Security and Defence, our so-called parent committee. He is also a member of the Standing Committee on Internal Economy, Budgets and Administration and the Standing Senate Committee on Energy, the Environment and Natural Resources.
Senator Atkins is from the Province of Ontario and came to the Senate in 1986. Senator Atkins is the former President of Camp Association Advertising Limited and former adviser to former Premier Davis of Ontario. He is also a member of the Standing Senate Committee on National Security and Defence.
Senator Day is from New Brunswick. He chairs the Standing Senate Committee on National Finance. He is also a member of the bar of New Brunswick, Ontario and Quebec and a fellow of the Intellectual Property Institute of Canada. He is a former President and CEO of the New Brunswick Forest Products Association.
Last but certainly not least, Senator Downe is from Prince Edward Island and was appointed to the Senate in June of 2003. He is currently a member of the Standing Senate Committee on Foreign Affairs and International Trade and the Standing Committee on Internal Economy, Budgets and Administration.
Rear-Admiral Tyrone H.W. Pile, CD, Chief Military Personnel, National Defence: Thank you for inviting me to appear before your committee. I understand that you invited me today to discuss issues concerning the care of injured soldiers.
To assist me, I am accompanied by the Canadian Forces Surgeon General, Brigadier-General Hilary Jaeger and the Director of Casualty Support and Administration, Lieutenant-Colonel Gerry Blais.
[Translation]
I will begin by describing the care provided to members of the Canadian Forces by the Canadian Forces Health Services Group. I will explain some of the services provided to members and former members under the auspices of the Department of National Defence/Veterans Affairs Canada Centre for the Support of Injured and Retired Members and Their Families.
[English]
The Canadian Forces leadership has a strong legal and moral obligation to provide comprehensive dental and medical services to members of the Canadian Forces whenever and wherever they serve. This mandate is based in part on the 1984 Canada Health Act, which specifically excludes Canadian Forces members from the definition of ``insured persons.''
As the Chief Military Personnel, I am responsible for all issues regarding the medical, dental, and spiritual well- being of military personnel and this includes ensuring that we have a robust and responsive system in place to care for injured or ill members. I also take great pride in the manner in which we facilitate the transition to civilian life upon the release of a member.
[Translation]
Health care services to members of the Canadian Forces are provided by the uniformed and civilian health care providers working in the Canadian Forces Health Services Group, under the direction of Commodore Margaret Kavanagh, the Director General Health Services.
Commodore Kavanagh also serves as the Commander of the Canadian Forces Health Services Group so she is not only accountable in a management sense for health services policy and program delivery, she has a direct leadership role as Commander of all health services personnel.
[English]
Separate and distinct from the Director General Health Services role, the Canadian Forces Surgeon General, Brigadier-General Jaeger, and the Director of Dental Services, Colonel Scott Becker, are the clinical authorities for establishing and regulating the standards of medical and dental care respectively. The health care benefits and services that are available and publicly funded for regular force members and other eligible persons, such as reservists on deployments or extended contracts, is described in the Canadian Forces Spectrum of Care. For example, it provides information on hospitalization and physician services, occupational health services, dental services, and supplemental health benefits, such as pharmaceuticals. The Spectrum of Care is managed by the Director General Health Services under my authority and is updated regularly to reflect advances in health care services.
[Translation]
The health care services provided to members of the Canadian Forces who may be injured or ill while deployed, whether they be members of the Reserve of Regular Force, will be identical in all cases.
The decisions related to the care of injured members are made by the attending physicians and other health care providers on a case-by-case basis.
In every instance, regardless of the nature of the injury, the clinical needs of the patient are what drive all subsequent events.
[English]
For example, deployed personnel in Afghanistan suffering from relatively minor injuries and illnesses that prevent them from carrying out their operational functions are typically repatriated directly back to Canada and sent to their base of origin. A medical officer in theatre will liaise with the base surgeon at the receiving base to sort out the treatment needs, care plan and clinical follow-up.
If the member wishes to recuperate elsewhere — for example, at another location where his or her family is situated — the base surgeon at the member's supporting base will assess the request from a clinical standpoint. If it appears feasible, the base surgeon will arrange for the appropriate medical care, follow-up and tracking of the member.
Canadian Forces members in Afghanistan with more serious injuries and illnesses who require specialized treatment are evacuated to the U.S. military facility in Germany known as the Landstuhl Regional Medical Center. This is a world-class medical facility that has provided outstanding support to Canadian troops.
When the time is right, and the patient is stable enough for transfer to Canada, the critical decision of where to send the patient is made by the Canadian Forces health services group liaison staff stationed in Geilenkirchen, Germany, in consultation with specialists in Canada. The member's medical condition is the determining factor in the decision- making process. Factors to consider include what type of care is needed and the best place to receive that care. Also considered is the availability of a strong psychosocial support system, the closeness to home and the patient's desired location. The requirement for highly specialized care may force the patient to be away from his or her home. For example, a soldier from Northern Ontario may need the specialized care offered at the Sunnybrook Hospital in Toronto or at the Ottawa Hospital. In the case of patients on the very seriously ill list, the next of kin and the extended family are brought to the care facility where the member is being treated.
The Canadian Forces liaison staff at the Landstuhl Regional Medical Center work diligently to meet all of the member's needs, including psychosocial and spiritual. As part of their assessment, the liaison staff will notify the receiving physician regarding the mental health status of the patient, or the need for dedicated case management services or other special requirements. The senior physician at the base or brigade level will make all of the necessary arrangements to ensure proper management of the injured Canadian Forces member.
In general, while members are in the Canadian Forces, they are offered a full range of health services, from health promotion and prevention to treatment and rehabilitation. If the health care clinic on a particular base cannot offer a required service, the service is purchased from the civilian health care sector. Arrangements have been made across the country to ensure that regional care is provided close to the member's immediate family and support system. Many of these links to civilian facilities have been arranged through the Canadian Forces health services group civilian-military cooperation section in conjunction with local health services clinic commanding officers.
[Translation]
For certain patients requiring long-term ongoing care, navigating through a mix of civilian health care providers and Canadian Forces clinical services can prove challenging. Not to mention the transition to civilian services in cases where this is necessary or desired.
To ensure this is simplified for the member, the Canadian Forces has put in place a robust case management program to coordinate all of the benefits and services required by the member.
This point of contact helps them to navigate effectively through the military and civilian health care systems to access required health care services and health related benefits with the ultimate goal of achieving optimal health and well-being. In addition, several of our health services clinics are located in larger cities, where much of the initial casualty management and treatment is done on seriously ill or injured members in civilian facilities. To maintain close liaison and follow up on Canadian Forces members admitted to civilian facilities, the Canadian Forces Health Services Group employs link nurses, that is, nurses who act as the link between the military and civilian health care systems.
[English]
To address psychosocial and spiritual needs, the member and his or her family will be supported throughout the continuum of care. Across the country, the Canadian Forces and Veterans Affairs Canada have established an extensive network of mental health care providers, such as the operational trauma and stress support centres in Esquimalt, Edmonton, Ottawa, Valcartier and Halifax, and the mental health clinic at St. Anne's Hospital in St. Anne de Bellevue. Canadian Forces health care clinics also provide psychosocial education and supportive care to the family regarding the member's health status.
When injured or ill members are ready to return to duty, they are assisted by return to work programs offered under the direction of the director of casualty support and administration. In cases where the medical condition precludes the member from returning to duty because of a medical employment limitation, the member may be released from the Canadian Forces for medical reasons. The case manager will facilitate an appropriate transfer of health care to the civilian health care system and coordinate their transition with Veterans Affairs Canada as applicable.
I will now elaborate on the role of the Department of National Defence and Canadian Forces Centre for the Support of the Injured and Retired Members and their families, commonly known simple as ``the centre.''
[Translation]
The Centre, which opened in 1999, was created to bring the efforts of both National Defence and Veterans Affairs Canada together in order to provide information and services to ill and injured members, veterans and their families.
The Centre is staffed by both Canadian Forces and Veterans Affairs Canada personnel who endeavour to meet the administrative needs of their clients.
Staff regularly liaise with case managers, personnel selection officers, base/wing administration staff, vocational rehabilitation counselors, and various other caregivers and interested parties in their efforts to ensure fair and equitable treatment of Canadian Forces members in their transition from military to civilian life.
[English]
Some of the services provided by the centre include: managing the Canadian Forces Return-to-Work program, the goal of which is to promote and restore the physical and mental health of injured or ill members by helping them re- integrate into the workplace as soon as medically possible; researching personnel files and documents in support of applications for disability awards and benefits; liaising with various internal and external organizations and providing advocacy support on behalf of a member or veteran, when necessary; providing information on Veterans Affairs Canada services and benefits and facilitating communication with staff at Veterans Affairs offices; providing emergency aid to daily living services and supplies for members and their families by means of a contingency fund; managing the vocational rehabilitation program for serving members, through which members may utilize up to the final six months of service immediately prior to medical release to commence vocational rehabilitation training; managing the transition assistance program that helps members in their search for employment after a medical release; providing a peer support network for members and veterans diagnosed with an operational stress injury or mental health condition, what we call operational stress injury social support, or the OSISS program; and advocating on behalf of injured or ill CF members and veterans who experience difficulties accessing services and benefits.
[Translation]
In closing, the care of injured soldiers is a responsibility that I do not take lightly.
I am very confident in the health services provided abroad, in a theatre of operations such as Afghanistan, and the health services provides in Canada. I am also very proud of the steps taken to care for our members' psycho-social and spiritual needs.
Certainly we are faced with a number of challenges as we care for the soldiers returning from Afghanistan with debilitating injuries.
Challenges related to a shortage of military physicians and other health care providers. Challenges of extending our services to all members of the Canadian Forces, regular and reserve force, spread across this great and vast country of ours.
Challenges in ensuring a smooth transition from military to civilian life, particularly for a young soldier who can no longer serve because of their injuries.
Despite these challenges, I believe that the Department of National Defence and Veterans Affairs Canada are working diligently to deliver the programs and services necessary to care for the men and women who serve their country with great honour and pride.
[English]
That concludes my opening statement, Mr. Chairman, and I am ready to respond to the questions of the committee.
The Chairman: Thank you, Rear-Admiral Pile.
[Translation]
The Chairman: I am sure the senators have many questions to ask you and your colleagues.
[English]
Senator Day: I thank all of you for appearing today and for your introductory remarks.
I would like to ask a few questions to gain some comfort with respect to services to Armed Forces personnel, retirees and their families. I want to be sure that there is a seamless transition from the Armed Forces to Veterans Affairs and the work that you are doing at the centre. In answering the questions, please bear in mind that I want to ensure that there are not two silos, which we have seen so often.
My first question pertains to service for injured personnel, in Afghanistan for example, and the transition and the role of the two different groups that you mentioned within the Armed Forces: one group under the direction of Commodore Margaret Cavanaugh, Director General Health Services; and the other more clinical services, including dental, under Brigadier-General Jaeger's group. How do the two groups get along? Who is responsible for handling an injured soldier when he or she might have to go to Germany for a short period of time? Who handles that transition? Who is in charge? How you are implementing the Veterans Charter and how it has affected things?
RAdm. Pile: The Director General Health Services, Commodore Margaret Cavanaugh, is responsible for all health care provision in the Canadian Forces and BGen. Jaeger is part of that organization. They are one within the same organization. BGen. Jaeger works for Commodore Cavanaugh. The organization is one and the same. It is a seamless operation as they work together on a day-to-day basis. The whole care provision formula, organization of program delivery, development and delivery of policies is done by the same organization, which, of course, comes under me, Chief Military Personnel, so that we can coordinate these policies.
It is of high importance to have a strong relationship between the two departments when a member is released from the Canadian Forces to be handled thereafter by Veterans Affairs Canada. That is when it is of high importance to have a strong relationship between the two departments. I work closely with my counterparts in Veterans Affairs Canada. In the development of the new Veterans Charter, we worked hand-in-hand and we will continue to work hand-in-hand because it is a dynamic document. We have not dealt with a situation like Afghanistan for quite some time. In some sense, we are going over old ground while we break new ground in dealing with modern combat casualties returning from that part of the world.
Brigadier-General H.F. Jaeger, OMM, MSM, CD, Surgeon General, National Defence: Thank you for your question, Senator. It was an all-encompassing, broad question but I will try to do some justice to part of it. As Rear- Admiral Pile pointed out, there is only one organization, the Director General Health Services, but it has responsibilities in the practices of both medicine and dentistry. In addition, Commodore Cavanaugh has the management and leadership responsibility in terms of a military hierarchical structure for the members of the group. My leadership responsibility for those medical professionals working within that group encompasses their clinical standards of care, their professional ethics, the clinical treatment programs we offer and everything that pertains to the profession of medicine as opposed to the military part of the profession.
Senator Day: I would like to know more about the details. Does the medical officer in theatre in Afghanistan work for you?
BGen. Jaeger: There are several, but the senior medical officer, the lieutenant-colonel who is commanding the health services company in Afghanistan, works for the task force commander of the task force in Afghanistan who, in turn, works for the commander of Canadian Expeditionary Forces Command, but he has a professional responsibility to me through the director of health services operations.
Senator Day: Do you have any medical officers in the hospital facility in Germany?
BGen. Jaeger: No, not permanently, but we have medical officers in Geilenkirchen who have what we can almost call a secondary duty. The captains were placed there so they can travel to Landstuhl whenever there is a Canadian admitted there to work with the patient and to act as a professional communications conduit to their families so they can explain what is actually going on with the patient before the families arrive in theatre.
Senator Day: Is that a medical officer who works for you or works for the commander in Afghanistan?
BGen. Jaeger: They do not work for the commander in Afghanistan. They work for the Canadian Forces Health Services Group.
Senator Day: When Rear-Admiral Pile in his presentation talked about the health services people looking after the liaison from Germany back to Canada and finding the proper facility to deal with that person's injuries, is that someone who works for you or for Commodore Cavanaugh or is this a seamless transition that takes place? That person may not be a medical person. That person is a health services person but he or she could be an administrative- type liaison person.
BGen. Jaeger: When I refer to a medical officer I am referring to a physician.
Senator Day: Thank you, I was, too.
BGen. Jaeger: We are clear on that point. We have permanently stationed staff in Geilenkirchen who are not medical officers. We have an air medical evacuation nurse qualified who is there permanently. I do not want to give the impression that we do not have any permanent staff in Landstuhl; we do.
The key person in deciding to where in Canada the patient will be evacuated is the captain medical officer that detaches from Geilenkirchen. That captain medical officer converses with the patient, assuming the patient is conscious, the patient's family, and the receiving hospital in Canada where we think there might be a match between the patient's clinical needs and his or her broad social support needs. That captain works for Canadian Forces Health Services Group and all of the direct line chain of command relationships in our group lead to Commodore Cavanaugh.
Senator Day: That would include, maybe, a physician, a nurse or one of the other health service-type people who are not medically trained?
BGen. Jaeger: Correct.
Senator Day: They all report through their own chain of command.
BGen. Jaeger: Simply put, my authority throughout the system is a dotted-line authority. We can draw a parallel to the situation in the Canadian health care system where a hospital has a chief executive officer and a chief of medical staff. I would be the chief of medical staff and Commodore Cavanaugh would be the CEO of the hospital.
Senator Day: If someone has been injured and has to go to Germany for a period of time before being brought back to Canada, can the family or members of the family go over to Germany if the person is there for an extended period of time? Do you ensure that takes place?
BGen. Jaeger: Nodding does not appear on anyone's transcript, but absolutely yes, sir. I do not believe there has been a single case where the patient was going to be admitted to Landstuhl for any significant period of time where family members have not been given the opportunity to travel to see the patient.
The United States authorities have bent over backwards in accommodating those families. The United States military runs a system of facilities similar to Ronald McDonald House. The Fisher House facilities exist to provide transient accommodation for people going over there. The Landstuhl Army Fisher House has been well used by Canadian families. There have been times when we have had to support family members in civilian accommodations because the facility has been full, but that has not posed a problem either.
The only time that would not happen, for instance, might be if we had an air medical evacuation flight landing immediately and a newly arrived patient was stable enough to get on that plane and come back. If there was only to be a brief delay before coming back to Canada would be about the only reason that a family would not travel to Germany.
Senator Day: When the soldier is able to return to Canada and you determine the most appropriate place for the service that he or she needs, and the family's support, do you provide the family with the type of support that might not be direct-type support?
Several years ago, we had family members of injured personnel who said they did not have money to take the taxi to go to the hospital or to look after babysitting. I am referring to those indirect supports. Has that been looked after now or are they basically left on their own to manage a single family?
Lieutenant-Colonel Gerry Blais, Director, Casualty Support and Administration, National Defence: Most of the families have an assisting officer assigned to them and that officer takes the needs of the family back to the unit and in all cases where there are regulations in place where the services cannot be provided they are at the unit level. For most extraneous cases or those a little out of the ordinary, if you will, a request can be sent to the centre where, through the contingency fund that Rear-Admiral Pile mentioned, we are able to provide that service for the family.
Senator Day: Who is this service officer? Is the person from the Canadian Forces?
LCol. Blais: The person is a Canadian Forces officer.
Senator Day: How long have you had that person in place?
LCol. Blais: As long as I have been in the armed forces, that service has been provided.
Senator Day: We know that was not working in certain instances in the past. What improvements have you made to that service?
LCol. Blais: I did not know that it did not work in the past.
Senator Day: Okay, we will have to work on that for you.
The Chairman: Now that the person is back in Canada, I suppose the next stage is the determination of whether that individual remains in the forces or, because of the nature of his or her injuries, has to leave the forces; is that correct? At some point that determination is made. Who makes that decision?
BGen. Jaeger: You are correct, senator; at some point that determination has to be made. I want to emphasize that we are not in a hurry to make that determination. We want to give our personnel the best possible chance at recovery. That means we want to see them arrive at a steady state, to achieve as much clinical recovery as he or she is able, before we start the process of imposing permanent medical employment limitations. By the title, ``permanent medical employment limitations,'' you should be reasonably confident that the limitations would be permanent. If we think recovery is possible, we should not be imposing permanent employment limitations.
The medical staff begins the process of awarding medical employment limitations. When they do so, they take into account the nature of the member's disease or disability and what that means in the context of being a Canadian Forces member. Can they, for instance, still run, walk, carry a rucksack, carry a rifle or dig?
We have a set of generic task statements that speak to the concept of universality of service. The universality of service applies to all members of the Canadian Forces. Then there are trade-specific statements that would be different for example if a member were an infantryman versus a sailor. You look at that from the practical effect of the member's condition. Can the member, in fact, physically do it? We also consider if doing that frequently will predictably make the person worse. For people with things like osteoarthritis, it may not be a good idea to be an airborne soldier. Would the nature of the impairment put other people at risk if the member were suddenly incapacitated?
We take a broader view than just the condition of the member. What impact does his or her condition have on the other people and on the likelihood of mission accomplishment or failure?
We roll all those things together. It starts at the local level, at the base where the member is assigned. It eventually comes to the director of medical policy, to the standard section, who is the final arbiter. We have a central agency to ensure a consistent approach across the country. Similar conditions resulting in similar types of disability should be awarded similar medical employment limitations.
Once the medical employment limitations are decided upon, those limitations are communicated to the director of military careers administration and resource management, who essentially decides what that means for a member of the Canadian Forces. It is not the health services world that decides if you stay or you go. The director of military careers administration and resource management says these medical employment limitations do or do not breach the universality of service principle.
That is where my part of it ends. We do not have a representative from director of military careers administration and resource management present today. Do you want me to carry on?
The Chairman: Before you do that, I should ask Senator Downe if he has a question on this area or something else because he has to leave us.
Senator Downe: I have two questions on other areas.
Do all ranks in the Canadian Forces receive the identical benefits and assistance for their injuries?
The reason I ask that question is I recall a number of years ago, when John McCallum was Minister of National Defence, there was an issue about rank and benefit. Someone had a certain injury and received more monetary assistance than someone at a lower rank, which was corrected by the minister. Is that still the case?
RAdm. Pile: As far as the level of care, all members of the Canadian Forces receive the same level of care. I believe there is a plan for general officers and flag officers, which they pay into, that is different than the non-commissioned members. I do not have all the details.
Senator Downe: You are talking about benefits, not care here.
RAdm. Pile: I am talking about benefits.
Senator Downe: The higher the rank, the higher the benefit, even though the injury may be identical.
LCol. Blais: There was the general officers' insurance plan for accidental dismemberment. At that time, the Injured Military Members Compensation Act came into effect. As an interim measure to correct the deficiency where the benefits were not the same — and now, through the insurance program that we have — there is the Accidental Dismemberment Insurance Program and that looks after people in exactly the same way.
Senator Downe: My second question is about the priority job placement in the public service for members who are medically released. Do you have any statistics on how many people have qualified since it was introduced in December 2005?
RAdm. Pile: I do not have the knowledge personally, but we can get that information for you.
Senator Downe: Do you know if it is government-wide or is it at the discretion of the deputy minister of the department.
RAdm. Pile: I believe it is at the discretion of the deputy minister of the department.
Senator Downe: I consider that a flaw in the legislation; do you agree that it should be government-wide? It is obvious to me the Department of National Defence would implement it and the Department of Veterans Affairs; but in other departments, you are dependent on the goodwill of the deputy minister. If the policy is good, it should be implemented across the board.
RAdm. Pile: I am not in a position to comment on policy.
Senator Downe: That was more of a statement.
The Chairman: If a member is injured or otherwise incapacitated for the job that he or she had been doing — let us take the case of an amputee, who obviously no longer can continue in the infantry if that is where he or she was before being injured — do you have any programs similar to the one Senator Downe mentioned? Is there such a government program to try to find employment for these people?
RAdm. Pile: That is part of the transition — the return to work program that we were talking about. Should a member not meet the military medical employment or the universality of service, and have a permanent medical employment limitation that would not allow them to meet that universality, we do have a transition program. We talked about priority in the public service and/or a return to work program that will also assist in that transition, on which Lieutenant-Colonel Blais can provide more information.
The Chairman: Could they, for example, end up as an administrative officer on the base?
BGen. Jaeger: The short answer to your question is yes, senator, they can, providing they respect the generic task statements, i.e., they meet universality of service.
The Chairman: I am still fuzzy on what the meaning of ``universality of service.''
BGen. Jaeger: It means that a member has to be deployable as a member of the Canadian Forces.
The Chairman: Sorry, I am an amputee; I am not deployable.
BGen. Jaeger: I would argue that you are deployable. It depends on what you can do with your prosthesis and those limbs that remain.
I think the gentleman to your right may be aware of an RCR officer who became a logistics officer after sustaining a below-knee amputation and continued to serve the rest of his career.
The Chairman: Please explain why I have to be deployable.
BGen. Jaeger: Every member of the Canadian Forces may be liable to go overseas and serve in a theatre. While there, the conditions under which they live may be very different than they are in Canada. The food may be different; the access to medical care is probably more limited than it is in Canada. Your sleep patterns may be disrupted.
We cannot, in most operational theatres, guarantee that you will always have access to all of your medications without interruption. I recall a shelling of the PTT building in Sarajevo where everyone ended up in the shelter in the basement for a number of days. All medications were left behind. If a member cannot withstand those kinds of hiccups, those kinds of realities that sometimes intrude in operational zones, then the member does not meet the universality of service requirement.
The Chairman: They cannot remain in the military; is that what you are saying?
BGen. Jaeger: That is not my position; I decide their employment limitations.
The Chairman: I still am not clear on the issue. I am getting the impression if I am not deployable, it is impossible for me, in theory, to become an administrative officer on a military base and remain within the military.
RAdm. Pile: I will answer another side to that question. There is the universality of service issue, which Brigadier- General Jaeger talked about. There is also the personnel tempo issue with respect to the population of the Canadian Forces, regular force and reserve.
There are only a specified number of positions that we fill in order to regenerate people. When we deploy a certain number of people, they have to come back to Canada to regenerate before we can re-deploy them. Theoretically, if we started to occupy all of those positions with people who were not deployable, we would not be able to regenerate that capacity.
If a member is on the path, where he or she does not meet the universality of service requirements and the health services group determines it medically, the member is sent to another organization to determine whether that member is either released from the Canadian Forces or retained.
Senator Kenny: It is good to see you here, Rear-Admiral. Were you responsible for all the fuss at the Grey Cup? I hope you were.
RAdm. Pile: I was, indeed as part of our Operation Connection.
Senator Kenny: I thought that was a terrific example that I hope you continue with it.
RAdm. Pile: Thank you, sir.
Senator Kenny: I share Senator Meighen's concern about this universality of service. I understand what you are saying about the deployment tempo, but we are currently going through a period of growth in the CF and there are a number of shortages. I do not understand the argument. We move people out of the Canadian Forces because they cannot be deployed, yet we face a shortage of members as we endeavour to reach a target of 75,000 members. It would seem to me that given the length of time it will take to reach that goal, the requirement that everyone be deployable might not be a useful requirement, for the next decade perhaps, until the growth period takes place.
RAdm. Pile: Of course, this is a balance between the desire of the member to stay in the Canadian Forces and a requirement for the Canadian Forces to ensure that it meets its mission requirements, which does not happen overnight. The accommodation policy allows us to retain members, even if they do not meet the universality of service principle. We can do that for as long as three years to help with the transition and prepare them for work and life outside of the Canadian Forces, whilst at the same time receiving the benefit of their skills, knowledge and leadership, et cetera.
Currently, I am looking at alternatives for this kind of transition. In the near future, I will work with the Royal Canadian Mounted Police to learn if there are opportunities in that area, and I will continue my work with the Public Service Commission of Canada.
Senator Kenny: We hear only the bad stories, but that is the nature of being in politics: when something sounds outrageous, then someone comes and tells you about it. Often, we hear only half the story. For example, I heard of someone who had a medical issue involving a kidney stone. That person became non-deployable because of the possibility or probability of another kidney stone developing. If that were to happen when on deployment, that member would be a real nuisance. As a result, this individual evidently was discharged. It would seem that individual could do many other jobs in Canada, where he would not be the same nuisance or problem.
When you know that you are short many people and you know your targets to reach if you are to grow over the next period of time, is there not some logic in at least deferring the implementation of everyone needing to be deployable until you reach that growth target? At that time, the question could be reconsidered.
RAdm. Pile: The principle is in place so that we can adhere to a principle that is enduring and serves us.
Senator Kenny: Do you think anyone in this room believes that everyone in the CF is deployable? Many of the folks in uniform will never go overseas and yet, in theory, they all have to be deployable. I would hate to wander through the Pearkes building and have to say ``we know you are never going to go,'' but you could do that.
RAdm. Pile: That is a pretty hypothetical statement about the population of the Canadian Forces. As you are probably well aware, we have a fitness standard that is required by every member of the Canadian Forces. That is one of the checks and balances used to ensure that members remain fit and deployable. We still adhere to that principle. I would defer the issue of the member with the kidney stone to BGen. Jaeger. We have policies and regulations in place such that, as she explained, when members deploy, they do not have all of the support systems in place that they would have normally in a domestic environment.
Senator Kenny: I accept that. I am simply saying that the fellow with the kidney stone probably could have done a job here in Canada. Your argument seems to be, yes, he could have, but he is not deployable and we want to save that spot for someone who has been deployed so that he or she can come back and have a useful thing while not deployed. I would suggest that you send him to Gagetown and use him as a trainer or in some other capacity. It strikes me that there is no shortage of jobs in the CF these days.
RAdm. Pile: We have the three-year accommodation period to utilize those skills with the accommodation policy that I mentioned.
The Chairman: What is the magic about three years?
RAdm. Pile: We had to pick a time period and that length of time seemed to fit an appropriate transition. Most people wish to transition out sooner than that.
The Chairman: On Senator Kenny's point, if the member with the kidney stone is a trainer and we all know you are short of trainers because most of them are in Afghanistan, then he could be sent to train members in Gagetown but after three years, as I understand it, he or she would be gone.
RAdm. Pile: Once again, I will speak to the deployment cycle and personnel tempo. We are filling those spots. Recruiting is going well and we are on track with our target.
The Chairman: Will it take only five years to recruit an additional 5,000 members? That is the evidence that we have heard.
RAdm. Pile: By the year 2010, we will have reached our goal of 70,000 members.
Senator Kenny: Many people with more stars on their shoulders have told this committee that there is not a chance of that happening.
RAdm. Pile: I am surprised to hear that.
The Chairman: If you were in private industry, how would you survive doing it in that way?
RAdm. Pile: We will meet our growth targets. We are on track now. Every predictor that we have indicates that the target of 70,000 regular force members will be met by the year 2010.
The Chairman: That is great news, Rear-Admiral. We will buy you dinner in 2010 if you achieve it.
Senator Atkins: If a member of the military, who has been in for a number of years, were diagnosed suddenly with diabetes, what would you do? Would that person be considered deployable?
RAdm. Pile: We would go through the same process.
BGen. Jaeger: It would depend in part on the type of diabetes diagnosed to determine the level of severity. Those with type 2 diabetes — non-insulin-dependent diabetes — can meet universality of service under certain circumstances and in some trades if they control their blood sugar through diet and exercise and, perhaps, small doses of medication. They can meet universality of service and can stay in some occupations within the Canadian Forces.
Diabetes requiring insulin treatment implies many variables in terms of medical stability. It also implies the necessity of keeping medication under certain storage conditions and always having it available. Therefore, insulin-dependent diabetics would not meet universality of service. The process of permanent medical employment limitations transitioning over to the administrative side of the house for a decision will be in all likelihood wither to retain the diabetic for this three-year period to continue to benefit from his or her skills and expertise or he or she will be medically released at that time.
Senator Atkins: That is interesting. I have a son with type 1 diabetes and he is a captain with the Toronto Fire Services and is on the rescue squad. He is not considered a high risk.
BGen. Jaeger: This is anecdotal, but I believe that Bobby Clarke of the NHL was an insulin-dependent diabetic. In such a case, there is a known schedule and the travel is within North America. That makes it possible to do the necessary things that you cannot do when you are outside the wire in Kandahar; that is just the way it is.
Senator Atkins: Since the chair and I have been sitting on this committee, we have seen a great deal of progress in the way that military has dealt with PTSD and other types of mental health problems.
Can you describe for us the process a soldier would go through — or perhaps more importantly, a wife would go through — to alert appropriate offices to the fact that the Canadian Forces member might have an operational stress injury?
RAdm. Pile: There are various avenues where a partner could report what she or he feels might be signs of an operational stress injury being experienced by a member. They can go through the chain of command; they can report it to their own health care provider; they can report it to Canadian Forces health authorities.
BGen. Jaeger: The avenues are redundant; and it is deliberate that they are redundant, because some people are more comfortable accessing certain providers than others. The member or their spouse can talk to an OSISS peer counsellor to sound them out — just to say how do you think I am doing, where do you think I should go, I am a bit lost — and that is available to members or their spouses.
The member can access Canadian Forces health care services directly. Some people are more comfortable talking to a doctor than a peer counsellor. The member or spouse or other family member can call the Canadian Forces member assistance program, which is a confidential 1-800 around-the-clock hotline through which they can obtain a certain number of counselling sessions. Either or both could approach a padre or social worker. The spouse could seek advice from the military family resource centre.
There are a number of avenues. Sometimes you might be concerned that perhaps a plethora of options just induces confusion, but I think the system is redundant intentionally to reduce the chance of people feeling there is nowhere to turn or there is nowhere they feel comfortable turning.
Senator Atkins: As an aside, Senator Kenny and I met with wives in Petawawa. We were amazed by the stress factor of the wives.
BGen. Jaeger: Just anecdotally, senator, I have been both the person deployed and the spouse left behind, and it is easier to be the former. It is less stressful and, frankly, it is more professionally rewarding to be the person deployed.
Senator Atkins: In your experience with operational stress injuries, do different theatres of operation produce different types of injuries?
BGen. Jaeger: It would be obvious to say yes. Every theatre of operations has its own stressors and every rotation of every mission is different. We tend to look back on Cyprus as the great Sleepy Hollow of peacekeeping missions; but if you were there in the summer of 1974, it was not a Sleepy Hollow. That was when the Turks invaded across the line and people were killed and seriously wounded. Every mission and every rotation is a little bit different; and every person within that mission will react a little differently to different stressors.
For the current mission, it is too early to tell how this will play out in any meaningful way. We deliberately do our post-deployment mental health screening four to six months after they return. For the PPCLI folks who returned in August, we will start that process right after the Christmas holidays. That will run through January and February; everyone who came back will be subjected to the mental health screen. We will have a much better idea after we study and analyze the data. We can compare that data to the other rotations to see whether the more vigorous operations increase the number of people with problems.
There is a psychodynamic theory that states that doing the job you are trained to do and taking action to the enemy can be less stressful. It presents stresses of its own, because you are in physical danger and there is also the stressor of possibly taking a human life, which is not to be discounted; but for some people in some circumstances, that can be less stressful than being an observer. Enforced passivity is a significant stressor as well. We do not know, relatively speaking, how that will play out in this group of individuals.
Senator Atkins: There is some reference in my notes to the fact that you have done surveys on this whole issue. You found, in certain cases where members of the military have served maybe two or three times in the theatre, that their stress levels and the potential for PTSD can be higher than in other cases.
BGen. Jaeger: We did a major mental health survey, senator. The survey data was collected in 2003 and the report released in 2004, although I may be off a year in my dates. My memory is not what it used to be.
We contracted with Statistics Canada the national authority in statistical data analysis. Statistics Canada looked at a range of mental health conditions across the Canadian Forces. What we found was that, largely, the number of tours, the number of over seas deployments, did not correlate with mental health problems, except for PTSD. There was a correlation between number of times deployed outside the country and the likelihood that a member, either in the past year or in their lifetime, had met diagnostic criteria for PTSD. That data was collected before we started the current mission in Afghanistan.
I am quite aware that the data is starting to get a little bit dated, but it was a very difficult, time-consuming and expensive survey to conduct. We are thinking about whether we need to do another one, but we have not committed ourselves to doing so in such a systematic and formal way.
Senator Atkins: In view of the circumstances in Afghanistan, I wonder if a member in the infantry who is on reconnaissance, has higher stress levels and a higher potential for stress injuries than other CF members in the military — especially when the infantryman does not know the enemy.
BGen. Jaeger: There are all kinds of stress factors at play. We know some people will be made ill; we know many people will not. Most people, in fact, will either exhibit symptoms for a brief period of time and recover or will be okay. We also know that everyone has a limit. It is just that everyone has a different limit. Everyone has a different limit for different kinds of stressors. Some people can tolerate physical deprivation and danger far more than they tolerate frustration or stressors that are more emotional.
Senator Atkins: Is there any way of measuring that?
BGen. Jaeger: Prospectively, as into looking out to the future, no, there is no way to measure it at the moment.
Senator Atkins: No, I meant, is there any way to measure it beforehand?
BGen. Jaeger: There is nothing reliable at the moment. There is research, but it is preliminary.
The Chairman: Do you not do a pre-deployment mental health screening?
BGen. Jaeger: We do. We do it through our social workers and the padres. There is screening in that way, but it is not a personality test; we do not do that. We assess people in terms of where they are in their lives, what other things are going on in their lives that may produce problems while they are overseas.
The Chairman: Say someone is going through a divorce or lost a child, would that person be eligible for deployment? Would person problems stop deployment?
BGen. Jaeger: Depending on what is going on, they may be classified as DAG red — DAG is departure assistance group; that is the examination process before going overseas. A red flag says the person should not go. If it is determined that the person is coping well and has life skills and has support structures in place, even with similar problems, he or she may get a green flag. That process is in place.
RAdm. Pile: I want to add comments regarding PTSD or operational stress injuries.
All of our soldiers, sailors, airmen and airwomen are professionally trained. We do a full pre-deployment screening of all members. That is what is known as DAG, departure assistance group, and Brigadier-General Jaeger referred to it.
The incidence of OSI, operational stress injuries, is obviously high if they are put into a high-stress situation, which could happen anywhere depending on the situation. Afghanistan is currently obviously a high-stress situation for the infanteers.
In my own experience, I have seen PTSD as a result of the Chicoutimi fire, for example. We have had PTSD cases as a result of the stress of deploying and doing patrols in the Northern Arabian Gulf.
We try to eliminate this stress as much as possible with the pre-deployment training cycle, by putting these members through experiences they could anticipate being put through while deployed. They are of course aware training will never achieve the full extent of the real thing, but that preparation process is an effective tool.
Senator Kenny: I would like to go back to Senator Downe's question regarding the discretion of deputies. You quite properly concluded you will not comment on that.
When you organize the response returning to the committee, could you organize it so the figures are sorted by department? That way we can see how many people have been picked up by each department. That will perhaps give us some assistance in deciding whether the discretion system works well or not.
RAdm. Pile: Yes, we will do that.
Senator Kenny: Thank you. I have a question regarding the capacity of the system.
How many people do you deal with in the normal course of events, and what is your surge capacity? Please tell the committee how many people suffering some sort of wound, injury or illness, you normally process. How close are you to operating at full capacity? What do you do when you hit full capacity?
LCol. Blais: Are the numbers you are seeking for the theatre of operations at the moment?
Senator Kenny: In a perfect world, before you had a theatre of operations, what were things like? How are things different now that people are in Afghanistan, there is more action, and more people becoming wounded and getting killed? What would you do if the numbers doubled tomorrow?
BGen. Jaeger: We must look at throughput from a couple of perspectives. First, we physically do for ourselves primary health care throughput and do not contract that out. Most of that workload is generated in Canada because, depending on who is counting on what day, the 58,000 or 60,000 members of the Canadian Forces not deployed to Afghanistan generate far more than the 2,300 or 2,500 who are deployed. That workload does not disappear or change materially.
Compared to most of Canada's health care system, we are at a reasonably steady state in our ability to manage that workload. We would be severely constrained to absorb much more into that stream without commensurate increases in health care provider resources.
Senator Kenny: Are you saying your waiting times are shorter? What are the metrics to decide that you are at a reasonably steady state? Does everyone wait six months or two months?
BGen. Jaeger: In terms of specific data, we are a relatively data-poor organization. We have the ability to collect and manage data, but we are awaiting the full implementation of our electronic health records before we can improve in that department. However, we keep a general eye on indicators such as cycle time, which means how long it takes to get through a walk-in clinic.
With respect to the third next available appointment, which is a measure of how easy it is to make an appointment, there are management reasons as to why one picks the third appointment and not the first or second. Those indicators across our bases are tracked and remain relatively constant. We are not eating into our waiting times, but we are also not losing ground. That is why I say we are at a relatively steady state.
Senator Kenny: Ultimately this hearing will be televised. Will we get several phone calls from people commenting on how they heard from the brigadier-general and she has no idea how long people will be waiting?
BGen. Jaeger: For primary health care, at some of our bases the third next appointment time can be four to six weeks out. It is not always short; however, there is the safety valve of the walk-in clinic presentation. In other words, that length of time is not becoming worse at the moment. We are doing our utmost to ensure it does not get worse and trying very hard to ensure it becomes shorter.
The rest of the question deals with specialist capacity and that capacity is of interest to the people coming back from Afghanistan, some of whom require very specialized services for a considerable period of time. They are the kind of services that are difficult and expensive to maintain and do not exist in large quantities across the country.
Thus far, we have not run up against a situation where, for instance, service was simply not available and we had to move people a long way. I am thinking about amputee rehabilitation in learning how to use one's prosthesis; a long process of rehabilitation is involved in that process.
Thus far, we have not run up against civilian rehabilitation facilities requesting us not to send anymore patients, but it is conceivable that would happen. The first safety valve for dealing with that is to move outside of a province to another province or major centre, recognizing that is not ideal from a social support point of view. However, if it is required, then it must be done.
Senator Kenny: In terms of the numbers, I think we all know the number of deaths that have occurred. I think it is less clear to us how many people have come back wounded or have problems.
RAdm. Pile: We have those figures available.
Senator Kenny: That is what I am interested in. Are they moving up? At what point are you at capacity? What will you do when you reach capacity?
LCol. Blais: Since the beginning of the Afghan mission, we have had a total of 170 wounded in action and 42 deaths.
Senator Kenny: What must happen to one in order to be qualified as wounded?
LCol. Blais: A ``wound'' is defined as any injury suffered because of the operational process.
The Chairman: Would that include if I twisted or broke my ankle walking out of my sleeping quarters?
LCol. Blais: That is not considered to be wounded in action. That is an injury, but you were not wounded in action.
Senator Kenny: What if he was in a firefight and he twisted his ankle?
LCol. Blais: That would be considered becoming wounded in action.
Senator Kenny: Are the treatments for both identical?
LCol. Blais: Yes.
Senator Kenny: What was the figure for that?
LCol. Blais: The figure is 170 wounded in action.
Senator Kenny: Do they occur in a steady state, or are there peaks and valleys? Could one look forward with some certainty to how many will be generated each month?
RAdm. Pile: It is difficult to predict. Occurrences do happen in peaks and valleys. We go through high periods and low periods. I will have LCol. Blais read off those statistics.
LCol. Blais: In August, there were eight wounded in action; in September, 71; in October, 18; and thus far in November, 2 wounded in action.
Senator Kenny: How do you manage for that when you have such a range going on? How do you cope with it? What would you do if 71 was your peak or if you had a month where you had 142, for instance? Do you have that sort of surge capability?
RAdm. Pile: It is part of our operational planning process. There appears to be higher activity periods in Afghanistan during certain months as compared to other months. We go through the operational planning process to deal with those types of surges and lulls in activity.
Back here on the medical side, we can tend to anticipate when we may get a surge in medical activity as well, for repatriation or dealing with the care of the injured.
BGen. Jaeger: The surge in theatre, senator, is managed at our very small but sophisticated facility in Kandahar airfield of which we are very proud. It runs two operating rooms. Therefore, if you had eight or 10 casualties arriving at the same time it could be overwhelmed. The safety valve, if you want, for that facility is our cooperative arrangements with the United Kingdom and the Netherlands who each run surgical facilities of their own in relatively close helicopter flying distance from ours at Kandahar airfield. Further back, there are facilities at Bagrum which is the airfield near Kabul. We can take overflow there and then through Landstuhl. If Landstuhl is too busy, we have agreements with our German friends. In the past, we have used some German civilian facilities or the United Kingdom provides us alternatives for the staging facility on the way back. We have a very good relationship with Landstuhl. It is a culture in which our soldiers are comfortable and we prefer to use it to the point where it becomes unavailable. Our capacity in Canada is limited by the capacity of the Canadian health care system.
The Chairman: We are all familiar with that system.
BGen. Jaeger: Thus far, they have bent over backwards to assign as many resources as we need to our people coming back.
As I mentioned, it is conceivable that in a local place, such as Edmonton, if the bulk of the soldiers are coming from that part of the country, or Ottawa now that the bulk of the soldiers are from Petawawa, that we may exceed their neurological intensive care capability or their amputee rehab capability. In that case, we move to the next closest physical place that has the same kinds of capabilities and see if we can accommodate the patients there.
The Chairman: You stated that whether you are a reservist or a regular, the treatment and the procedures are the same, certainly on a deployment. What about in Canada if you are a reservist and doing some training, do you get the same treatment and procedures as if you were a regular at home?
BGen. Jaeger: The short answer, senator, is no. The dividing line comes on what type of reserve service you are serving and what led to your need for medical care. Policies are clear in conceptual terms, but as with most things when it comes to implementation, there are grey areas when it comes to interpretation and application in an individual case.
A reservist serving for more than 180 days has the same entitlements as a member of the regular force; that is easy. Reservists who are serving on what they call a class B, which is continuous service but for less than 180 days, or on class A, which is their parade nights and weekend's kinds of service, they would only be entitled to medical care if that entitlement was related to what they were doing. If they were camouflaging a vehicle, fell off and sustained a back injury or a fracture, then they would receive care for that injury. The grey area arises when the member believes that their medical condition arose from doing something related to their duty but the health care system may not see it that way.
The Chairman: My final question relates to what Rear-Admiral Pile was telling us at the end of his presentation about the challenges. He listed three of them. My eye stops on shortage of military physicians and other health care providers. Is that the greatest challenge? Can you tell us frankly, if you could wave a magic wand, what is the greatest impediment to delivery of the services you are providing?
RAdm. Pile: Across the scope and breadth of the health services profession in the military, historically, over the last decade there were certainly some significant shortages in terms of medical officers and nurses. Pharmacists still exist today as one of our critical areas. We have come a long way is the message I would like to pass on to you in terms of how we recruit. We are starting to see the fruits of that labour. I can let Brigadier-General Jaeger provide you some of the specifics on that, but we are certainly better off now than we were even just a few years ago. However, we need to continue to address that challenge because it will not go away. There is a very competitive market for medical officers, for physicians, nurses, physiotherapists and pharmacists. We compete with that market to try to bring the best of those into the Canadian Forces to serve.
The Chairman: Is the challenge money? If I was a sympathetic Minister of Finance and said you can have additional funds, would that not solve the challenge?
BGen. Jaeger: No, senator, the challenge is not money. It is simply availability of appropriately trained people who are willing to come to work for us either in uniform or as public servants or civilians under contract.
If I had a magic wand, I would wave it on mental health providers at the moment. As of today, that is our biggest challenge in hiring. You may hear from people in Petawawa. Petawawa is not that far away from Ottawa, but from the point of view of where well-trained medical health care providers want to live, it might as well be on the moon, because they are hard to entice to the Upper Ottawa Valley.
The Chairman: What about Gagetown?
BGen. Jaeger: Gagetown is difficult as well because of the large army concentrations of troops who are busy. Small isolated communities that are busy army area are two big hiring challenges.
The Chairman: I am sorry to end it. We could go on for much longer. We have appreciated very much your evidence today. It has been very helpful to us. It has provided an excellent introduction to our study.
On behalf of the committee, I thank each of you for coming today. We appreciate the time you took to be with us today. If you could forward that information that you agreed to provide us with, it would be very helpful to us.
The committee adjourned.