Veterans Affairs Committee on April 26th, 2007

[Dr. Victor Marshall]

Yes, I am.

[The Chair, Conservative, Rob Anders]

All right. Sir, the floor is yours.

[Dr. Victor Marshall]

Thank you very much for inviting me to address this special committee.

I'll make some brief remarks. I'm quite sure I won't take 20 minutes, and then I'll be happy to answer any questions you might have.

I thought you might, in the first place, wonder why you're speaking with someone from Chapel Hill, North Carolina, so I'd just like to give you a little background on myself.

I am a Canadian. I was born and raised in Calgary—Calgary West riding, by the way. While pursuing my BA at the University of Alberta, Calgary, as it was called at the time--that was the last graduating class before it became the University of Calgary—I was in the reserve officer training program of the Royal Canadian Navy Reserve, so that's the UNTD, or the University Naval Training Division. I was commissioned in the naval reserve, but I went on the inactive list when I went off to the United States to do my PhD. Then I returned to Canada for an academic career, first at McMaster University for eight years and then at the University of Toronto for twenty years. It was during that period, in fact ten years ago, that I was appointed chair of the Gerontological Advisory Council of Veterans Affairs Canada. In 1999 I moved here to the University of North Carolina, where I direct its Institute on Aging, but I have continued to be asked to chair the Gerontological Advisory Council, and it's frankly an honour and a privilege to do so.

I want to begin by telling you a bit about the Gerontological Advisory Council and its mandate, and how this led to the report that we issued last November called Keeping the Promise. I'll then highlight the main principles and features of the report before turning it back to you for questions.

The Gerontological Advisory Council will celebrate its tenth anniversary in July. Its members include representatives of the three veterans associations that are focused on the traditional veterans: those from World War I, World War II, and Korea; people from the health care sector who provide services to these veterans or who otherwise have experience with long-term care; and the leading Canadian researchers in aging and health.

Veterans Affairs Canada asked us for advice, and I am pleased to say our advice has been, for the most part, taken, and we think it's had an impact. From an academic point of view, I can tell you that's rare, and we're pleased about that.

Our mandate is formally restricted to the traditional war veterans from World War I, World War II, and Korea. As I'm sure you all well know, the average age of the World War II veterans is now about 83 years old, and that of the Korean veterans is 73 years old. That's why we're a gerontological advisory council. A few years after we were established, a Canadian Forces advisory council was established for the remaining veterans. As chair of the Gerontological Advisory Council, I sat as an observer with that council, the Canadian Forces Advisory Council. Its chair, Dr. Peter Neary, sits as an observer on our council as well.

We're an arm's-length council, and our mandate is specifically limited to giving advice when we are asked for it. I do confess that from time to time, we have exceeded our mandate by giving advice not specifically asked for, but we're really not supposed to do that. In no way do we speak for Veterans Affairs Canada.

About two years ago, we were asked by the department to give an assessment of their services to the traditional veterans and our best advice as to how to improve these services. Any recommendation that we make has to pass three tests, in a sense, given the nature of the council. It has to meet the needs of the veterans' groups, as they see them. It has to be realistic in terms of the clinical and health care experience of the providers, and it has pass the scientific criteria that are so important for the academic researchers on the council. I believe it's fair to say that the recommendations in Keeping the Promise have passed these three tests and are therefore recommendations for reform, based on what is known as evidence-based practice.

Building on the momentum of the Veterans Charter, which focused on the Canadian Forces veterans and drew on recommendations from the Canadian Forces Advisory Council, we reviewed existing arrangements for the traditional veterans and developed a framework outlining the best ways to support health, wellness, and quality of life for the estimated 234,000 war service veterans.

In Keeping the Promise, then, we have outlined some basic principles. Currently, 40% of war service veterans receive Veterans Affairs Canada health benefits, and we take the position that all war service veterans who could benefit from VAC services should be eligible. In other words, a vet is a vet is a vet.

We wanted to start from first principles. We commend the department. It's made a lot of great progress and innovations in serving veterans, but we wanted to look at the state of the art in gerontology and geriatrics. What is today's wisdom about the best way to provide services for an aging population? We also adopt a social determinants of health perspective, which is very Canadian in its origin. Health, wealth, and social integration are seen as the major factors leading to well-being in later life. This builds on a framework adopted both by Health Canada and by the World Health Organization in its active aging framework. We also adopt a life-course perspective, which is very common in the field of social gerontology, but it means that to understand people in the later years, you have to understand where they've been over their lives. If you want to influence what happens to people in later years, it doesn't hurt to start early.

Early life events can produce delayed adverse health outcomes, as the general PTSD literature and also the Australian research on Korean War veterans that we cite in our report, attest. This implies that health promotion and disease prevention should be an important component of VAC services. That recommendation would be consistent with the federal health program review recommendations. We also take an ecological perspective. A chart on page 9 very graphically shows this. This places a veteran in the context of his or her family and community. It rests on the principle of trying to provide care programs close to home. I think most importantly we advocate for a program based on needs rather than on the complex service-based eligibility requirements that now exist.

We maintain it is neither feasible nor necessary to relate a current health condition in the later years to a specific war service related event. I might say that when all the university professors and experts on aging came on the council, they were truly astonished looking at the complexity of the table of eligibility. We couldn't believe it was that complex. The state of the art and thinking about the delivery of health and social services is to move as much as possible to needs-based criteria with carefully developed screening.

When putting all this together, we saw the need for a new way to organize a comprehensive integrated health and social services system for Canadian veterans. We sketched a plan based on two well-evaluated service delivery systems from Quebec. We developed this plan with the idea of getting to veterans early; that is, before serious frailty or disability occurs. With the average age of World War II veterans at 83 and Korean veterans at 73, it's impossible to be too late. It's almost too late to be early with this population. But experts in health promotion and disease prevention stress that it's never too late as well as never too early to initiate health promotion strategies that will produce positive results and be cost-effective.

The recommendations we made are in the report, and they're summarized in nine bullets. I want to highlight the three key recommendations for you. The first is that Veterans Affairs Canada should combine its current three health and social programs into one called Veterans Integrated Services. Second is that services be available to all veterans who served in the Canadian Forces during World War I, World War II, and Korea. A vet is a vet is a vet. Third is that services be expanded to include early intervention and health promotion services, more extensive home supports, and a wider range of residential choices.

I think Keeping the Promise is an important report showing how to go beyond the new Veterans Charter that was implemented in April 2003 and targeted at reforms and services for Canadian Forces veterans.

We are well aware that the Canadian Forces veterans are themselves aging. The average age of the Canadian Forces clients of Veterans Affairs Canada is actually 53. Particularly in the health promotion area, our recommendations could be very useful to guide services for these veterans as well, and frankly, while our mandate is to give advice regarding the traditional veterans, we quite deliberately and explicitly in the report suggested that the program we're outlining could have many benefits for services for the Canadian Forces veterans as well.

The current initiative—the health care review—will be drawing on this report, and in fact we've established two committees to assist in implementing our recommendations so that they could be helpful in this regard.

One of these committees is in the critical area of health promotion. The other will deal with the development of a screening instrument that can be used to direct veteran clients to appropriate levels of care.

When we formally released Keeping the Promise last November, I was proud to have standing beside me representatives of every one of the veterans organizations. They have all endorsed Keeping the Promise, and needless to say, the council hopes that government will be sympathetic to our recommendations.

That concludes my remarks.

Thank you.

[The Chair, Conservative, Rob Anders]

Thank you very much.

We now have some committee members who would like to ask some questions.

First would be Ms. Guarnieri from the Liberal Party, for seven minutes.

[Albina Guarnieri, Liberal, Mississauga East—Cooksville, ON]

Thank you, Mr. Chair.

Dr. Marshall, first let me thank you for your insights regarding your extensive experience, for leading the work of your advisory council, and for being a force for continued analysis and improvement of veterans affairs programs.

My first question addresses the goals of your proposal for veterans integrated services that would, and I quote from your press release,

—be more comprehensive, flexible and responsive than VAC's current health programs; reach more Veterans and families; help them enhance their health and well-being; and give them access to more appropriate health and social services when they need them.

Essentially, from what I understand, you are calling for a further redesign of existing programs that would change eligibility criteria, allowing more veterans to qualify, and at the same time provide a broader range of services to thousands more veterans.

I wonder if you have a sense of how long it should take administratively to implement the changes you are proposing, and how many months would be required to set up new regulations and add the appropriate systems and resources to deliver these new services.

[Dr. Victor Marshall]

Yes. I will try to answer some aspects of your questions, which are good ones. When it comes to implementation, that is something the department itself would have to grapple with. I don't have the expertise on the timetabling of moving through the legislative process.

I could just say that the recommendations in our report are being considered in the current exercise that's going on. We are actually hoping for the system that we're proposing, but you need some good assessment tools, because if you're going to expand the services based on need, that doesn't mean everyone will get services. They have to have a demonstrated need, and we need better assessment services for that. We do hope that actually by the early summer we'll be well on the way to being able to recommend specific assessment tools for that.

The general organizational principles already exist in the province of Quebec. As I mentioned, we drew very heavily on two of the programs in the province of Quebec that have been not only implemented but well evaluated, so it's not like creating a system that's totally new.

I'm sorry, I just can't tell you in terms of the legislative process how much time that would take. The other component that would need to be worked on is that there would be some retraining aspects for Veterans Affairs Canada staff to fulfil the three roles that we outlined in the process, at the different levels of care.

[Albina Guarnieri, Liberal, Mississauga East—Cooksville, ON]

Dr. Marshall, I asked you to estimate the time to market, if you will.

You stressed two points in your discourse, in your previous intervention. You stated that action needs to be taken immediately and that the war-service veteran population is declining at a rate of 2,000 a month.

I wonder how you would regard the government's decision to carry this health care review into 2008, and to only then begin implementing changes. Given that the timeframe for the health care review is being dragged out for another year, what changes do you think could be implemented immediately to meet the needs of veterans today, and what can and should be done now in advance of that review?

[Dr. Victor Marshall]

I think if we're not moving to a needs-based principle right away, then somehow trying to simplify the table of eligibility would help.

To be very specific, for the spousal benefit for the VIP I don't see a reason to wait to do away with that restriction, which is that you have to have been enrolled in the program from 1981 before a spouse can become eligible on the death of the recipient. I think there is general widespread agreement that is a good thing to do. It's going to take some money, but I don't see why that couldn't happen in advance of the completion of the review.

I also think health promotion is very good business in the sense that it's really quite well established now that a number of health promotion interventions are very low cost, and if more veterans were referred to health promotion interventions that already exist in the community there would be long-range cost savings in the sense of keeping people healthier longer.

We would really advocate that eventually, as soon as possible, a strong evidence base be used. There are a lot of health promotion interventions that are sort of people's favourites and they may or may not work, but it's not really established exactly the extent to which they work.

On the other hand there are a number of programs that work very well and have been shown to work very well. We call these evidence-based programs. A turn towards those programs would be useful as well.

[Albina Guarnieri, Liberal, Mississauga East—Cooksville, ON]

Given the timeframe that now appears to be set in stone, the number of veterans who will actually benefit from your proposed changes will be far fewer than the 220,000 or so that we have today.

I wonder if you can comment on the appropriateness and the quality of the services we provide to widows, as they are a rising percentage of the clients.

[Dr. Victor Marshall]

It was a good thing. The VIP is sort of like a flagship program. It is a wonderful program. It's really a model program, I would say, a service program that Veterans Affairs Canada organizes.

It used to be, of course, that if the veteran and his or her spouse were receiving those benefits and the veteran died, they would continue for one year. Now they continue for the life of the spouse, except that there's this restrictive provision.

You can have the situation where someone has spent their whole life taking care of, let's say, a husband who had a war-related injury. Still, now, some of these people are not eligible for the continuation of the services because of this artificial timeline. That's the easy one, I think, to work on, as far as I'm concerned.

We really think it's important to place the veterans in a family context. Even if you think of operational stress injuries and PTSD kinds of things, there are clearly effects on families. When veterans have PTSD there's an increased risk of spousal abuse and things like that, and of course the increased burden of caregiving on the spouse.

So we really think that the unit of analysis should be the family, not just the individual veteran.

[Albina Guarnieri, Liberal, Mississauga East—Cooksville, ON]

Thank you for your insight. My time is up.

[The Chair, Conservative, Rob Anders]

Thank you very much.

Now we are going to move on to Mr. Gaudet, with the Bloc Québécois, for seven minutes.

[Roger Gaudet, Bloc, Montcalm, QC]

Thank you, Mr. Chairman.

I haven't had time to read all of your brief. Why did you call it "The Future of Health Benefits for Canada's War Veterans"? There's also Bosnia, the Gulf War, Afghanistan—

[Dr. Victor Marshall]

Yes, that's a very good question. The term “war veterans” is in common usage at Veterans Affairs to refer to this group for which our council is mandated to give advice: World War I veterans—I think there are still three remaining—World War II veterans, and the Korean War veterans. We have had Bosnia, and of course we have Afghanistan right now.

This is not an official position of council, but let me just say that I, myself, find it difficult to make a distinction between Canadian Forces veterans and traditional veterans. Again, as we say in the report, we think a veteran is a veteran is a veteran. If you've worn the uniform and put yourself at risk for your country, you should be considered a veteran. The distinction may have had some administrative usefulness, and it may still have some administrative usefulness. But in terms of the kinds of needs any of these veterans are going to have, we think they're the same, whether they've been in peacekeeping or peace enforcement or in actual, formally defined wars. But we had to live within our mandate as a council for the war veterans.

[Roger Gaudet, Bloc, Montcalm, QC]

Thank you, Mr. Marshall.

How do you analyze post-traumatic stress disorder for young war veterans? Does your document cover this?

[Dr. Victor Marshall]

The council did not do an analysis of post-traumatic stress disorder or operational stress injuries for the young veterans, because that would have taken us beyond our mandate. Again, there is this other council, the Canadian Forces Advisory Council, and we would have been going beyond our mandate if we had explicitly done that.

I happen to be, personally, as are a number of members of the council, aware of PTSD issues for younger veterans. I have actually been analyzing some Canadian data on PTSD. But the council itself really was limited by our terms of reference, so we did not consider the younger veterans with PTSD.

[Roger Gaudet, Bloc, Montcalm, QC]

Mr. Marshall, there are not very many war veterans sitting on the advisory council. There is one: Mr. Kenneth Anderson, a war veteran from the Canadian army, navy and air force. The purpose of this committee is to come up with something for war veterans. However, I don't see very many people amongst the committee members who have served.

[Dr. Victor Marshall]

Again, we are the advisory council for, basically, the World War I, World War II, and Korean War veterans. The three major organizations of veterans for those traditional veterans groups are all represented on the council.

Now, in terms of this report, we met with all the other—I think six—veterans organizations, and they all have endorsed this report, as I mentioned. They were there when we publicly released it. So they support the report. The other veterans organizations are all represented on the Canadian Forces advisory council.

[The Chair, Conservative, Rob Anders]

Thank you very much.

Now we'll move to Mrs. Hinton from the Conservative Party for seven minutes.

[Betty Hinton, Conservative, Kamloops—Thompson—Cariboo, BC]

Good morning, Dr. Marshall. Thank you very much. It's been very informative. I've tried to speed-read your report, but I'll have an opportunity later on to go through it in detail. It seems that you did a great deal of work, and it sounds to me like you enjoy very much what you're doing.

There were a couple of comments I would like to correct for the record. You suggested that the new Veterans Charter was implemented in 2003, and it was in fact implemented in 2006. It's a minor detail.

I think you also indicated that you're aware that Veterans Affairs is trying to move forward on this health care review. Our committee is supposed to be dealing with the health care review as well. We have run into a few little snags. We were sidetracked by the PTSD issue. It is a very important issue, but we haven't yet started the health care review. Hopefully that's going to happen very quickly and this committee will have an opportunity for some serious input into which way we're going.

What do you think the committee should actually concentrate on when we eventually get to this health care review? That's the first question.

The other thing I'd like to say is that I like your approach very much. You say that in order to know where a vet is going, you need to know where he came from. That makes tremendous sense to me. I think the approach you're taking is admirable.

On the second question, do you have any idea, having done some research, what the cost would be to once again expand the VIP? As you said, we did this once as a government already when we included the widows from 1981.

[Dr. Victor Marshall]

I think that broadening the eligibility criteria would be the thing to focus on. But if you do that, there would be more people coming into the system. Now, most of these people would be coming in at very low levels of contact with the system.

When you have time to read the report more slowly—not speed-reading it—you'll know we're advocating a single point of entry to the system. In many cases, a first screening would lead to referral to an early intervention specialist. This is for someone who doesn't really have heavy care needs but who could probably benefit from health promotion interventions. The interventions themselves would most likely be delivered not by Veterans Affairs Canada personnel but by programs that are already existing in communities. You still need some training of Veterans Affairs Canada personnel within the health promotion area in order to capture people in that area.

So I think the first thing I'd say is about eligibility. You should go to a needs-based system right away. That does require some in-house training of the what we call the early intervention specialist, the care coordinator, and the high-needs-care manager. They don't need training, but they need organization.

In terms of the costs, we were actually asked to make our recommendations without having cost considerations explicitly in mind. In the sense that if you're going to recommend A you have to take away B in order to remain cost-neutral, explicit cost projections were not part of our job. That's something we'd turn over to the department to struggle with.

However, let me say what would probably happen if our recommendations were fully implemented. There would be some modest increases in cost, but because, as has been pointed out earlier, the older veterans are dying off at a few thousand a month, these costs will curve down. So initially there are higher program costs, but it's like a bubble: they're going to pass through the system as the traditional veterans die. That is also the reason we'd like to see the thing implemented as quickly as possible, so we can get benefits to them before they die. But we do see it as an up-and-then-down phenomenon.

We also think that the health promotion aspects of our program should actually lead to enhanced life expectancy. We do know that most health care costs of older people are actually incurred, you might say, in the dying process, in the two or three months before death. But the older you are when that period of terminal decline occurs, the lower the costs that are incurred. So there are further savings. By keeping people living healthier into their older years, you will also have savings.

I can't put a number on it, but I would anticipate a rise and then a fairly quick and stready drop-off, as the clients die.

[Betty Hinton, Conservative, Kamloops—Thompson—Cariboo, BC]

Dr. Marshall, I envy your not having to consider costs. It would be a wonderful position to be in. I also agree with you that this is an issue that should have been dealt with more than ten years ago. We are on the right page now. We are moving forward. I also agree with you completely when—you didn't actually say the words—you made the suggestion, which I've made for many years, that there is a cost savings if you are able to keep a veteran, or any senior for that matter, in their home where their quality of life is better. They're not being displaced. Early intervention and all those sorts of things make a much better departure from this world, shall we say. No one deserves to have a smoother road than a veteran does. So we're on the same page with that one.

[Dr. Victor Marshall]

I'm glad to hear it.

[Betty Hinton, Conservative, Kamloops—Thompson—Cariboo, BC]

To sum up, you said you want this committee to look at broadening the eligibility and early intervention.

Oh, he's holding up the sign; I have to stop now.

[Dr. Victor Marshall]

Yes.