National Defence Committee on Nov. 27th, 2006

[The Chair, Conservative, Rick Casson]

I call the meeting to order.

As we continue our hearings on the issue of Afghanistan, I would like to welcome this morning, from DND, Commodore Kavanagh, commander of Canadian Forces health services group and director general of health services; and General Hilary Jaeger, Canadian Forces surgeon general.

Welcome. We appreciate your being here. I know there's been some interest in your visit, so after your presentations I'm sure we'll have some pretty interesting questions from some of the members of the committee.

The floor is yours for your opening statements, and then we'll turn it over to questions from the members.

Welcome.

[Cmdre M. F. Kavanagh, Commander of Canadian Forces Health Services Group and Director General of Health Services, Department of National Defence]

Thank you, Mr. Chair.

Thank you for the opportunity to explain a little about the Canadian Forces health care system, and more specifically how we provide health service support to the troops in Afghanistan.

My name is Commodore Margaret Kavanagh. I am the director general of health services and commander of the Canadian Forces health services group. Joining me, as you have said, is Brigadier-General Jaeger, the surgeon general.

I'd like to preface my comments by providing a brief explanation of why there is a separate military health care system in Canada. The Constitution Act of 1867 assigned sole responsibility for all military matters, including military health care, to the federal authority. The National Defence Act gives the Minister of National Defence the management and direction of the Canadian Forces, who in turn gives management and direction of the medical and dental services to the Canadian Forces.

In addition, the 1984 Canada Health Act specifically excludes Canadian Forces members from the definition of “insured persons”. We are also excluded from insurance coverage under the public service medical and dental care plans. Accordingly, the Canadian Forces leadership has a strong legal and moral obligation to provide comprehensive health care to Canadian Forces members, whether in Canada or abroad. In return for the commitment and unlimited liability to serve their country, Canadian Forces members must be provided with health care comparable to that which is provided to all Canadians, yet tailored to meet their unique needs.

The Canadian Forces health care system has many facets. In today's construct, it is inextricably linked with the Canadian health care system, both federally and provincially. You may want to understand more about how we provide health care in Afghanistan. To do so, it is important to first understand what we do at home.

Our activities in Canada, medically and dentally, prepare personnel for deployment and provide care to those who need it upon their return. We carry out public health and health protection functions; acquire medical equipment and pharmaceuticals in conjunction with the civilian sector; train health care professions; and provide direct patient care, predominately in the primary care setting. Almost all specialty care, in-patient, and rehabilitative services are now acquired from the civilian system, through a variety of arrangements.

Health care in general in the 21st century is very complex. It requires appropriate professional oversight. As the director general of health services, I am responsible and accountable to the CDS, through the chief of military personnel, for the leadership, management, and administration of the health system. As the commander of the Canadian Forces health services group, my job is to generate and sustain combat-ready health services units, subunits, and individuals who are capable of supporting the navy, the army, and the air force in operations. This includes the professional development, training, and preparation of health care personnel in order to meet their operational roles. Within the Canadian Forces health services, there are 19 different occupations, ranging from specialist medical and dental officers, to a variety of medical and dental technicians, all of whom have unique training and professional development requirements.

The surgeon general, as the senior Canadian Forces physician, focuses on the professional oversight of the clinical practice of medicine in the Canadian Forces. Likewise, I have a counterpart to the surgeon general, the director general of dental services, who has professional oversight of the practice of dentistry.

Brigadier-General Jaeger's main duties include the setting of clinical policies; the delineation of clinical scopes of practice, which in layman's terms means deciding what health care providers should be authorized to undertake what types of tasks; the determination of clinical and professional content for both formal CF courses, such as those offered at our school in Borden and what we call the “maintenance of clinical skills programs”; and the final review of complaints pertaining to clinical care or the occupational health aspects of CF practice. The surgeon general sets the CF's priorities for medically related research, acts as the interface between the CF health services group and the various provincial licensing bodies, and is the guardian of the clinical professional ethics of the suitable practice of medicine in the CF context.

An approximate civilian comparison to the two of us would be that of a hospital CEO with his or her respective chief of medical staff. I say approximate, because the health system aspects of a military health care organization makes the duties far more complex than those experienced by a single institution. I myself, my command team, along with the medical and dental professional leaders, work together to provide a continuum of health care to military members at home and on overseas missions.

To do so, the Canadian Forces health care system carries out many of the policy functions of Health Canada and the Public Health Agency, the health care delivery functions of the provincial health systems, the occupational health functions of the workmen's health and safety system, plus the equipment and pharmaceutical acquisition and distribution of the civilian sector. We also work closely with several other federal government departments, especially Veterans Affairs Canada, to ensure the most appropriate service for Canadian Forces members while still serving or as they transition to civilian life.

When the Canadian Forces health services group is directed to deploy on operations, we commence an operational planning process to determine what health services are required for each and every operation. First and foremost, we assess the risks based on the mission, the tasks assigned to the Canadian Forces personnel, and the geographical location of the mission. Through our medical intelligence, we know what naturally occurring health risks exist in the area of operation—for example, malaria—and we recommend the appropriate countermeasures.

Likewise, our intelligence gives us information about the state of the host nation's health care, so we can determine exactly what Canada, or Canada in conjunction with its allies, needs to provide to the mission. We must include everything from preventative measures to routine care, both medical and dental, to full specialist and surgical capability. We must have a robust chain of evacuation on the ground and/or in the air to meet the tactical need, but we must also have strategic air evacuation to bring patients back to Canada.

All of these aspects of health care are currently being met in Afghanistan through robust multinational arrangements and our facility located on the Kandahar airfield. We also have arrangements with our coalition partners that in the event of a mass casualty that overwhelms our facility they will take our patients.

In conclusion, providing effective health service support to the troops in Afghanistan requires not only a robust capability on the ground, but also the appropriate pre-deployment preparation and post-deployment rehabilitation. To accomplish all of these tasks, the Canadian Forces requires health care personnel who meet a high level of excellence as military and health care professionals, supported by an effective civilian health care system.

Finally, we are providing this level of support at a time when all western nations are struggling to meet the personnel demands of their health care systems. Nonetheless, the military and civilian health personnel working within the Canadian Forces health care system are dedicated to the health and welfare of the men and women serving in the Canadian Forces.

This concludes my opening remarks. I'll ask the surgeon general to address some of the clinical issues relevant to the current operational tempo.

[The Chair, Conservative, Rick Casson]

General Jaeger.

[BGen Hilary Jaeger, Canadian Forces Surgeon General, Department of National Defence]

Thank you, Commodore Kavanagh.

Mr. Chairman and members of the committee, I appreciate the opportunity to address you about topics that may be of interest in light of the CFs recent operational experiences.

I would like to begin with some general observations about injuries sustained on modern operations. I should preface these remarks by making it clear that most of the data underlying these observations comes out of the U.S. military's experiences in both Irak and Afghanistan, but our own data appears to be consistent with this trends.

The most important trend to notice is that soldiers are surviving incidents that they would not have survived in previous conflicts. This probably cannot be attributed to a single development, but to a combination of efforts. Better intelligence, better tactics, better vehicles and most certainly better body armour all play a role.

But we in the health services also think that improvements in battlefield health care have played a role in this success, and these improvements start right down at the individual soldier level, with each and every one having completed additional first-aid training, including being taught how to apply a tourniquet and use our new pressure bandage and hemostatic agents, all of which are carried by individual soldiers.

Reinforcing the individual soldiers are a cadre of soldiers trained in combat casualty care, a two-week course that gives them some additional skills. Our medical technicians are trained initially as primary-care paramedics, and at the corporal rank level also have advanced emergent care skills and can perform useful screening for ambulatory care issues. A medical technician accompanies virtually every patrol that goes out in Afghanistan.

Backing up the medical technicians will be a physician assistant or a military physician, and of course we have our small but quite capable hospital at Kandahar airfield. It may interest the committee to know that this hospital is the first Canadian military facility to utilize a CT scanner in operations.

Our health care providers are more confident in their skills than was the case a few years ago, as a result of the maintenance of clinical skills program, which takes CF uniformed providers out of our clinics and employs them, anywhere from 20% of their time for a general practitioner to almost 100% of their time for a clinical specialist, in busy, full-service health care settings where a much broader range of skills is needed.

Giving soldiers a better chance to come home from operations alive is certainly something to be proud of, but for many of these soldiers, it can be a mixed blessing in that they may face significant disabilities. The effectiveness of our personal protective equipment, added to the current adversary's preference for attacking with improvised explosive devices, produces a different pattern of wounds than previously experienced. We are seeing fewer wounds to the thorax and abdomen and more to the extremities, including more traumatic amputations. We are seeing more closed-head trauma than in previous conflicts. What this means for us when planning health care in theatre is that the orthopedic surgeon is just as much a must-have in an operational theatre as the general surgeon, whereas in previous conflicts it was the general surgeon who was at the centre of the action, and orthopedics considered something of a “nice to have”.

What this type of injuries mean, once the casualties arrive back in Canada, is multiple surgical procedures and a long period of specialized rehabilitation.

I believe the committee is aware that the CF does not provide the services directly, but works in cooperation with civilian institutions and providers. The dispersion of the CF across this vast country, coupled with the provincial responsibility for health care, makes ensuring a uniformly high level of care to all our personal a challenge, but one that we believe we are meeting.

It is important to emphasize that the CF, unlike our US counterparts, could not operate its own tertiary care hospital, or rehabilitation centre. We do not currently employ the correct types of health care providers, and even if we were to concentrate all CF casualities in a single facility—which has obvious drawbacks from the point of view of the member's family and social support networks—we would not have enough patients to develop or maintain an acceptable level of expertise.

The committee may also have concerns about how we approach mental health care for deployed soldiers and may worry whether we are doing enough to prevent, detect, and treat mental illness. Perhaps it will be clearer to you if I describe all the mental health related activities that occur around the deployment cycle. Not all of these are primarily health services activities. Of primary importance is the pre-deployment training that the member received, for at least two reasons: one, the more confident the member feels in his or her skills, the better they will be able to react when challenged; and two, the more the member feels part of a cohesive group, the better for mental health, and collective training is extremely important to building that cohesive team.

All soldiers are given a thorough but general psychosocial screening before deploying. Spouses are normally invited and encouraged to attend with the member. The intent is to discuss any personal concerns or complicating circumstances the member may have, anything from their own health status to an ailing parent to pending legal action, and to assess the impact that the deployment would have on these kinds of stressors. The member will also have a general medical screening done prior to being cleared for the mission.

While in theatre a member can access the mental health team, which currently includes a psychiatrist, mental health nurse and a social worker, or can discuss concerns with a Chaplain or general duty medical officer.

We believe that the current generation of combat arms leaders is very aware of the crucial role they play in looking out for the mental health of their personnel, and they do consider the possible emotional reactions to each incident, encourage peer support, and they do not hesitate to ask for advice.

At the discretion of the Task Force Commander, a process known as “third-location decompression” is initiated. For the current mission this involves a few days' stopover in Cyprus on their way back home, with the intention of minimizing this stress associated with coming back home. While much of the value of this activity is in the rest and recreation it affords the soldiers, there is a educational component that we hope allows members to recognize, understand, and in some cases control their emotional reactions to certain situations.

Four to six months after returning home, all deployed members undergo what we call the enhanced post-deployment screening, which consists of a standardized, fairly extensive questionnaire followed by a semi-structured, one-on-one interview with a mental health professional. We believe this is an excellent tool for early detection of mental health and coping concerns. Further, we believe four to six months is about the right point at which to do this testing, because at this point, many people who may have had symptoms initially will have seen them resolve spontaneously, and some others may have either had delayed onset of symptoms or may be more willing to admit to symptoms that have been there all along. Of course, a member who has any concerns about their mental health at any time can seek help from a variety of sources without waiting for this particular screening to be scheduled.

If a member is felt to need further assessment or treatment then he or she will be referred to the most appropriate provider. While we believe our members enjoy better access to mental health care than does the average Canadian, we also know that the faster we can implement appropriate treatment, the better the chance of recovery will be. Therefore, we are in the process of greatly increasing our mental health provider resources across the country, and working with the VAC and the RCMP to establish a joint network of mental health clinics.

Mr. Chairman, members of the committee, there is much more that I could say about health care in the Canadian Forces, but I do not want to take any more time away from the committee members. Commodore Kavanagh and I thank you for your interest and your attention, and we look forward to your questions.

[The Chair, Conservative, Rick Casson]

Thank you very much.

We'll get right to the questions. I believe opening round is seven minutes.

Dr. Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thank you very much for that complete overview, and thank you also for the specific questions around the mental health screening.

I'm going to surprise you by talking about feet. I think that we've heard a couple times that the soldiers are upset about their footwear. I come from the Women's College Hospital in Toronto, where we set up the first foot store and shoe store. In the February 2003 newsletter about how smart training techniques reduce injury, there were some recommendations about how the Canadian Forces can't afford to lose personnel through preventable injuries. There was also discussion of some of the issues around training and cross-training and about some of those science feedback loops that we need. One of those recommendations was to adopt a high-quality cross-trainer shoe after you'd stopped letting people run in their combat boots. Better shoes and scientifically based training guidelines and methods for female and aging warriors were to be used, including a bridging physical training program to keep people fit while they're recovering from an injury. There were also guidelines on how to train safely in the cold and how to stay fit on deployment.

I would like to use that as an example. I understand there are some very serious shoes that are now being deployed by the Navy Seals and that are NATO-approved. Other forces have them, and there are even ones that are sandproof for Afghanistan. I just want to know how you get the feedback from your clinicians. How do you use patterns? How do you use clinical research, the epidemiology of what you're seeing in the office, and get that fed back into policy and changes in training so that you actually can see that you're reducing these kinds of recurrent themes within your clinical practice?

[BGen Hilary Jaeger]

I'm going to leave the specific question of footwear aside for a moment, if I may, ma'am, and we'll come back to it.

On the general question of how we take observations from theatre and feed them into policy, the main part of the tool is a NATO epidemiological data collection system known as EPINATO, an obvious acronym that stands for epidemiology for NATO. It's a viciously detailed spreadsheet that the folks in theatre have to fill out on a weekly basis and send back through the medical chain. Our director of force health protection collects those results and analyzes them to see if there are trends.

The tool is imperfect. The tool requires a skilled person on the front end to decide how to codify everything that happens so that the data make sense on the far end. Theoretically, things should be able to be identified through the EPINATO tool, analyzed by our epidemiologists and our occupational health specialists and our sports medicine specialists and the director of force health protection, and that would form a link back into policy.

I would have to get back to you on specific questions of initiatives that have been taken on footwear. I'm perfectly aware that we stopped training in combat boots, and that was a very good step forward. I'll say anecdotally that in my career I have seen what is probably the fifth iteration of different kinds of combat boots people have tried in order to get it right. I think that's in the grey area between the practice of medicine and the acquisition of equipment for the Canadian Forces.

[Carolyn Bennett, Liberal, St. Paul's, ON]

So you can influence equipment acquisition if you start seeing trends?

[BGen Hilary Jaeger]

I believe we can. Certainly for individuals we have a very wide latitude to provide them with special footwear to address problems--individual orthotics and foot architectures for people whose feet are different sizes. We can provide special footwear on an individual basis and always have had that ability.

[Carolyn Bennett, Liberal, St. Paul's, ON]

In relation to the screening four to six months later, as chair of the women's caucus I learned at both the Edmonton base and when meeting with military spouses in Fredericton that they're concerned that the guys sometimes don't self-identify mental illness. Most people know what the right answer is, but you have to feel pretty safe to be able to admit you're not feeling okay.

There was some concern that people who were already a little bit in trouble could be redeployed when indicators like domestic violence and those kinds of other things were obviously there. You're saying that at the four- to six-month screening, the spouse is sometimes included; as you know, and as you've heard me say before, I'm really concerned that families aren't treated as families and that the spouses would have to go out of their way to tattle on their spouse before that screening, or to call the physician they're seeing, as opposed to the regular way the rest of Canadians are treated, which is that the same physician looks after the whole family. If it's optional for the spouse to participate in that four- to six-month screening, do you think we're missing some? Is there something more we should be doing?

[BGen Hilary Jaeger]

I want to clarify, Dr. Bennett, that it's the pre-deployment screening to which the spouse is invited. At the post-deployment screening, a different tool is used. In that case the spouse is not involved; it's a one-on-one interview with the mental health professional. I brought along a copy of the screening tool we use, dans les deux langues officielles, if you're interested in having a look.

I know what you're saying about people being reluctant to self-identify, and that, of course, is why we interview everybody. We score the standardized instrument to give the mental health professionals some idea, when they speak to somebody, of what areas to focus on, but it doesn't matter if you answer “no” to everything; you're still going to get interviewed, because we think it helps to break down stigma. Otherwise, if you only get interviewed if you score above a certain threshold, then obviously if somebody gets called in for an interview, his buddies may say, “Oh, look, Corporal Boggins got called for an interview.” We didn't want any of that, so everybody goes for an interview.

They're well-respected, standardized instruments. I'm sure you'll recognize many of them. It would be hard to snow without blatantly lying.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Some of the spouses think so.

At four to six months, is it possible to screen the family unit?

[The Chair, Conservative, Rick Casson]

Just a short response, please.

[BGen Hilary Jaeger]

We have to be a bit careful here. We can't compel families to do anything. We can compel behaviour of the member but not of the spouse or the family.

We have restrictions in terms of providing health care directly to spouses, but they have full access to the social work services on the base. They have full access to the 1-800 Canadian Forces member assistance program. They have access to the family resource centre. They have access to the operational stress injury social support project and peer counsellor network.

So they do have avenues to raise their concerns. We really hope these give them enough resources.

[The Chair, Conservative, Rick Casson]

Thank you.

Mr. Bachand.

[Claude Bachand, Bloc, Saint-Jean, QC]

Thank you, Mr. Chairman.

I would like to begin by thanking you for being here and by offering you my congratulations. I do not think that the Canadian army boasts many female generals. There are two of you here today — how many of you are there altogether?

[BGen Hilary Jaeger]

Four, I believe. The two of us, and General Colwell and Commodore Siew.

[Claude Bachand, Bloc, Saint-Jean, QC]

Congratulations. I think that we can think of you somewhat as precursors. It is difficult for women to reach the highest echelons of the armed forces and I am delighted that you have managed to reach this rank. Indeed, I hope that you will one day become the Canadian army's Chief of Staff — we would all like that a lot.

Do medical personnel accompany combat units into the combat zone of a theatre of operations? Do medical personnel go with combat units?

[BGen Hilary Jaeger]

In theatres of operations, armed personnel are divided into two major groups. Half stay with the combat unit, the infantry, which at the moment is the Royal Canadian Regiment. I believe the group comprises two doctors, a physician assistant and several paramedics. They accompany any soldier leaving the camp; they have armoured ambulances and stay close by the soldiers.

[Claude Bachand, Bloc, Saint-Jean, QC]

Are the ambulances and paramedics clearly identified?

[BGen Hilary Jaeger]

The physicians' assistants and paramedics are known to the combat unit, but they do not display the Red Cross insignia outside of the Kandahar camp.

[Claude Bachand, Bloc, Saint-Jean, QC]

Why?

[BGen Hilary Jaeger]

It was a decision made by the chain of command after having evaluated the risks and benefits of doing so.

[Claude Bachand, Bloc, Saint-Jean, QC]

Would you or the Chief of Staff be able to tell me whether the decision not to display the Red Cross insignia in a theatre of operations is compatible with the Geneva Convention?

[BGen Hilary Jaeger]

We studied the question carefully, along with our lawyers, in order to be able to advise the chain of command in its decision.