National Defence Committee on Feb. 7th, 2008

[The Chair, Conservative, Rick Casson]

I call the meeting to order. Today we start our study on health services provided to Canadian Forces personnel, with an emphasis on post-traumatic stress disorder.

We have Major-General Walter Semianiw, chief of military personnel, and Brigadier-General Hilary Jaeger, commander, Canadian Forces Health Services Group, director general of health services, and Canadian Forces surgeon general.

We'd like to welcome you both. I don't think appearing in front of a committee is new to either one of you. We'll give you the time you need to make a presentation. I understand there's going to be just one presenter, and then we'll start our rounds of questions.

We have been waiting with anticipation to start this study. It's been on our agenda for some time, and now we've got some of the issues we've dealt with out of the way, we're looking forward to this study and the forthcoming report. We think it's a critical time right now in the history of our armed forces due to the fact that we are deployed, so we want to make sure that not only are we providing them with the proper equipment and support services while they're in the field, but when they need help, the appropriate help is there for them as far as health issues are concerned.

I'll turn it over to you and we'll give you the time you need to make your presentation. Then we'll start the questioning.

Go ahead, sir.

[MGen Walter Semianiw, Chief of Military Personnel, Department of National Defence]

Mr. Chairman, members of the committee, ladies and gentlemen, thank you for having invited me to appear before your committee to speak to the health challenges involved in consecutive deployments.

I am MGen Walter Semianiw, Chief of Military Personnel of the Canadian Forces. With me today is Brigadier-General Hilary Jaeger, Commander Canadian Forces Health Services Group, Director General Health Services and Canadian Forces Surgeon General.

My mission as the chief of military personnel for the Canadian Forces is to recruit, train, prepare, support, and recognize military personnel and their families for service to Canada. I'm therefore responsible for implementing programs and services that promote the medical, mental, and spiritual well-being of military personnel.

It has been abundantly clear since the beginning of Canada's mission in Afghanistan that the Canadian public demands full-spectrum, high-quality health care for our men and women in uniform, those whose health has suffered as a result of military operations. Accordingly, we have made care of the fallen, the injured, and their families a top priority for our organization. At the time, it's critically important for military personnel to be healthy, fit, and ready for deployment in order to fulfill Canada's military commitments at home and abroad.

Soldiers, sailors, airmen, and airwomen are the most complex, sophisticated, and valuable systems in the Canadian Forces. It takes an equally complex system to keep military personnel in top form, to care for them, and to help them recover when they suffer injury.

Health care services for personnel of the Canadian Forces are provided by uniformed and civilian health care providers working in the Canadian Forces Health Services Group under the command of Brigadier-General Jaeger.

The Canadian Forces Health Services Group is a multi-faceted organization with approximately 120 different units of varying sizes in different areas around the world. The units can range from a large group of about 300 health service personnel on bases such as Valcartier or Petawawa to two personnel providing health care support on any of Her Majesty's ships or at Canada's most northern military station at Alert.

Canadian Forces personnel are offered a full range of health services, from health promotion and illness prevention to treatment and rehabilitation. If the health care clinic on a particular base cannot offer a required service, then that 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, which is a foundation of the conceptual construct that we have in place.

Relocation away from extended networks of family and friends is a part of military service that military members selflessly accept. This creates difficulty during times of illness or following an injury. A strong social support network is an essential ingredient to the successful recovery from any significant illness or injury. In recognition of this, the Canadian Forces has instituted a number of programs and services, such as the operational stress injury social support network, the return to work program, and an evolving enhanced local casualty support capability.

I'd be remiss if I did not take this opportunity to also mention the services available to our families. Although the Canadian Forces is not mandated to provide direct clinical services to family members, some examples of the types of assistance available that we provide include Canadian Forces social workers and other mental health professions who provide counselling to the entire family, if required, as part of the healing process for the individual suffering from a mental health illness, that being the member. There is also the Canadian Forces member assistance program, a confidential service available through a 1-800 number 24 hours a day, 365 days a year. It is available to family members who need psychological, financial, legal, or spiritual assistance. On a personal note, I have personally used this system and I can attest to the fact that it has provided me a response within 24 hours. The operational stress injury social support network also has a family support program in place. And finally, military family resource centres at bases all across Canada offer a myriad of services for family members.

For certain patients requiring longer-term, ongoing care, navigating through a maze of civilian health care providers and Canadian Forces clinical services can prove challenging. That is indeed a fact.

Members also face uncertainties when they're released from the Canadian Forces for medical reasons and are required to obtain health care services and benefits from Veterans Affairs Canada or through a provincial system. To coordinate and simplify this process for the individual, the Canadian Forces has put in place a robust care management program.

Case managers service a primary point of contact for the member to help them navigate effectively through the military and civilian health care systems. In addition, several Canadian Forces health services clinics are located in larger cities where much of the initial casualty management and treatment for seriously ill or injured members is done in civilian facilities. To maintain close liaison and to follow up the Canadian Forces individuals who are admitted to civilian facilities, the Canadian Forces Health Services Group employs link nurses, that is, nurses who act as a link between the military and civilian health care system.

I now wish to elaborate on mental health services that have recently seen dynamic changes to increase capacity to deal with post-deployment mental health care, an issue that I'm sure will be examined here as part of this committee.

In the latter part of the 1990s, instances of post-traumatic stress disorder and other psychological injuries began to appear in military personnel following deployment to the former Yugoslavia and peace support missions in Africa. To effectively manage this need for specialized mental health care, the Canadian Forces established five operational trauma and stress support centres, which we also call OTSSCs, which opened in September 1999.

The mental health care providers, working in the operational trauma and stress support centres, provide comprehensive assessment and treatment for operational stress injuries such as post-traumatic stress disorder, using a standardized, interdisciplinary model of care. In her November 2007 report on Canadian Forces health services, the Auditor General did state that the Canadian Forces is employing a best practice in the mental health field, that is, an evidence-based practice whereby its qualified professionals in social work, addictions counselling, and the treatment of mental health illness take part in training and have access to the information and development in treating mental health illnesses in order to keep up in their profession.

Canadian Forces personnel also receive psychological fitness training throughout their career, beginning with their initial recruitment training. This training provides them with tools to help them look after their individual well-being or with the skills they require to help others. For example, leaders learn how to recognize and react to stress conditions in their subordinates. Medical personnel receive clinical training in recognition and treatment of mental illness, and mental health professionals receive in-depth, specialized training.

For the current mission in Afghanistan, mental health providers, consisting of a psychiatrist, a social worker, and a mental health nurse, are assigned to each rotation. These professionals take part in the pre-deployment training and are part of the overall health care team based in the Kandahar airfield. Deploying mental health professionals has been an invaluable tool in preventing and providing early intervention for operational stress injuries.

One area of ongoing concern that has been recognized is the reluctance of soldiers to come forward when they experience symptoms. This is being addressed through an outreach educational effort to change attitudes within the Canadian Forces toward those suffering from mental health illness. The Canadian Forces operational stress injury social support peer network has also made significant inroads to break down barriers to receiving care and to reducing the stigma associated with mental illness.

One very important tool in early detection and in addressing the stigma is the post-deployment screening of personnel who have returned from Afghanistan. The screening is intended to take place between months four and six after returning, although nothing prevents an individual who has any concerns from coming forward to seek help at any time. Unit commanders are accountable to ensure their personnel complete their screening. As well, commanders who recognize there is an issue with a particular individual are aware of the resources that can be used for support and are fully encouraged to move as quickly as possible, when an instance arises, to provide that support.

Since 2003, when the Canadian Forces received the results of a Statistics Canada survey on mental health within the Canadian Forces, massive changes have taken place in mental health. A national mental health strategy, known as the Rx2000 mental health initiative, was developed. It is close to being finally implemented.

By 2009, the Canadian Forces will have nearly doubled its mental health human resources, going from 229 to 447 mental health professionals involving an estimated $98 million.

Let me close by stating that the Canadian Forces health care system is the 14th medical system in Canada and must mirror all aspects of care for its military personnel that are provided by an individual provincial health care system. It has the added and most significant responsibility of caring for those who are injured on operations, nothing a provincial system must do up front.

I'd like to stress that medical mental care is available for the asking to any member of the Canadian Forces. There is a robust and adaptive system to ensure that those with post-traumatic stress disorder and other deployment-related health problems get promptly identified, appropriately supported, and effectively treated.

Men and women of the Canadian Forces are getting the care and support they need. This is corroborated in the May 2006 report by Senator Kirby, entitled Out of the Shadows at Last, where he states:

The Committee is pleased that the Department of National Defence offers such a wide array of services to Canadian Forces members who may experience mental health problems. The provision of services for family support as well as medical treatment and casualty support is commendable.

Ladies and gentlemen, Chairman, I thank you for this opportunity to address you, and I look forward to your questions at this point.

[The Chair, Conservative, Rick Casson]

Thank you very much.

We will immediately get into the questioning.

The opening round is for seven minutes from each party, and we'll start with Mr. Coderre.

[Denis Coderre, Liberal, Bourassa, QC]

Thank you, Mr. Chairman.

I would like to begin by thanking you for being here. I had the honour of visiting the military hospital at the base in Kandahar, and I witnessed the professionalism of our people and your extraordinary contribution. I also spoke with the psychiatrist, who gave me a good briefing as to the situation on the ground. Congratulations are in order: I liked to what I saw.

I have several questions, and here is the first.

General Jaeger, I'd like to know how many injured we have in our Canadian Forces since our mission began in Afghanistan.

[Brigadier-General Hilary Jaeger, Commander Canadian Forces Health Services Group, Director General of Health Services and Canadian Forces Surgeon General, Department of National Defence]

Interesting, sir, that you've addressed that question to me, because as the Auditor General's report points out, I work for an organization that is very good at collecting individual data points but not very good at rolling them up collectively.

On the other hand, General Semianiw has brought that injury data with him, so I'm going to turf that one over to him.

[MGen Walter Semianiw]

Thanks a lot, Hilary.

I know that question has been posed here. Clearly, to balance those two very much competing interests, the need of the public to know and the need for military security, we can tell you that the Canadian Forces policy on the release of the wounded in action statistics was changed in mid-October 2007—

[Denis Coderre, Liberal, Bourassa, QC]

Excuse me, General. I went through that with General Atkinson already.

[MGen Walter Semianiw]

I have more information.

[Denis Coderre, Liberal, Bourassa, QC]

I would like to get the numbers right away, because we only have seven minutes.

[MGen Walter Semianiw]

The information will now be raised and provided at the end of each calendar year. That decision was made in mid-October 2007, and I have that information with me today. Just to remind you, the information is broad; it's not specific. It needs to be broad.

First we have to take a look at it in the broad sense of how many Canadian Forces personnel have served in Afghanistan over the years from 2002 to 2007. From our information at this point—because this information has come to me some time today—we're looking at approximately 20,000 Canadian Forces personnel who participated in the theatre of operations and supported it throughout those seven years.

Having examined that, that's from 2002 to 2007, and the information I have is up to date as of the close of 2007. That information is organized into a number of areas for you, organized into first—and there are different types of injuries, non-battle injuries that range from individuals who may have broken their small finger...and I'll go through them in a minute—

[Denis Coderre, Liberal, Bourassa, QC]

General, I've many more questions for you. Can you give us the numbers right away, if you don't mind?

[MGen Walter Semianiw]

Oui.

If you take a look at the overall numbers of injuries, among the 20,000 personnel who have been there since then, the total number of deaths and injuries has been 749. When one looks at it from a purely percentage point of view, the numbers do come down, and looking at the different categories, they have been organized as non-battle injuries, wounded in action, non-battle deaths, killed in action, and total deaths and injuries. I think an important point to make is that we ensure that we look at this number within that perspective, to ensure we have an informed discussion on this, not just the overall number affected.

[Denis Coderre, Liberal, Bourassa, QC]

I understand, General. I see that you have a chart. That should be handed out to everyone and then I can move on to my other questions. Is that all right with you?

There are physical injuries, but there are also psychological ones. With regard to that issue, there are many taboos and we still don't really understand post-traumatic stress syndrome. I would like to know two things. First, we have been told that when our soldiers are sent on three or more deployments, there is a higher level of post-traumatic stress syndrome. I would like you to explain this phenomenon to us.

This leads me to the decompression stage. After every deployment to a theatre of operations, before going home, there is an important period of decompression. I was told that this happens in Cyprus and Thailand. In any case, the soldiers are guided through a process of decompression. I would like you to explain to us what happens when a soldier goes through the decompression process. But could you first tell us whether you are concerned that the post-traumatic stress level increases after several deployments.

[BGen Hilary Jaeger]

Thank you for your question. It makes sense that a soldier has a higher level of post-traumatic stress after several missions, because the more often one is deployed, the higher the likelihood that one has experienced something extremely stressful. Based on our most recent data, we know that, with regard to the people who have come back from Afghanistan, those who have experienced the most extreme shocks are most likely to suffer from post-traumatic stress disorder, which only makes senses. I do not think it surprising that the level of post-traumatic stress is higher after three deployments.

As far as decompression is concerned, please understand that this process was not created to decrease the level of post-traumatic stress. Rather, the point of decompression is to make it easier for a soldier to go home again, which is not the same thing. It is to reduce the tension which can arise when a soldier goes from a theatre of operations to his family the next day. Everyone thinks that it will be great once they are home, that there won't be any problems, but that is not the case. While the soldier was gone, the family has reorganized the way it functions—

[Denis Coderre, Liberal, Bourassa, QC]

There are ups and downs.

[BGen Hilary Jaeger]

—and when the soldier returns home, things have changed.

[Denis Coderre, Liberal, Bourassa, QC]

But do we agree that decompression is also a good way to identify post-traumatic stress? I was told that some people had expressed concerns during the decompression process because it seems that the level of stress had gone up amongst the soldiers.

[BGen Hilary Jaeger]

We are always willing to provide treatment and we take advantage of the process to inform the soldiers that help is available depending on what they need. This is an important part of the decompression process.

[The Chair, Conservative, Rick Casson]

Thank you, Mr. Coderre.

Mr. Bachand.

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

Thank you, Mr. Chairman.

If I understood correctly, you said a few moments ago that over seven years, 749 troops had been killed out of a total of about 20,000 who had been in a theatre of operations. You have a chart before you; we had agreed that we would look at it.

What is the most frequent type of injury? How is that broken down? I understood that you broke down the types of injuries, and I understand that someone who falls off his chair at the office is not injured to the same degree as he would have been in combat. You said that some injuries were sustained in combat. General, is there a breakdown by type of injury in your chart?

[MGen Walter Semianiw]

It is in the chart.

As I said, it is broken down by

non-battle injuries.

So, you are correct.

If I fell off my chair and got injured and had to be sent home, I'm included in that 749.

Conversely, there are injuries sustained in battle.

So it goes from one extreme all the way to the other extreme, which is why I come back and say that it's important to look at all the categories, to get an accurate reflection of what actually happened.

When you look at it—and you're going to see it, so I'll give you a little bit more here. Take this figure: wounded in action, 280. So now the number starts becoming a little bit more crystal, a little clearer: 280 wounded in action, from an overall 749.

There were 395 non-battle injuries. I wanted to mention this when the first question was posed, but I was asked to go to the end. Nevertheless, 395 is the number of non-battle injuries.

So as you said, it is as if I had suddenly fallen off my chair.

Then you have wounded-in-action, non-battle deaths; that's another issue. I would tell you, I've been in Afghanistan for six months, and to answer your question, what is the biggest piece, the biggest piece is non-battle injuries.

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

Non-battle?

[MGen Walter Semianiw]

There were 395 non-battle injuries, which happen, because, remember, we still....

For instance, when I was in Afghanistan, I went to the gym every day to work out. But if suddenly there was a problem

and I injure myself. It's still an injury, which is recorded.

At the end of the day, I have to provide that support to that individual as much as I do to the individual who is injured in combat.

So it is very important to look at the files in detail.

looking at each column.

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

How is the medical services budget spent?

Ms. Jaeger, do you have an annual budget?

It is fairly difficult to establish a budget at the beginning of the year. For example, if one year we decide not to go to Afghanistan, and the following year, we stay home, the budget will be different. How much did those 749 wounded troops cost taxpayers?

You could always send me the answer in writing.

[BGen Hilary Jaeger]

That is a fairly complicated question. My annual budget is approximately $300 million, which does not include pay for the troops, but only salaries paid to civilians and Blue Cross employees. That amount also includes things like medications and preparations, but not the troops' salaries. The amount also does not include things which are directly related to the operation in Afghanistan. It's what we call

SDOA, special duty operations.

We have an additional budget for that.