National Defence Committee on April 3rd, 2008

[The Chair, Conservative, Rick Casson]

We'll call the meeting to order. We're meeting today pursuant to Standing Order 108(2) and the motion adopted Tuesday, November 20, 2007, on the study of health services provided to Canadian Forces personnel, with an emphasis on post-traumatic stress disorder.

Today we have a two-part meeting. The first part is the witnesses, and I'll introduce them shortly. The second part is to consider the third report of the subcommittee on agenda and procedure that we held Tuesday to deal with future business. We'll give these two gentlemen as much time as we can, but we'll try to switch over probably at 5, 5:10, or somewhere in there.

Today we have General Gauthier, commander of the Canadian Expeditionary Forces Command, and Colonel Bernier, director of health services operations.

Do you both have presentations to make?

[Lieutenant-General Michel Gauthier, Commander, Canadian Expeditionary Forces Command, Department of National Defence]

Yes, we do.

[The Chair, Conservative, Rick Casson]

General, are you going first? Please take as much time as you need, and then when we get into the questions, we will start with a seven-minute round for each party and then switch to five minutes, and we'll get as deep into that as we can.

[LGen Michel Gauthier]

Thank you very much, Mr. Chair and honourable members. I will try to keep my remarks relatively short and stick to the comments I have in front of me. I can't guarantee the same approach to answers to questions, of course. We'll see how that works out.

Good afternoon.

I am pleased to have this opportunity to speak with you about Canadian Forces health services in support of deployed operations.

As you know, as Commander, Canadian Expeditionary Force Command, I am responsible for all Canadian Forces personnel deployed on international missions. I take strategic direction from the Chief of Defence Staff, produce plans, and oversee the resulting operations. In current Canadian Forces language, I am a Force Employer. The Force Generators, most notably the Navy, Army and Air Force, have the task of producing, equipping and making ready their personnel for both domestic and international assignments. These are then assigned under my operational command while employed overseas consistent with direction provided by or on behalf of the CDS.

Currently, there are a total of 16 overseas missions, involving roughly 3,000 Canadian Forces personnel, both regular and reserve. Overseas missions have varied widely in the past several years. They have included traditional peacekeeping, maritime interdiction, evacuation of non-combatants, and humanitarian assistance. The missions vary widely in terms of local conditions, but, in general, all assigned personnel serve in environments that pose heightened personal risk and hardship.

Clearly, the Canadian Forces' largest, highest profile, and most demanding mission is the one in Afghanistan. This mission is not as large as some of the missions of the past 15 years, notably the mission in Bosnia at its height. But it is clearly the most intense, in that it involves counter-insurgency operations against the determined enemy. Of course, this means our personnel in Afghanistan experience psychological stresses associated with physical hardship, violence, and danger on a significant scale.

Command authority over personnel during periods when they're undergoing mission-specific training prior to deployment rests with the appropriate force generator, principally, commander of the army, commander of the navy, and commander of the air force. It also reverts back to them, of course, once these forces arrive home for recuperation and preparation to resume their normal duties. Therefore, I will focus my remarks on how I discharge my command responsibilities for the provision of health services to personnel deployed overseas and concentrate on Afghanistan, the largest effort.

For any potential overseas task, CEFCOM conducts an analysis process to determine the composition and size of forces necessary in relation to the assessed operating environment, the mission, tasks, and the concept of operations. Force protection, logistics support, and health care requirements are all specific red-line imperatives for which the CDS must be satisfied that the deploying force has what it needs to assure mission accomplishment.

As the mission evolves, force composition is scrutinized in great detail between ourselves and force generators every six months to ensure it remains relevant and appropriate to the mission requirements. Likewise, through a relatively robust lessons learned framework, lessons are captured on a continuing basis in-theatre and analysed by force generators to adapt and improve doctrine, equipment, training, and operating methods for those deploying on future rotations in a very dynamic way.

In Afghanistan, our medical and dental presence is the most comprehensive we have deployed since the Gulf War, with a total of 166 health service personnel, a small number of civilian contracted clinical augmentees and a further 21 in direct support at other forward locations. A tiered system, based on progressively larger and more diversified levels of care, addresses the needs of our in-theatre personnel inside and outside the wire.

At the basic level, all troops are Combat First Aid qualified and able to provide immediate rudimentary care. Many are trained to a more specialized standard of Tactical Combat Casualty Care. Though clinically non-professional, these individuals provide an initial and potentially critical first response. The first level of professional medical expertise is defined as role 1. At this level, medical technicians, the equivalent of civilian paramedics, deploy on high-risk patrols and provide emergency stabilization in situ. Role 1 also includes physician assistants and medical officers at forward operating bases providing routine medical care and care beyond the scope of a medical technician. This ability to provide urgent initial treatment is extremely important to increasing survival chances and more complete recovery.

Where the seriousness of the injury requires more complex care, the patient is rapidly evacuated to our Role 3 medical facility in Kandahar, which is capable of surgical and other specialist interventions. This world-class facility, which I believe a number of you have seen, is multinational in composition, but is led and predominantly staffed by Canadian Forces personnel. Through the skilful and dedicated application of modern battlefield medicine, these individuals have saved many lives. I make a point of visiting the Role 3 facility just about every time I go into theatre.

Patients whose conditions are serious enough to preclude continued involvement in the mission are repatriated to Canada after undergoing a limited period of advanced care and stabilization at the United States military's Landstuhl Regional Medical Center in Germany, another world-class facility, where a number of Canadian lives have been saved.

With over 20 visits into theatre now over the last six years, I have a very positive view of the health support foundation we have in place in Afghanistan, in terms of health care professionals, trained soldiers, and a chain of command that's absolutely seized with the importance of looking after our men and women. I believe our soldiers have a strong sense of confidence that wherever they happen to be in harm's way, they will be looked after quickly and with the best of care.

In addition to the physical injuries our personnel can sustain, those related to operational stress receive equal attention and commitment of resources. I can assure you that leaders at all levels of the chain of command, from the section or crew level right up to the chief of defence staff, are acutely aware of the high-risk character of operations in Afghanistan and are absolutely mindful of their responsibility to ensure that the necessary in-theatre support framework is in place and the units, as coherent teams and as individuals, are as well prepared as they can be to face the associated challenges.

In this whole area, the Canadian Forces in general has made significant strides in the past decade, in that operational stress injuries are increasingly viewed in the same context as physical ones.

During force generator-conducted pre-deployment training, every effort is made to simulate, as realistically as possible, the conditions under which our troops will operate. Knowing what to expect can enhance an individual's ability to cope with stressful situations. But the training also includes educating leaders at all levels to detect signs of undue stress and pressure in their subordinates and means of providing support and referring to professional mental health workers who are part of our health services component in-theatre.

Once referred, patients are carefully screened to determine if treatment is required and, if so, whether that level of treatment would restrict them from continuing the mission. These assessments are only made by competent clinical professionals, while keeping the chain of command apprised of any consequent employment limitations and patient requirements. You will hear more from Colonel Bernier about the health services infrastructure in-theatre as it relates to mental health.

I would simply add to this that the first layer of both response and protection is the team that surrounds each soldier, whether it's a vehicle crew or an infantry section, together with the leaders at each level, all of whom see themselves as having a central role to play in looking after each other.

Under my direction, an interim post-deployment decompression activity is an integral part of the return process for all deployed personnel. The purpose of this program is best thought of as an inoculation against reintegration stress by providing an interim venue between the dangerous, fast-paced, rigid structure of the combat theatre, and the domestic home environment. Designed to provide a positive environment away from the pressures of the operational treater, troops are able to socialize, relax, reflect on their experiences and receive educational briefings on stress-related injuries. This process has been well received by our personnel, though the true measure of its effectiveness will only be apparent over time.

With respect to health issues in general, and mental health issues in particular, information is maintained by our CF health care professionals, and it is analyzed and discussed with the operational chain of command as appropriate.

In my experience of a bit more than two years of commanding operations in Afghanistan, I can say that operational stress injuries have not been identified by any of the three theatre commanders--General Fraser and then General Grant and then General Laroche--at any time as having either a detrimental effect on operations or in posing them with a challenge that was beyond their capacity to handle. The most obvious indicator of mental health issues adversely affecting operations would be the number of personnel who need to be repatriated from theatre for operational stress-related injuries. So far these numbers have been extremely low. It is indicative of the success of our mental health provider footprint and pre-deployment training.

From a very practical point of view, the health and well-being of our people is essential to mission accomplishment. Naturally, confidence in our ability to provide necessary health care is an important contributor to strong morale among deployed forces.

Finally, there's a much more general principle in the ethos of military leadership that exercising diligent care for those under one's command is a moral and ethical necessity and commitment, especially in light of the acceptance of ultimate risk that those individuals have taken.

As commander responsible for the mission in Afghanistan and other deployed forces, I'm confident that our personnel who are deployed in harm's way are receiving an excellent standard of attention and care. Given the challenges they face in Afghanistan in particular, they deserve nothing less.

I'd be happy to take any of your questions, though I caution that I'll defer to Colonel Bernier on matters of a specific medical nature. Of course, I'll hold off on answering your questions until Colonel Bernier has spoken.

[The Chair, Conservative, Rick Casson]

Thank you very much, General.

Colonel, go ahead.

[Colonel Jean-Robert Bernier, Director, Health Services Operations, Department of National Defence]

Good afternoon, Mr. Chairman, ladies and gentlemen. Thank you for the opportunity to appear before you today with General Gauthier.

I'm the director of health services operations in the Canadian Forces health services group. In addition to providing medical advice to the strategic joint staff, my directorate works through the Canadian operational support command to support the operational commands in planning, preparing, and executing all aspects of health service support to military operations.

Among others, my key responsibilities include: assessing the health threats specific to an operation; determining and organizing the appropriate health measures and capabilities necessary for the health protection of deployed forces and for the treatment and evacuation of casualties from point of wounding all the way back to Canada; organizing the appropriate professional and technical training of deploying health services personnel and units; coordinating with the health services of host nations and allies to maximize the efficient employment of coalition resources; ensuring that deployed health services elements are provided with whatever professional support and health services resources they need during the mission, and evaluating and coordinating modifications to the training, capabilities and capacity of deployed health services according to the most current health needs of the force.

As you know, the nature of many military operations makes the development of some mental health conditions unavoidable, even with the best preventive and treatment efforts. I would, however, like to summarize the preventive and treatment efforts that are relevant to mental health in operations.

Regarding prevention and early identification, health screening occurs at enrollment, during periodic health assessments throughout a member's career, and at pre-deployment to identify those whose past or current health status might place them at increased risk of having inadequate operational capability or of suffering a serious health problem during operations.

Realistic training at enrollment with units and before deployment helps our members develop confidence in their skills, weapons, equipment, colleagues, and leaders. This is important because strong unit cohesion, social support, realistic training, and good leadership have been associated with lower rates of combat stress and are thus amongst the best preventive medicine efforts.

Stress awareness is briefed during pre-deployment training and is being integrated into officer and non-commissioned officer courses. In combination with the various chief of military personnel programs to promote good mental health, these efforts form a strong foundation for a deployable force that's as mentally fit as possible.

Determination of the mental health and other treatment capabilities to be deployed for particular missions is based on consultation between my staff, the operational commands, and senior health specialists. They take into account the threat, the nature of the mission, previous experience, medical evacuation timelines, host nation and allied health services resources, and many other factors.

Mental health staff currently in southern Afghanistan include several primary care physician assistants and physicians, two social workers, one mental health nurse and one psychiatrist. Canadian troops are also supported by a cadre of chaplains for pastoral counseling and by some US and UK mental health staff. Visits to forward operating bases by mental health specialists are conducted routinely to provide education and early intervention.

Wait times for care are negligible and emergency cases are seen immediately. Surge support in the event of mass casualties is available from other NATO health service facilities in Afghanistan, and higher level care is available at the US military's Landstuhl Regional Medical Centre in Germany.

The adequacy of the deployed Canadian capability is continually reassessed. This is based on a weekly review of patient visit statistics, regular reports and recommendations of the task force surgeon, periodic staff assistance visits from Canada, detailed biennial after-action reports, expected future operations, regular consultation with allies and many other factors.

Early identification and treatment of problems is pursued with the aim of returning members to duty, but repatriation is necessary if it's in the best interests of the member's health or if the duration and type of any employment limitations or treatment would adversely impact his or her operational capability.

As for all health conditions, these determinations are not based on blanket policies but on a professional assessment of each individual's condition and health needs. It is, for example, possible for a soldier with a well-managed condition in the maintenance phase to carry on doing all duties if doing so is in the patient's best health interests and if there are no significant risks related to the condition or prescribed medications. Among the clinical considerations is that studies have demonstrated that mental health casualties taken away from their units do not do as well and are at higher risk of developing chronic conditions such as PTSD.

As the Surgeon General previously noted, patients with acute mental health conditions would not be employed in combat duties. Normal psychiatric and occupational medical practice and Canadian Forces policy would preclude their return to such duty without a deliberate determination by competent medical staff that it was medically and operationally safe to do so.

Transient spikes in visits to medical staff may occur after high-tempo operations and traumatic incidents, but the vast majority of patients quickly recover and return to duty. The number of operational stress injuries manifesting during operations has so far not had a significant operational impact.

At the end of their deployment, members must complete a declaration of injury or illness listing potentially harmful exposures or health conditions they sustained. They undergo an initial post-deployment health screening and those with potential mental health problems are identified to their home base medical staff for follow-up. An enhanced screening is conducted three to six months later that focuses specifically on mental health concerns.

A Third Location Decompression Program also occurs over a few days in Cyprus before returning to Canada. This is an effort to ease the reintegration process by providing members an opportunity to rest and readapt to western comforts, to achieve a sense of closure by having relaxed time in a safe environment with their comrades, to provide access to mental health professionals for counseling if needed, and to provide education about operational stress injuries, common reintegration problems and how to get help.

Though not a medical intervention shown to impact the burden of operational stress injuries, there is some evidence that its educational component is contributing to the earlier presentation for care of members with mental health concerns.

Following the enhanced health screening in Canada, all members continue to have access to the pastoral, health promotion and treatment programs mentioned by previous witnesses. Individual health also continues to be monitored through periodic health assessments that include mental health screening elements.

In summary, the mission in Afghanistan may potentially have a significant long-term mental health impact, but the Canadian Forces strives to improve, and has improved, a robust program to deploy forces that are mentally ready, to support them well in-theatre with mental health resources, and to maximize the early identification and treatment of conditions that manifest after deployment.

Though not predictive of the ultimate toll on our members' mental health, the caseload in-theatre today has not been unexpected, is well within our deployed medical management capabilities, and has not had a significant operational impact.

Thank you for your patient attention. I would be pleased to answer your questions.

[The Chair, Conservative, Rick Casson]

Thank you very much.

Our opening round will be seven minutes. Before we get into that, I'd like to welcome Mr. Wilfert to the committee and congratulate him on his new duties with the official opposition.

It looks like you get first run, sir, at the seven minutes.

[Bryon Wilfert, Liberal, Richmond Hill, ON]

The vice-chairman isn't here, so I guess I do. Thank you, Mr. Chairman.

I'd like to welcome our witnesses. It's good to see you again, General.

I have two questions. First, I certainly congratulate you on what you're doing in the field. When I was in Afghanistan a couple of years ago, I heard nothing but very positive comments from the rank and file there about the medical facilities provided.

If someone comes home, if they leave the military—some leave earlier than others—then with regard to provincial health care plans or health care facilities for both them and the family, what kind of coordination, if any, is done in that regard in terms of support?

Second, in terms of the issue of potentially the long term that you'll be evaluating with regard to Afghanistan, what types of assessments do you put in now in order to prepare for that? As we know, in the past this used to be called shell shock or battle fatigue. We didn't understand it as well then as we do now. How do you do an assessment to look at whether there's the potential to prepare for that? What kinds of resources do you need, or would you need, in order to do that in case that impacts in the longer term--in three to five years, say?

That's through you, Mr. Chairman, to the general or the colonel.

[The Chair, Conservative, Rick Casson]

Colonel.

[Col Jean-Robert Bernier]

Those are areas that are outside my lane, but I can answer generally. Far greater detail on them can be provided to you. Because it's such an important area, we have a specific deployment health section whose only purpose for existence is to do a long-term follow-up and evaluation study of all of the most current literature and to conduct original studies following up our troops.

With respect to your first question about what happens when troops retire from the armed forces, there's an extensive collaboration between DND and Veterans Affairs, and specifically between the medical elements of both those departments. There are progressive efforts that are improving continually, which the chief of military personnel, I believe, mentioned in his initial testimony to this committee, relating to that. But there's good coordination.

I don't know all of the details, but there's a common centre, for example, for the care of injured soldiers to enhance that kind of coordination. There are various efforts to ensure there's a smooth transition of all the clinical care records to Veterans Affairs. There's the involvement of the military medical staff in ensuring that Veterans Affairs and the soldier get information required for medical records to support whatever applications they have to Veterans Affairs to access additional services. There are efforts in our periodic health assessments to ensure that all of this is recorded as well for the long term, both for individual clinical mental health and for other physical disabilities, as well as for occupational exposures or environmental industrial exposures that may in the future result in some kind of harm.

All of that is either centrally recorded and/or in individual medical records. Those records are accessible to any CF member for provision to Veterans Affairs.

With respect to your second question, long-term evaluation post-Afghanistan is conducted primarily by this deployment health section that I've mentioned. Some of the records and some of the statistical data collection will end up having to be conducted by a different directorate, called the directorate of health services delivery. There's an effort that's progressively improving, that will be improving substantially once we have an automated information management tool in place, called the Canadian Forces health information system, that can permit the automated collection and aggregation of the data for analysis.

In the meantime, we have enhanced post-deployment health assessments that I mentioned earlier, which occur at three to six months post-deployment. Because we know that some operational stress injuries will manifest after that six-month point, we also have a periodic health assessment based on the Canadian task force on preventive health, those guidelines. Because those guidelines for younger populations were only once every five years, we determined that wasn't enough, particularly for mental health surveillance. So we will be compressing that down to doing it once every two years. That periodic health assessment includes mental-health-specific questions, validated questions, to help identify earlier mental health problems. So every two years, unrelated to the deployment, we'll also be able to carry on evaluating and to pick up earlier cases that might have been missed because they didn't manifest themselves before the six-month point.

Finally, there's a health and lifestyle information survey that we conduct once every four years. Again, it's conducted by another directorate, so I won't go into too much detail about it. I'll try to stick within my lane. There's a directorate of force health protection that looks after most of the preventive health programs, except for mental health, which is so important that it has a separate organization.

The health and lifestyle information survey, conducted once every four years, specifically asks questions from members, and the accuracy of that data is fairly well validated by other sources. The last one was conducted in 2004 and the next one will be in 2008. That will give us significant additional data. It will help us validate. It'll give us a better picture in a number of areas, including mental health. It's mailed out to thousands, or even tens of thousands, of Canadian Forces members, and there's a reserve component as well, so it involves a substantial number of reservists.

In addition to that, periodically, depending on the issue, there are ad hoc additional studies that are conducted. For example, there was a very extensive Gulf War series of studies conducted for the Gulf War veterans. So we have a whole series of efforts to try to follow up epidemiologically and to do health surveillance on individuals after they return from Afghanistan or any deployment.

[Bryon Wilfert, Liberal, Richmond Hill, ON]

Thank you for that.

[The Chair, Conservative, Rick Casson]

You have about one minute and 25 seconds. Do you want to save it for the next round?

[Bryon Wilfert, Liberal, Richmond Hill, ON]

I'll transfer it to my colleague, please. Thank you very much.

[The Chair, Conservative, Rick Casson]

We'll get around to you folks again.

Mr. Bachand.

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

Mr. Chair, I would like to welcome the general and the colonel.

Could you describe the process of an incident in an operational theatre, for example in a forward base, starting from the moment a soldier falls victim to an attack? How do things unfold? First, who determines the severity of the wound? You said that everyone has basic training. When the wound is more serious, who on the ground decides that the person who has stepped on a mine, or been attacked or shot needs additional care? Who in the group is responsible for deciding how serious the wound is and if it can be treated on the spot? How do you proceed under those circumstances? Where do you take the wounded soldier first? Do you take him to Kandahar and, from there, if he needs more care, do you transport him to Germany?

[LGen Michel Gauthier]

The process is very clear, but we must be careful, for security reasons, not to reveal all the details of how we care for our soldiers on the ground in an emergency. Colonel Bernier will handle that challenge.

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

Are you telling me that things like that are classified?

[LGen Michel Gauthier]

They are classified in the sense that if I paint you a detailed picture of how we react to enemy action, it could provide an advantage to those who oppose our efforts in Afghanistan. To a certain extent, that is a serious concern. However, I think we can give you a good idea of the way it works.

[Col Jean-Robert Bernier]

The assessment of the severity of the wound and the steps to be taken, knowing whether the person can be treated on site or whether he should be transferred to a higher level of care, those decisions are always made by the medical personnel.

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

Are there medical personnel at each forward base?

[Col Jean-Robert Bernier]

Yes, and not just there. There are medical personnel in most patrols up to a certain level of deployment. Even our medical technicians are trained to identify mental health problems to a certain extent.

[LGen Michel Gauthier]

Each separate element has a basic medical capability and personnel.

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

To determine the severity of wounds.

One thing troubles me, and I read an article about it. I hope that you will be in a position to answer my question. We know that the Taliban are listening to us, more or less live. We are often told so, and I am inclined to believe it. A forward base can be located 200 or 300 kilometres from Kandahar. I have been told that, if the designated person decides to evacuate a casualty, travel by road may be out of the question because of the severity of the situation. A helicopter evacuation is needed and these are done by the American army. So there is not much we can do if American authorities tell us that they are sorry but they do not have a helicopter available.

Do I understand that we give our soldier first aid until an American helicopter is available?

[LGen Michel Gauthier]

To my knowledge, the only limitation involving helicopters was a direct result of weather conditions that prevented the helicopter from flying. That is the only example I am aware of. Perhaps Colonel Bernier can give other examples or a more direct answer.

[Col Jean-Robert Bernier]

When operations are planned, we always make sure that we have a way to evacuate patients. This is always factored in by the chain of command.

At the moment, the Americans provide the service, but everything is directed by the medical team at NATO regional headquarters. They determine where evacuation resources will go, according to the need. So, if other troops—the Dutch, the British or the Americans—needed them, that is, if their cases were more serious, they would have priority. Likewise, when the troops come back, the wounded are taken either to a Canadian hospital, or another country's hospital, whichever is most appropriate. In no way is this giving the control over to the Americans. They are very generous and they provide us with exceptional service. Things are not as they are because we cannot provide the service ourselves but because they offered it to us when the operation was being planned.

If needed, we have the capability to provide the personnel required. In that case, the responsibility would lie with the operational commander of the Canadian Expeditionary Force.