National Defence Committee on Feb. 25th, 2009

[BGen Hilary Jaeger]

Everybody is searching for perfection, and part of my sad duty is to tell you that this is 2009 and perfection in the realm of detection, prevention, and treatment of mental illness is just not possible.

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

However, you should not use that as an excuse to distort the facts. We still have a major problem. Many people are telling us that they have to live with post-traumatic stress disorder.

It is important to look closely at the department's true intention. Let me give you another example. In 2002, you said that it was extremely important to have an information system and a data base for health. How come, seven years later, we still do not have that data base? Nonetheless, in 2002, the department said that it was entirely in support of this recommendation. Are there not some attempts, not to cover-up but to minimize what is happening to the Canadian armed forces? We, as members of Parliament and as legislators, have a right to investigate the department's true intentions.

I do not want to cast judgment on your intentions. However, I cannot help but note that there is no data bank in 2009 although seven years have gone by and even though the department said that it wanted one in 2002.

Now I will let you answer.

[BGen Hilary Jaeger]

Shall I respond, Mr. Chair?

[The Chair, Conservative, Rick Casson]

A short response, if you can.

[BGen Hilary Jaeger]

I would ask Mr. Bachand if he's ever been involved with the management or implementation of a large information technology project. The Canadian Forces health information system is now in phase three of its three-phase roll-out. The project concludes about a year and a month from now, and at that point we will have gone.... It's like building a sewer system and then we're going to turn the taps on in the next year. So we've spent all this time digging and laying the sewer pipes, and the amount of useful information is just going to explode, but we have about another year to the finish line.

[The Chair, Conservative, Rick Casson]

Thank you very much.

Ms. Black.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

I'll continue along these lines, because we had the past interim ombudsman here before you, and she, again, has given another report. It was given to the minister in September 2008 and was released publicly in December. The military ombudsman is calling again for the creation of a database to track the number of personnel who are affected by stress-related injuries. It was recommended in 2002 but was never implemented.

I have here a quote from a story by Helen Branswell of The Canadian Press. She quotes a senior official with public affairs at the Department of National Defence, Major André Berdais, who responded to her about that kind of data. It relates to a study that was done in the U.S. Berdais said that this kind of data is not tracked by the Department of National Defence and that it “isn't essential in supporting our primary responsibility of patient care”.

That would indicate a reluctance, in my view, contrary to some of what we've heard today, to implement this recommendation that's been waiting now for seven years to be implemented. I want to ask if what this gentleman articulated is still the position of the Department of National Defence. And how can that be justified when the ombudsman has clearly stated that this kind of tracking is absolutely essential to effectively deal with post-traumatic stress disorder and operational stress injury?

[BGen Hilary Jaeger]

I'll answer along two lines, Madam.

First of all, André Berdais is my public affairs officer. He works for me, and the words he releases have all been cleared by me.

It has been my leadership decision not to set out and create--stealing staff effort that I need in other places--a mini database separate from the health information systems project. The rationale behind that is that I need every smart person I can get my hands on to keep that major project moving forward. It's had its challenges with timelines and.... I'm not sufficiently geeky that I can go in and get that thing to work by myself. But we've flogged that horse about as hard as we can. So a decision was made to not divert any effort that we really need to get that big piece done.

The other side is that we don't track patients with the national database. The patients are tracked, monitored, and followed at the clinic level. Yes, I'd love to have great data so I could say on any given day of the week how many patients have depression and who was seen in the last week for depression. I'd love to have that. But as to the difference it would make to the care of the individual patient, I don't believe it would make a significant difference.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

So you stand by your public affairs officer's statement.

[BGen Hilary Jaeger]

I do.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

In your remarks to us earlier, you said that you're actively cultivating contact with U.S. counterparts on these issues. There was a report from the Institute of Medicine, a body in the U.S., commissioned by the U.S. Department of Veterans Affairs. It came out, I think, a few months ago, in mid-December of last year. It said that traumatic brain injuries have become the signature wound of the wars in Afghanistan and Iraq and that troops who sustain them face a daunting array of potential medical consequences later on.

This body, the Institute of Medicine, said that military personnel who sustained even moderate brain injuries may go on to develop Alzheimer's, dementia, symptoms similar to Parkinson's, a higher risk of seizure disorders, and psychosis. It said that people with even mild brain injuries are more likely to develop post-traumatic stress disorder.

In the 2002 study there was a mental health survey done, which was a follow-up. The ombudsman reports now that the information is very dated. Again, that information is seven years old. It was before we were in a combat situation in Afghanistan.

Will the department be conducting our own new study? The numbers you reported earlier were reflections of volunteer participation and were not from a medical, scientific study. So will there be a new study, as the ombudsman recommends, of the mental health situation of the Canadian Forces in light of what has now, I guess, been eight years of combat in Afghanistan?

[BGen Hilary Jaeger]

There are a lot of implicit questions in there. The short answer to the last part is, yes, in fact we're in the middle of collecting data on the health and lifestyle information survey at the moment. I have copies of this survey in English and French, which I can leave with the clerk.

It's a long period to collect data, but I believe 50 of those questions are related to mental health and they really focus on PTSD and depression because of the two most significant problems we found in the 2002 survey. That survey is going to be repeated at two-year intervals. It also includes questions pertaining to experiences while on operations and related traumatic brain injury.

On the subject of traumatic brain injury, first of all, if you've had a moderate traumatic brain injury or a severe traumatic brain injury, believe me, you know it because you are going to be hospitalized for that. These people are knocked out. They have significant neurological deficits from the outset of that injury, so they're not hard to find. Yes, recovering from brain injury is a very.... You only have to think of Captain Greene. That is a severe traumatic brain injury.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

You are talking here about mild--

[BGen Hilary Jaeger]

We're talking about mild. We had a national-level conference on the issue in April last year. Since then we have put decision support tools into Afghanistan, algorithms that help our people in the front line determine whether there is cause for concern.

You are right. I call it an association between traumatic brain injury and PTSD, and it's not hard to understand why that would be, because to have a mild traumatic brain injury, you've probably been pretty close to an explosion. That's the kind of significant stress that can also trigger PTSD, so it's really not surprising there is a close--

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

Have you read the study?

[BGen Hilary Jaeger]

I have, yes.

[The Chair, Conservative, Rick Casson]

I'm sorry, we'll have to get back to that.

Over to the government, Mrs. Gallant.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Mr. Chairman, I'll be sharing my time with Mr. Hawn.

First, I'd like to commend Colonel Ethell for his work with OSIs and now his expanded duties with the full range of mental health issues for our soldiers.

I congratulate Colonel Grenier. For many years you were the lone voice in the wilderness when it came to PTSD, and through your tenacity in pursuit of helping your fellow soldier you have brought the issue right to the House of Commons Standing Committee on Defence.

On April 15 of last year the veterans affairs committee travelled to Base Petawawa, and among the different forums we had some soldiers who had suffered PTSD. They related their experiences to us in a private forum. One soldier had been injured over a year ago. He had been travelling in a troop carrier, and other people died. He lived. He had been asking for psychological/psychiatric help for over a year, and it wasn't until that day, when the veterans affairs committee just happened to be coming, that he got his first appointment with a specialist. It was too late for him because he'd already applied for medical release.

Last week we had General Semianiw who said:

A decision was made, not in the last four years but before that, not to put an operational stress injury clinic in Petawawa. In hindsight, it was probably a bad decision. What we see here today is that having an OSI clinic in Petawawa would have been the right thing to do. It was not done, but we're dealing with that issue to ensure the men and women in uniform get the support they need in Petawawa.

The military ombudsman just related to us today that over 8,500 soldiers have deployed out of Base Petawawa to Afghanistan. How can you assure this committee, and, more importantly, the mothers, the fathers, the spouses, the children of our soldiers who are starting to return right now, that they will obtain the proper medical care they need, be that physical or psychological care?

[BGen Hilary Jaeger]

At some risk, I will disagree with General Semianiw. When you decide where you're going to put your major treatment centres for operational stress injuries, yes, proximity to the population at risk is very important, but you also have to be realistic about where the resources can be found.

Petawawa, I know, is two hours up the road from Ottawa, but we have been trying, unfortunately, for the last three or four years to hire people into that position. The reason we're posting military social workers and a military psychiatrist there this summer is that we cannot attract civilian providers to Petawawa. It's a beautiful place in the upper Ottawa Valley, but we have been unable to attract them there.

If we had decided back in 1999 to open the OTSSC in Petawawa, it would have half the staff it has now in Ottawa. The ideal would be to have all the providers you want where you want them, but it's better to have them close by than not to have them engaged in your organization at all. Of course, 8,500 people have rotated out of Petawawa, but the total base population is somewhat less than that. That accounts for the fact that people get posted and people get rotated.

We are continuing our efforts to build the clinic in Petawawa. When we achieve what we're going to get to this summer, they will have a full general mental health program. Of course, they have a full psycho-social program. The only thing they will be missing is the OTSSC label, but they will have all the components of an OTSSC.

I'll turn it over to the director if he wants to correct me on this, but I don't see any reason we could not institute the assessment protocols right in Petawawa.

[Colonel A. Darch, Director, Mental Health, Department of National Defence]

I agree.

With Petawawa, one of the problems, as General Jaeger said, is getting enough mental health care professionals there. Part of the problem is the number of mental health care professionals we depend on who are civilians. With Petawawa, we're dealing with the fact that there is a general shortage of mental health care professionals across Canada. There is a lot of competition for those mental health care professionals. Petawawa is a semi-isolated location, and the amount of money we can pay under Treasury Board guidelines is not competitive with what some civilian organizations can pay. We're just having a lot of difficulty getting civilian mental health care professionals to work there.

To improve that, our Ottawa OTSSC is operating satellite clinics in Petawawa, and the health care professionals go there. One of our senior Canadian Forces psychiatrists is spending a minimum of one day a week in Petawawa. We have a tele-medicine pilot project that will link Ottawa with Petawawa. Through high-definition medical cameras, soldiers will be able to have tele-medicine consults with mental health care professionals in Ottawa. While we wouldn't recommend that for initial assessments, it would be useful for ongoing care.

We posted a major social work officer to Petawawa this last summer who is taking the lead as a mental health care professional there and leading the clinic, and that has made a big difference by itself. This summer we'll post in three more social workers and a military psychiatrist, which will augment their capability significantly. Along with that, we've not been able to fill all the civilian positions, so we're going to transfer five of those to Ottawa: one psychiatrist, two psychologists, and two social worker positions that are not filled. We'll be able to fill them in Ottawa. Those people will then be used to run the tele-medicine capability that will link Ottawa and Petawawa. They will also do satellite clinics in Petawawa.

In addition to this, I have a lieutenant-colonel within the new mental health care directorate who is capable of spending up to two days a week in Petawawa as a psychiatrist.

As well, we still have the capability for patients to come to Ottawa to get help. It's not that far down the road. So where that works out for them, we can manage that.

[The Chair, Conservative, Rick Casson]

We're right on schedule.

We'll go to Mr. Wilfert, and then back to the government.

[Bryon Wilfert, Liberal, Richmond Hill, ON]

Thank you, Mr. Chairman.

In the December ombudsman report, “Battling Operational Stress Injuries”, of course she looks at what has and has not been attained by the department at this point.

Trying to prioritize 31 recommendations is a very daunting task, and no one expects that all 31 can be done instantly. Given our continued presence in Afghanistan and the fact that we are seeing more of these cases coming home, as a framework this would indicate that clearly we need to be better prepared in terms of dealing with the personnel who are coming home. In her report she clearly says there is a need...“so that they can continue to be contributing members of Canadian society”, within the forces or outside, that it is absolutely paramount, and that we still have very much what is considered an ad hoc system.

I want to go back, just for more clarification, to the data system, and then I want to go to recommendation 9. On the data system, maybe I didn't hear it correctly. To me that is the most important thing in terms of being able to understand what you have to deal with presently in terms of the information, in terms of the personnel affected by these injuries. Can you tell us when you see this completed? To me this would be one of the most paramount things given the fact that we're seeing increased casualties and certainly response from people coming home from Afghanistan in particular.

[BGen Hilary Jaeger]

In regard to the CFHIS project, sir, its authority to spend money expires in--I'm not sure which--April or May 2010. So we're about a year away from the end of the project. I think it will probably take us about six months after that to get really good at manipulating all of the ways to pull data from the system. That's as close to an accurate timeline as I can give you.

We have alternate sources of data. A lot of our understanding of workload...we do receive, as I've briefed, counts of new patients coming in from the clinics. We do the enhanced post-deployment screen, which is not a diagnostic tool, it's a screening method. But screening methods by their nature are supposed to produce more false positives than false negatives. They're supposed to err on the side of saying there's a problem rather than denying there's a problem. So we do have some measure of the size of the problem. What we can't do is go across the system on any given day and say how many patients were seen this week for PTSD.

[Bryon Wilfert, Liberal, Richmond Hill, ON]

In terms of these surveys that you initially talked about, what about six months or a year from now when these people may in fact be experiencing latent symptoms, or in fact circumstances develop because they're either still in the forces or now they're in civilian life and we see the kinds of problems that may have happened, some domestic issues, and that type of thing?

[BGen Hilary Jaeger]

We actually did give some thought to that because we know there are people who will present with problems after the six-month screening has been done. We did give some thought to whether there was a need to systematically go back across and re-screen. It is an enormous effort to do that screening. I would never say that the effort would not be worthwhile because that's a harsh kind of thing to say.

But I want to give you some encouraging information. I had occasion to review all of the files from the Chicoutimi fire, for all of the sailors who were on board Chicoutimi. Over time, since that fire, a little over 50% of them have in fact been diagnosed with PTSD. They underwent the enhanced post-deployment screening, and probably only about half that number screened positive at the time. I think the effect of that mandatory screening made approaching people for mental health care a whole lot less scary, so that maybe six months after they were screened, when they realized that things weren't going very well and they were having flashbacks or nightmares, it was not threatening to walk into the clinic or to pick up a phone. I think that's a very powerful effect of the enhanced post-deployment screening, and I'm hoping that applies to the problems the army finds.