National Defence Committee on Nov. 6th, 2012

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

Thank you, Mr. Chairman.

Thank you to our witnesses.

Earlier in your testimony you mentioned Calian as an entity that was a third party to find providers. What percentage of a doctor's pay would Calian receive? How is Calian or a company like that compensated when they find a professional, such as a psychiatrist, to work for the armed forces?

[BGen Jean-Robert Bernier]

Calian does receive a certain percentage of the money that they charge the defence department. A certain proportion of that money they keep for overhead; I can't recall the exact percentage, but I think it's between 10% and 20%—something like that—because of all the recruiting they have to do. But then, they all pay whatever the market rate is above that to pay for the salary of the clinician who's hired to do the job.

They have much greater flexibility, nimbleness, and speed with which they can find and hire people, not just with respect to process, but also in their ability to pay what the local market demands. It won't necessarily be one pay scale that they'll apply for physicians or physiotherapists, say, across the country. Depending on the specific region and the difficulty in attracting people to work in that specific region, they have the liberty and the flexibility to increase the charge or the salary in order to be able to attract people and fill the capability gap.

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

So that remuneration for the third party is a percentage of what the doctor is being paid. If a doctor is being paid $100,000, the recruiter would get $120,000?

[BGen Jean-Robert Bernier]

That's correct. Over and above whatever they pay the clinician, they would also be receiving from the defence department, as part of the contract, an amount to cover their overhead cost, the cost for them to do their recruiting and personnel management function.

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

To go over to operational stress injuries, has there been a difference in the manifestations of PTSD arising from the soldiers who were in the Medak Pocket versus Afghanistan? Has there been a difference emerging in the PTSD manifestations?

[BGen Jean-Robert Bernier]

I don't think we have specific data for OSI cases from the Medak Pocket, or even data on whether...

May I ask Dr. Heber to respond to that question on the clinical aspect?

[Lieutenant-Colonel Alexandra Heber, Psychiatrist and Manager, Operational and Trauma Stress Support Centres, Department of National Defence]

Again, thanks for that question.

I've worked for DND since 2003, so when I started working there I was certainly seeing a lot of people from Bosnia, Rwanda, and Somalia. Those were most of the people I saw. Now, of course, the majority of people we see in the operational trauma clinic are from Afghanistan.

I also want to say that if we put it in context, the majority of people we see in mental health in any of our clinics are not people who come back with an operational stress injury. It's people who, like the general population, suffer from a depression or an anxiety disorder and who probably would have that no matter what kind of an occupation they had. But in the OTSSC, in our operational trauma clinic, I've seen that scope of patients.

In terms of symptoms, the symptoms are the same, and that makes sense because our diagnosis is based on a certain spectrum of symptoms, right? Those don't change. If somebody who'd been in Bosnia receives a diagnosis of PTSD, and if someone who was in Afghanistan receives a diagnosis of PTSD, the profile of the symptoms are the same.

How people suffer is sometimes different. How long it's taking people to come forward for care is different. When I first started working in the clinic in 2003, it was very typical for a soldier to come in and tell me that he'd had nightmares every night for 10 years. That was very typical.

Now we see people from Afghanistan, and in fact, at three to six months post-deployment, after Afghanistan, when they are doing the enhanced post-deployment mental health screening that we do, if they are identified in that screening procedure as probably having PTSD or another OSI, almost half of them are already in care. When they're told by the social worker that it looks like they need to see somebody, almost half of the people already are seeing someone. That's a big difference that we see.

[The Chair, Conservative, James Bezan]

Okay. Thank you.

The time has expired. I know: it goes by fast when you're having fun.

Ms. Moore, you have five minutes.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Thank you very much.

I would like to come back to the personnel shortage in remote regions. Regarding the reserve force, currently, non-medical regiments—for instance, field ambulances and medical companies—don't have the positions of physician's assistant, nurse or physician. Therefore, they cannot hire someone from the region who could work part time according to the regiment's needs.

Should that rule be maintained, or would it be better to allow reserve regiments to have the positions of nurse, physician or psychiatrist, if they can recruit them as part-time employees to care for people in remote regions?

[BGen Jean-Robert Bernier]

Thank you for the question.

In addition to certain medical units, we currently allow certain people associated with the establishment of field ambulances to work and live with a remote militia unit. So we are talking about a combat arms unit or any service weapon unit. However, the process is still problematic. We cannot recruit people and create the positions of physician or nurse, or a similar type of position, for each unit.

We have, however, established what we call field ambulance medical link teams. Those people work part time. They are mostly nurses whose responsibility is to monitor injured part-time members or reservists who have fallen ill or suffered injuries as a result of military operations or military service. They must ensure that those members receive the care they need, normally in the regions.

Regarding mental health issues, we encourage members to have their mental health assessment done at a specialized centre of the Department of Veterans Affairs, the Department of National Defence or the Canadian Forces. We will pay all their travail expenses and the wages of a part-time militia member. However, we are very open. If they are unable to travel, we will accept assessments by regional mental health clinicians and allow them to be monitored and treated in the region.

Normally, reserve members want their initial assessment to be carried out at a centre of expertise specializing in military medicine, and that is always in their best interest.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

I want to go back to one point. There is apparently a shortage of health care professionals across the country, both in mental and physical health. For instance, all the hospitals are competing for nurses. We are seeing that it is also difficult to recruit nurses for the Canadian Forces. Currently, it is virtually impossible to recruit people outside the major centres. Let's take Rouyn-Noranda as an example. You know where that town is located. A nurse who may be interested in working part time in Rouyn-Noranda for the Canadian Forces would have no opportunity to do so as part of the reserve. So this person would move to join the Canadian Forces full time to be on a base where they would be sent 10 hours away from their home and would have to be brought back.

Isn't that a problem? The goal is to recruit more people, but the structure is such that people can only be recruited in certain locations. In addition, a range of health care professionals who are open to working across the country, and not only in major centres, are not being used.

[BGen Jean-Robert Bernier]

We can send our patients to any civilian health care professional. To do so, we use the Blue Cross, which covers the costs for us. All that can be paid. Any clinician in Canada will be paid to care for our injured or ill members.

In the reserve, we also have the framework of the primary reserve, which is part of the first field ambulance and hospital. That enables us to enrol clinicians from any part of the country. They are not active; they only work two weeks a year with the Canadian Forces. They are volunteers who are part of the reserve force—that reserve is inactive, except when its members are called up for military service.

When necessary, we can call them up for a minimum period of two weeks a year for military service. They may be called up to provide health care, participate in an operational deployment, take courses or anything like that.

So we have mechanisms that enable us to enlist members of a professional health care corps who live in regions where there are no militia units or Regular Force units.

[The Chair, Conservative, James Bezan]

Mr. Opitz, it's your turn.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Thank you, Mr. Chair.

Thank you very much, General and Colonel, for appearing today, and congratulations on the NATO distinction we received for our work. It certainly demonstrates that the Canadian Forces, as General Hillier used to say, certainly punches well above its weight. It's noted by our allies and is recorded over and over again.

General, you mentioned OSI cases. How many OSI cases are coming down in the next couple of years? I think 1,300 was your estimate.

[BGen Jean-Robert Bernier]

There are many qualifiers, based on the quality, the methodology, and the many, many variables, but based on what we know now, we expect roughly probably about 1,300 to 1,500 more just from Afghanistan. These are cases specifically related to Afghanistan, as opposed to the normal baseline that constitutes the majority of our cases: the same cases of mental health illness as a result of stresses that afflict all Canadians.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

That could be anywhere from today to five years to 10 years from now.

[BGen Jean-Robert Bernier]

Roughly, based on that study, we'd probably anticipate it in the three-year to five-year range. But we're still having people present from Bosnia, from the Swissair disaster of 1998, and also from the Korean War—Veterans Affairs has people presenting from that far back.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Understood.

Colonel, feel free to weigh in on any of these questions.

I'd like to talk a little bit about stigma and post-traumatic stress and maybe delve a little more into what actually creates it. There's a relationship between mild traumatic brain injuries, concussive injuries, post-traumatic injuries: what do you think are some of the main contributors to developing PTSD in the first place?

[LCol Alexandra Heber]

In terms of risk factors for PTSD, what the research has shown us is that, first of all, we understand about half of what they are about. There's a lot that we still don't know, but out of the risk factors that we do understand, generally they tend to be divided into three groups.

The first is the pre-trauma group of risk factors, which includes things like people who have had a previous mental health problem and people who were abused or neglected as children. Interestingly, another pre-trauma risk factor is lower socio-economic status.

Then there are the risk factors that occur during a trauma and they tend to be, again, how severe the trauma is and whether it's repetitive.

Post-trauma, there are also risk factors. Those risk factors, which are also significant, by the way, include lack of social support—which is a big one—and being re-traumatized.

The good news about this is that we can't change what happened to people when they were children, but we can change what we do after the trauma. I guess in a lot of ways that's where our efforts are being deployed.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

That's great. Your quote from Field Marshal Slim was a good one, because you're right: officers are key to helping this happen. In my unit, I always encouraged guys to come forward. Two did, we got them treatment in good time, and I think they're doing well.

But stigma is a huge part of a soldier's perception of what this is. Oftentimes, it's related to being weak, and we know that's not the case. I'd like you to discuss briefly, if you wouldn't mind, if there is a noticeable increase in the awareness of operational stress injuries and other types of injuries—especially, General, since you began as a CF member—and how stigma factors into this. Related within this, of course, just broadly, are the family unit's involvement and the role of children and so forth in all of this awareness. I know that it's a big question.

[BGen Jean-Robert Bernier]

There has been a very significant reduction in stigma, but it will always be there, particularly in an organization like the armed forces, but in society generally. Stigma exists not just for mental health conditions but for injuries generally, for various types of illnesses.

We do have objective evidence that the level of stigma has dramatically decreased. There was a study in I think 2008, published in the Journal of the Royal Society of Medicine in the U.K., comparing the five Anglo-Saxon allies. It showed that the Canadian Forces had the lowest level of stigma overall. A study in the U.S. by Charles Hoge, I believe, found that we had roughly about a third the level of stigma found in U.S. forces.

Colonel Heber was just talking about how people presenting at the three- to six-month enhanced post-deployment screen with their mental health conditions are already in care. A few years previously, it was about 5.5 years before people would present for care, which is another demonstration of a significant reduction in stigma.

A lot of that has come from various measures, from all the educational measures that you're probably aware of with your the armed forces, such as the various campaigns, the educational program, Road to Mental Readiness, and the enhancements for confidentiality protection. If the troops understand and if our patients know that their health information will be well protected, that increases their confidence.

Peer support has been very, very significant in getting people forward, as has education, not just for the chain of command and the military leadership, but for families. I'm not sure we have data on it, but certainly anecdotally, in many cases, people present not voluntarily on their own, but because they've been pushed to present by their family members, their peers, or their colleagues at work. The whole treatment of operational stress injuries—like any other injury in the armed forces—and the fact that we award the Sacrifice Medal to people who wish to receive it, who have suffered an operationally related operational stress injury, send a very clear message.

We continue to treat people. We deploy them even outside the wire in Afghanistan if they're stable. We do everything we can not to stigmatize, not to treat them differently, and to treat this like any other illness, and it objectively has borne fruit.

Do you have anything to add, Dr. Heber? No?

Thank you.

[The Chair, Conservative, James Bezan]

Thank you. The time has expired.

Mr. Kellway, it's your turn.

[Matthew Kellway, NDP, Beaches—East York, ON]

Thank you very much, Mr. Chair.

I want to thank the witnesses for coming today.

I'm going to hand my time over to my colleague, Christine Moore, who, because of her time in the forces as a nurse, has much more intelligent questions than I do.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

I would like to come back to recruitment.

You may not have these figures on hand, but I would like to know, across various professions, what percentage of those who wear the uniform are already trained when they join the Canadian Forces and what percentage of them receive their training through programs.

[BGen Jean-Robert Bernier]

The majority of Canadian Forces members—I am not talking about our civilians, who are members of the public service—are trained by the Canadian Forces.

We have programs that enable us to directly enrol people with certain clinical skills, especially when we are experiencing a shortage. In most cases, the training of our people is financially supported by the Canadian Forces, once they have been enrolled. In addition, it all depends on the profession.

We use civilian institutions as much as possible for their training, so that we can establish the same standards and skills as those the general public has access to. We also provide them with additional training that meets the specific needs of the Canadian Forces.