National Defence Committee on Nov. 6th, 2012

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

Okay.

Unfortunately, the recruitment process can sometimes take more than a year or two. People with professional qualifications—so people who are already nurses, physicians or dentists, for instance—already have a job. So they are not in need nor do they have a minimum-wage job. In other words, they don't especially need the work conditions offered by Canadian Forces, compared with those offered by civilian employers.

Is priority given to those people's files to ensure that they don't change their mind during the process?

[BGen Jean-Robert Bernier]

In the case of professions experiencing a shortage, health services is trying to find candidates by accelerating the recruitment process. The process is long, and it is often slowed down by certain complications. For instance, candidates may have a medical condition, or the file may not be complete enough for the recruitment authorities to make their decision.

For occupations facing a shortage, we try to provide additional support through a health services employee. Health services has a directorate for the employees who help those people and are involved in the recruitment system, especially when there is a shortage in a profession and needs have to be addressed.

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

A dozen recruitment centres have been closed in Canada, especially in remote regions. Aren't you worried that this may influence staff recruitment?

It is already difficult to recruit qualified personnel. Candidates, especially those in remote regions, sometimes have to miss two or three days of work to pass medical examinations or aptitude tests. It should be understood that nurses, for instance, may have accumulated over 40 days of leave because their employer refuses to give them time off.

Aren't you afraid that this will influence or negatively pressure the recruitment process?

[BGen Jean-Robert Bernier]

Yes, that is a concern. I am not familiar with all the details, but I know that those in charge of recruitment look into all kinds of other ways to make up for those drawbacks. They are working on making the recruitment process more streamlined and quick. For instance, they tend to use the Internet more, and they send recruitment teams to the regions, to villages and cities that no longer have a recruitment centre.

I cannot talk about this any further, as it is beyond my area of expertise. Nevertheless, this is a concern. I know that we are currently taking certain measures and making changes to not only fill in the gaps, but also improve the situation.

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

Thank you.

[The Chair, Conservative, James Bezan]

Thank you very much.

Mr. Chisu, it's your turn. You have the floor.

[Corneliu Chisu, Conservative, Pickering—Scarborough East, ON]

Thank you very much, General, for being our witness today.

First of all, I would like to thank all the medical corps who served for years in Afghanistan, especially the personnel at the Role 3 hospital in Kandahar. Also I share the grief of the lost lives of medics in combat at the front line. I know there were several of them.

General, are you able to expand on your experiences of running the NATO combat hospital in Kandahar? That was a very interesting operation and a very interesting role that Canada had in an area of allied operations. You didn't see only Canadians who were injured. You have seen all kinds of casualties from different nations.

What kinds of physical and mental health-related injuries did you see the most? Was the hospital ready to give you the services needed to address the injuries that came in? How did this situation evolve over time? How did the hospital improve over time? Were there any injuries or cases that you did not expect to see?

As you know, and as I explained to the committee, the Role 3 hospital was very important to stabilize the injured survivors and save lives; before we speak about any kind of operational stress injuries, we speak about saving lives first. In this context, can you elaborate on the lessons learned from Afghanistan to be applied at home in order to increase the time to treat the operational stress injuries, in order to reintegrate the soldiers more quickly to be combat ready? That is the role of the forces: to have soldiers ready to be deployed again.

[BGen Jean-Robert Bernier]

Thank you very much for your comments about the medics and their tremendous sacrifice. Reading their citations for some of their valour declarations is breathtaking: their bravery, their courage, and their sacrifice.... Thank you very much for that.

It was a very complicated thing to run that Role 3 hospital, because it's the first time NATO has run a multinational hospital in a combat zone, with mass casualties coming in almost daily. There were many obstacles to overcome with respect to differences in national standards, credentials, and cultural differences in the types of different scopes of practice for different health occupations, and to coordinate them into a smoothly running team, particularly with trauma teams and in the operating room.

Generally, it went very well, particularly with allies who share the same common types of medical practice in their home countries, like the British, the Americans, the Australians, and the New Zealanders. Things evolve progressively. The biggest challenge was that the vast majority of the casualties treated were not NATO casualties. The original mandate to be there was to treat NATO casualties, coalition casualties. The majority, about 80%, were Afghans, and Afghan civilians, mostly. That was a difficult thing that we weren't entirely ready for right at the start. We had to react to it fairly quickly.

The medical rules of eligibility for care in the NATO hospital change, depending on the senior leadership of NATO and the political drivers. For us to take on more and more care of civilians, including children.... Military hospitals, except in humanitarian assistance missions, typically aren't structured to deal with large numbers of casualties. They're designed to have a minimal medical footprint on the ground and a very efficient medical evacuation so that we get people, give them the stabilization care necessary in surgery, and get them to a hospital with greater capabilities in a more secure zone.

Equipping is based on that: equipping in equipment, capability, and clinical skills. With the Afghan population, we could not medically evacuate them to other countries. There were sometimes some very difficult ethical situations faced by our clinicians in having to do the best they could with Afghan casualties, particularly children.

On the other hand, if we were to establish a full-up pediatric centre of excellence, say, we would essentially positively harm Afghanistan's development of a pediatric capability in their own region, because we would basically put all of their clinicians out of business for the entire local population. That was a big challenge.

As for mental health-related lessons learned, I'll ask Colonel Heber to mention this.

[LCol Alexandra Heber]

There are a couple of things that come to mind. At least one of them has been mentioned already. One of our big lessons learned there was the importance of the leadership's role, the role of the chain of command, in dealing with mental health issues. When the leadership supported the person and, even more importantly, told the member, “I expect you to have a couple of days of rest, and after that, I'm expecting you to be fit again”, it was amazing how important that sense of expectation from their leadership was.

One of things we learned quickly in Afghanistan, as the mental health team, was to really engage leadership and really do training with the chain of the command about how to handle people who came in with what we were calling combat stress response. We weren't calling it PTSD, and most of these people did not go on to develop PTSD. They would get a bit nervous. They hadn't slept for several days. Leadership really took on the role, often with the help of the medical technicians, of dealing with that. That was one thing.

The other thing was how much mental health needs to be integrated into all the medical services. The best example of that was the casualty management teams we set up for people when they came home. We made mental health part of that right from the beginning. It was very important.

[The Chair, Conservative, James Bezan]

Your time has expired.

Part of my job here is a little bit like a traffic cop in having to direct things.

You have the floor, Mr. Brahmi.

[Tarik Brahmi, NDP, Saint-Jean, QC]

Lieutenant-Colonel Heber, I think I heard you say, in English—I am not sure I have understood the sentence properly—that most people you treat would have the same symptoms even without their military experience. Does this mean that, in most cases, you cannot establish a connection between combat-related stress and those symptoms, since they are the same as they would be in civilian life? Can you elaborate on that?

[LCol Alexandra Heber]

Thank you very much for that question.

PTSD is of course considered a mental condition or a mental illness, and it has a certain number of symptoms that we look for. Then there are a number of other things. We have to rule out certain things. We look at the person's level of functioning and how long he's had the symptoms. But there are very well-prescribed symptoms. Whether somebody has developed PTSD because they were sexually assaulted or abused as a child or has been in a combat zone, although the details of the events are different, the symptoms they suffer from essentially are the same.

That's I think what I was alluding to in terms of, yes, there can be people we diagnose with PTSD who, again, perhaps were abused as children, entered the military, and spent many years in the military, and who then for some reason come forward. They can have PTSD; it may not be related to combat. But certainly, most of the PTSD we treat is related to, yes, being in the war zone.

[Tarik Brahmi, NDP, Saint-Jean, QC]

You talked about predetermining factors, and that brings me to my next question.

Do combatants—those who are really sent into combat—undergo a systematic psychological assessment before and after? I assume that is the case, but I would like your confirmation. Those assessments of combatants when they return from combat could help identify factors that would explain the onset of symptoms that could occur several years later. That would help establish a connection between identifying trauma in combatants when they return from a combat zone and the onset of symptoms later on.

[LCol Alexandra Heber]

There's a couple of things. First of all, before we deploy people, they go through a medical, which includes an evaluation. We don't test people, but they are seen by a family physician who looks at their history, both their medical history and their psychological history. We do that.

Again, when we talk about risk factors for PTSD, let's say that somebody has a history of childhood abuse, they've joined the military, they want to be and are a fully fit military member, and they want to deploy. Again, I think it would be a disservice to them, if they're functioning well, to tell them that because of this childhood abuse we don't think they should deploy. Again, it's important to remember that for those risk factors I talked about, there are many, many other people who have those risk factors but never develop PTSD—

[Tarik Brahmi, NDP, Saint-Jean, QC]

I have to interrupt you, as we don't have much time.

Are you saying that the soldier recruitment process does not involve a systematic assessment of psychological risk factors? Is that what you are saying?

[LCol Alexandra Heber]

It's in the recruiting process. Again, people have a medical history taken, and that includes their psychological history—

[Tarik Brahmi, NDP, Saint-Jean, QC]

So you are telling me that this assessment is not done by a military psychiatrist . It can be done by a family doctor.

[LCol Alexandra Heber]

At the recruitment stage, yes. It's done by a physician's assistant or a family doctor.

[Tarik Brahmi, NDP, Saint-Jean, QC]

It is not done by a psychiatrist.

[LCol Alexandra Heber]

No.

[Tarik Brahmi, NDP, Saint-Jean, QC]

Thank you.

[The Chair, Conservative, James Bezan]

Thank you very much.

Mr. Norlock, you have five minutes.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

Thank you very much, Mr. Chair.

My thanks to the witnesses for appearing today.

This question is for you, General. When you took over as Surgeon General from Commodore Hans Jung this past summer, what were the personal goals you wanted to fulfill in this new job of yours?

[BGen Jean-Robert Bernier]

Thank you for the question.

I was Commodore Jung's Deputy Surgeon General for three years, so we were quite aligned in where we wanted to go. We achieved tremendous capability as a result of operations in Afghanistan and had tremendous support from the government for the capabilities that we managed to establish. My priority, given that operations were winding down and that deficit reduction must occur in this country, and given our responsibility to assist in balancing the books, is to maintain the capabilities that we've established so we're ready for the next operation, whatever it might be.

We've developed quite a breadth of capability and expertise. I want my priorities to progress in areas such as establishing an institutional memory of lessons learned and at least a minimal capability in everything that we needed in greater quantity in Afghanistan, as well as in other elements of operations that we've undertaken over the years, such as the response to the earthquake in Haiti.

First of all, we must maintain all those capabilities to some extent, and we must expand them in those areas where the lessons learned demonstrated that we had some shortfalls—for example, in modularization. I have focused a lot on modularizing and on having a much more rapidly deployable surgical capability, which may not have been necessary for Afghanistan but may be necessary in the next operation, whether it be humanitarian assistance or otherwise.

We should lighten the load. If we break up the deployment of a field hospital so that, instead of requiring seven chalks of a C-17 to move the whole field hospital before it's functional, we break that up into smaller chunks, there will be a surgical capability with the first chalk that lands, which will simply increase in quantity with subsequent chalks of C-17 flights.

There are some things like that related to the lessons learned, but the primary thing is to maintain our established capabilities, particularly with respect to mental health. We must equally maintain our operational capabilities to support the armed forces for the most extreme types of missions that they may have to undertake in future.

[Rick Norlock, Conservative, Northumberland—Quinte West, ON]

Thank you very much.

Changing gears a little bit, can you speak about how our forces are discharged after deployment? Do you think the method of third location decompression is one that helps in the transition from active duty to everyday life?