National Defence Committee on Dec. 11th, 2012

[Cmdre Hans Jung]

One of the things that was very obvious to me when I was in uniform was the difficulty the veterans were having in seeking family practice practitioners when they retired. They couldn't find anybody because there was a shortage, they felt. That was often the biggest one. I was frequently asked what I could do about the veterans and the families. I said that I couldn't do much because as long as I was in uniform as a surgeon general, my mandate was very limited.

As I was contemplating retirement, I asked myself what I should do in my second career. The obvious venue was to provide an opportunity for veterans to see a doctor who knows where they're coming from. I now have patients coming to me who already have a family doctor. Because they come to me, I ask them why they changed. It was because they couldn't communicate with that person, whereas I know the language. By looking at their rank, by looking at their trades, I know what they did. We share the same operational experience.

It's not that we speak different languages in terms of English or French, it's just that we share a certain culture. Having been in operations together, they feel comfortable. Often they don't have to explain; they just have to say a few words and I understand. I know exactly what they mean. It's my ability to understand their unspoken words, and then take the next step as to what we do about that.

It's something as simple as understanding how the VAC application system works, what it means, what a CF-98 is. No civilian is going to know that. It's things of that nature, the words you need to provide when you fill out the VAC form that VAC can understand. We must remember that most civilians hate to fill out forms. Often when you show up at the doctor's office saying you have your form, they just say they're not going to accept you as a patient.

I do all that, and I don't mind doing it, because this is my ongoing service to the veterans and Canada. It was a natural transition. It's simply because we share the same culture; I understand where they're coming from. When they talk about things, I intuitively understand what they mean, not necessarily just what they're saying.

[The Chair, Conservative, James Bezan]

Your time has expired. We're now going to the five-minute round.

Ms. Gallant, you have the floor.

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

Thank you, Mr. Chairman.

Since the beginning of our troops going to Afghanistan back in 2001 until now, we've seen a complete 180 in terms of how the military views operational stress injuries. Back then it was matter of sucking it up and ignoring it, to the complete opposite now when you're supposed to be recognizing in yourself when it's time to seek help. We introduced along the way the decompression phase because families were telling us that the troops were coming home too soon, that they need a little bit of time before they're brought back into the family and the community. There was still one further point to go and that was to have the observations of any potential problems in theatre and operations. Can you tell us what steps are taken when a platoon is on an operation and there's somebody who is impacted or showing signs of a potential OSI?

[Cmdre Hans Jung]

I'm not sure what we have done that's new. It's something that's implicit in part of the make-up of the platoon, the companies and battalions when they deploy, that there are medics, physician assistants, a battalion doctor. Of course the leadership and the soldiers themselves are now much more trained to understand and be aware of more social and psychological issues. If there is an issue that comes up, then we have a process whereby the medic or the physician assistant will determine whether or not it's something they can handle. There's a protocol for that kind of stuff. If not, there's a natural referral process.

Of course, as you know, we try not to, again, stigmatize mental health issues in the battlefield by sending them back to the rear echelon and punting them home right away. This is something that was well delineated during the First World War and the Second Word War. You have to treat them as close to the front as possible. If you bring them home, the chance of their going back to duty becomes dramatically less. The idea is to provide therapy as close to the front line as possible, and because of that, as you know, we deploy a mental health team, a social worker, a mental health nurse, and a psychiatrist in theatre so that if a high level of care is needed, it can be done on-site and then the soldiers can go back into their battalion and become combat capable. This is something that was in the SOP right from the beginning. We've continued to do that.

Of course, if somebody does have an issue, their file is flagged, and when they come back they're followed up. If you look at the statistics, the number of people repatriated in theatre because of that is extremely small.

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

All right.

Another issue is turnover in the military. It was reported in the news not too long ago that from 2006 through to 2011, the number is over 98,000. Now that has not been verified in this committee, but it seems like a lot of attrition for that period. There's not an insignificant amount of money invested in these soldiers, and there's a lot of training. What percentage each year of the people who do release from the military would be releasing medically?

[Cmdre Hans Jung]

I don't have that number. It's been a while and I haven't kept track of this. Of all the releases that occurred in the last two or three years, I can't remember. I honestly don't know.

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

All right.

Recently we had two soldiers here with the service dogs. They were expressing that they were due to be medically released. They weren't sure if it was 30 days, three months, or six months. They wanted to stay in the military and it was to their dismay that they were being medically released. They had the will to get well. At what point does the military say that they have to go? Is it a part of their having to cut down on personnel and they're at the bottom of the pack, or are there other criteria?

[Cmdre Hans Jung]

I think the answer to your question has two parts.

Part of it is that after a prolonged period of assessment, from a medical perspective, our job is to give them what's called a temporary category or a permanent category.

A temporary category means a person is still in flux, transition; they have not stabilized one way or the other. Once they've stabilized, meaning they're completely better or they've reached a plateau, a level at which we are confident they're not going to fundamentally change, we will give them a permanent category: they need regular specialty care, or a certain amount or type of sleep. There are, as you know, restrictions based on medical requirements.

That's what we do. Once we make a determination, that file goes to the director of military careers administration, the DMCA, who looks at it and determines whether that individual's rank, trade, and limitations are compatible with ongoing service in that trade or in another trade in the military that they could potentially remuster to. If they can, then they're retained, but if they cannot, then they violate universality of service, and the only option is release.

In that regard, that becomes more pressing and a very important issue the smaller the military is. The more and more people you have who are medically unfit, they hold military billets and other people can't be promoted into those positions, and neither can other people be recruited to fill them.

While you're carrying that person in terms of both pay and position, the rest of the Canadian Forces gets relatively smaller. Now you have a greater burden on the remaining people for both operational and personal tempo. That will drive up their fatigue, and it's more likely they'll get out also.

[The Chair, Conservative, James Bezan]

Thank you. I'm going to have to cut it off there. We're way over the time.

Ms. Moore, the floor is yours.

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

Thank you very much.

I would like to go back to the matter of medical release. The timeframe in cases like that are really not known; it varies from 30 days to three years. I have seen cases where people had only been in service for 10 weeks and had to wait for three years before being released.

During that time, you never know what is happening and when you will be released. That is a source of stress; you are not able to get your life under control. How can people like that stay motivated at work knowing that they are going to be released at some stage? I have seen cases of adjustment disorders and situational depressive disorders associated with the wait for release.

Have measures been taken to stabilize the cases of people waiting for release so that we do not get people who are asking for release for physical reasons ending up with psychological syndromes?

[Cmdre Hans Jung]

That really is a good question. If I may, I will give you the answer in English, so that I can communicate clearly and express the subtleties that are necessary.

There are two types of medical releases, if you like. One is a clear-cut physical one, for example, the individual is an infantry soldier who had a severe back injury, and he knows he cannot carry rocks and cannot march. He can no longer be an infantry soldier. That's very clear. Those things are quite obvious. You can see it on the X-ray. You can see it in the performance. Usually within six months to a year we know what their final condition is going to be, so we give them a permanent category. They know they can no longer be soldiers given their physical limitations, and psychologically they know they need to move on.

Those are the easier ones. It's the mental health ones that are much, much more difficult. First of all, often there is a delay in diagnosis, for a number of reasons. The person didn't know he was having problems and was just carrying on, but eventually when the diagnosis is made, you have to start treatment.

Again, mental health treatment is not like surgery. If someone breaks a leg, the treatment is very clear. You put the leg in a cast, or, depending upon the situation, there's surgery to fix it. You know that in six weeks to about three months it's going to heal. There will be six months of physio. The natural history of that situation is well delineated. We know what's going to happen, and the individual knows what is going to happen.

Mental health is not that simple. It's very complicated. The individual may get better for a while or may get worse. There are many factors that come into mental health. It may take up to three years to determine whether or not the person is going to get better and how well he is going to get. Is he going to get totally better, or partially? It takes many, many years.

At the same time, as you know, many of these people want to stay in the military. They really want that. In time it becomes known, for some, that they're not going to get back to a level at which they can continue. Eventually they're given a permanent category. This may take, as I said, three years.

With the new policy, once the diagnosis is given, and that may take three-plus years, the permanent category is given and they are called complex cases. The system gives them another three years to prepare psychologically, occupationally, vocationally to transfer to the civilian sector. It is a long drawn-out process. I know there are people who say “It's too long. Just let me out of here. I want to go”. Others want to stay as long as possible to retrain, or sometimes with the hope that they will eventually get better.

Unfortunately, there is no simple way to answer your question. Every individual is different. It is very, very complex. We have to look at each case individually.

At the end of the day, once they've stabilized, and we try to stabilize them as much as possible, we ask whether they have reached the level where they can become operational. If they have not, then the current policy is that they be either released, or I think they have a different avenue that they can follow to stay in uniform but not in the Canadian Forces per se.

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

Someone with a serious knee injury clearly will no longer be able to work as a soldier, even if he has tasks that do not require him to be in combat. If that soldier gets the knee injury in the fourth week of basic training, say, and a year goes by before he can go back to being a civilian, do you think that is normal?

[The Chair, Conservative, James Bezan]

The time has expired, so if you could make a very quick response, I'd appreciate that.

[Cmdre Hans Jung]

I'm not sure the issue is normal, but we do not want to send anybody to the civilian sector while in transition because of the complexity of the medical care on top of that. We try to get them to a level of equilibrium to then hand them over to the civilian health care sector. To hand somebody over, whether they have a physical condition or a mental health condition, during that transition makes the continuum of care very difficult.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. Opitz.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Commodore, thank you very much for your service. It was 31 dedicated years, and what you're doing now, post-CF, is very important for the troops. As you described, they know a kindred spirit. They can talk to you, and you intuitively know what they're telling you. That's sometimes very difficult to explain to a civilian doctor.

We did have a couple of soldiers here last week, and the young bombardier was saying.... Sir, you've just described the system and the process of three years and so forth very well, but could there sometimes be a failing in that? He described the situation and felt essentially that the sword of Damocles was hanging over his head because he didn't know if he was going to be released in three months or three years, that sort of thing.

Can the system be that uncertain at times?

[Cmdre Hans Jung]

If the system is played out right, that should not happen. Based upon the complexity of your condition, you will be told whether you're going to be in the three-year transition or the six-month transition.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

Okay. We didn't have the specifics of his case at the time.

We talked about post-traumatic stress and brain injuries and mental trauma, but what about physical trauma? There are a lot of amputees who still return to duty. Can you tell us a little bit more about that program?

[Cmdre Hans Jung]

Just to be clear, I'm not aware of the return to duty, especially in the combat arms, of anyone who lost a leg above the knee. The ones who have returned are below-the-knee amputees. Although the amputees get, rightly, a lot of visibility, the numbers are not huge, relatively speaking. For the individual, though, it's devastating.

We have developed a system in conjunction with civilian rehab centres to ensure that they get the best health care possible. I think we've partnered with nine centres. They get the best health care possible in those jurisdictions, the best health care possible for a warrior. The requirements for a severe diabetic who's had a foot amputated are very much different from those for an amputation as a result of combat. The level of rehab that they've been exposed to, and that we've given them, is not available in the civilian health care sector. In fact, I think this has given the civilians new insight into some of the ways of providing rehabilitation to younger accident victims. We have also given them unique technology, as in the CAREN system. We try to ensure that our soldiers have the best and the latest technology to give them the greatest possible opportunities.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

I know you're a believer in the education factor, not only for our troops, but also for people outside the CF. Do you still think that education is at the crux of mental health awareness, and the treatment of mental health issues, in the CF and perhaps outside?

[Cmdre Hans Jung]

Oh, absolutely. Ignorance breeds contempt, prejudice, and a number of other negative things. I believe education is the most important thing.

Some 30 years ago, when people mentioned the C word, you were a pariah. If you had cancer, people thought it was contagious and they stayed away from you. That was 20, 30, 40 years ago, but over time, with education, it is no longer the case. People are now very much interested in making sure they have screening tests done for cancer. I think it's similar for mental health. I believe the evidence shows, and I know my civilian colleagues will support me on this, that the Canadian Forces have blazed a path for the whole of Canada to get a handle on mental health, not as a stigma, not as something to be ashamed of, but rather as a disease that we can and should try to mitigate.

[Ted Opitz, Conservative, Etobicoke Centre, ON]

I believe I heard you mention that our allies see our system as something to model themselves after and have great admiration for it.

Staying with education a little bit, we have pre-deployment training, the execution of the mission, and then post-deployment training and decompression. When do you think is the best time to start applying treatment? I'm sure it varies from individual to individual, but once we start seeing the symptoms develop, when do we begin? Are we doing enough during pre-deployment, for example?

[The Chair, Conservative, James Bezan]

I should mention that time has expired, so please be brief.

[Cmdre Hans Jung]

Treatment has to start at the earliest possible moment. Of course, often that depends on the individual coming forward. That's the issue. If you break a leg, it's impossible to hide it, but if you are suffering a mental problem, you can hide it. Unless you come to the table, there's nothing we can do for you.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. Kellway.