National Defence Committee on Dec. 11th, 2012

[Cmdre Hans Jung]

I don't think we have a problem with having enough military doctors in uniform. We have all the uniformed doctors we need in the military right now. It's the civilian doctors at our clinics that we don't have enough of. We do exactly that. The training system and the process to get into medical school in Canada are fundamentally different from those in France. The French military is so huge the military has its own medical schools. We don't. Therefore, it's a bit of an apples and oranges comparison. We have no problem right now having enough uniformed health care providers.

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

You say that the number of military doctors is not a problem, but you do not have enough civilian doctors. If there were more military doctors, there would be less need for civilian subcontracting. Would that not be a way to solve the problem? This is the principle of communicating vessels. If there are enough military doctors, but you have to call on inadequate civilian resources, is the solution not to use military doctors in greater numbers?

[Cmdre Hans Jung]

That is an option, obviously. However, with the way the CF works and the number of military positions that are available, if we increase the military health care providers in uniform, we have to decrease somebody else, because the total number the government has for the number of people in uniform has to stay fixed. Therefore, the requirement for who should be in uniform is dictated by how many people of what specific health care profession are needed for operations. That's the number we have. For anything beyond that we go to civilians.

[The Chair, Conservative, James Bezan]

Thank you. The time has expired.

Go ahead, Mr. Strahl.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Thank you, Mr. Chair.

At the end of this, I think we're going to want to come up with some recommendations for the government.

One of the things you mentioned is that flexibility is the key to meet surge demands. Maybe you could explain some of the choke points that are preventing that flexibility. What are your specific suggestions to ensure that the CF can respond quickly to the urgent medical care needs?

[Cmdre Hans Jung]

Well, obviously I can only talk about the health care requirement. I guess in DND and the CF all the expertise for health care management and leadership and organization is within the health services.

In my ideal world, it would be wonderful if the leadership said to me that this is the outcome they want, the level of service they expect health services to deliver to the Canadian Forces both in operations and at home, and they gave me the resources needed for that. Of course, there would have to be some discussion about that, but once it's decided, it is simple for them to tell me to execute that and then hold me, the surgeon general, accountable. Once that determination is made, it is up to me to hire for the position.

Let's go back to the case of mental health. There were some 440 positions that were approved and funded. Logically if they're approved and funded, then I should be able to hire people to fill those positions. However, even after they are approved and funded, each position has to have documentation submitted to the public service system, the CMP, chief of military personnel, system, to the DM, deputy minister, system. There are many levels of review where they say yes or no, and it takes time. It's somewhat illogical. Once the positions are approved and funded, why doesn't the system let me hire those people with minimum bureaucracy and then hold the system, vis-à-vis the surgeon general, accountable as to whether I have been able to deliver what I've been told to deliver?

The intent is clear. There has never been an issue about the intent from either the minister or the CDS. Their intent to me was clear: this is what we want you to do.

I went to the PMB, program management board, each year and said what the intent was, what I needed, and what we needed to do. Each time the PMB said, “Here are the resources you requested”. Then I turn around to the bureaucracy and the machinery and I try to hire those people, and it comes to a grinding halt. The year end comes, and I can't spend the money.

As I said and continue to say, I'm optimistic, but I'm somewhat cautious whether this additional money that has been given can actually be spent.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

That's troubling. You also mentioned in response to another question that money was never the issue, etc., but the brief we received says you had expressed concerns over budget cuts to the vice-chief of the defence staff, Vice-Admiral Donaldson, saying “Before we take action as per direction, I want to be sure that you...fully understand the implications...”, etc..

Could you reconcile those two statements for me, that money wasn't an issue but you were very concerned about the proposed cuts to the budget? What ended up happening? Were the reductions as problematic as you worried they would be?

[Cmdre Hans Jung]

The resources that were given to me were sufficient prior to the potential cuts. The issue wasn't even the cuts themselves. It was the rapidity of the submissions we had to provide to make those cuts that by their very nature constrained my flexibility to search out what would have the least impact.

Because of the way the processes were driven, my hands were tied in a certain way that would have led to cuts that I felt were completely unacceptable. Because of the pace at which it was moving, I felt I had no choice, given my personal accountability to myself rather than anybody else, to make sure that the leadership was aware that the train was going down a track, and unless you switch over, if you're not careful, it was going to go down. Once it starts rolling it's very hard to stop. That's why I sought out the vice-chief, as you know, because again, his intent was clear to me. I went and as you know, the train was stopped. It didn't go down that route, so I'm happy about that. Now I think the process is rolling out a little more methodically to try to really prioritize various potential cuts. But let's be clear. When you make a cut, it doesn't mean it isn't going to have an impact. It just means where's the impact?

Here I have to be very concerned about the terms “too much head” and “too much tail”, those kinds of aspects, because health care doesn't quite fit in the head and it doesn't quite fit in the tail either. If you cut administration, that sounds simple, but most of that administration isn't necessarily there to provide doctors with care. It's to provide answers to Parliament. It's to provide answers to the newspapers and a number of other areas. If you cut those admin positions, somebody still has to do them. It's not like I can say, “If you cut that, don't come to me with any questions.” If you cut those positions, somebody else has to pick up that piece. That means eventually, some clinician is going to spend less time seeing patients, to find out how many patients were seen for this and that. Cuts will have an impact.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. Alexander.

[Chris Alexander, Conservative, Ajax—Pickering, ON]

Thank you very much, Commodore Jung.

Once again, thank you for your service and leadership, and congratulations on the award from NATO, which recently came to many of you who were helping to lead the Role 3 Hospital in Kandahar. I think it very much reflects on the quality of leadership we had when you were surgeon general.

Could I ask you the very basic question about how we have cared for the toughest cases? I'm talking here about visible injuries, casualties coming back from Afghanistan, the Panjwai. People try to kill our soldiers. Take us through an example. A platoon is on a patrol and one or more soldiers trip an anti-personnel mine or a booby-trap. Someone's lost a leg. Someone's in danger of losing their life, far from their vehicles. What happens? Take us through the movements, briefly.

What has Canada done particularly well in Afghanistan in these sorts of situations to earn the admiration of others? What could we be doing better? What should we be looking at improving before we ever embark on a combat mission again?

[Cmdre Hans Jung]

I think one of the biggest things we've done is to train our medics and soldiers well so that in the moment of injury, which is what we call—we hate to use these terms but it's very colourful—the platinum 10 minutes, the soldiers and medics can make sure the person does not bleed to death. The greatest cause of preventable death still is exsanguination in the battlefield.

With technology, with blood-clotting agents, special bandages, and special techniques we have trained our soldiers to do and the medics, we've been able to save lives right there.

Then we owe a huge amount of gratitude to the Americans for their medevac system, the way they can get the helicopter on the ground rapidly and then bring the person to our hospital.

There's the training we provided our surgeons, our nurses, everybody there, to provide the highest survival rate in the history of warfare. Coalition troops had a 97% survival at the Role 3 Hospital, the highest in all of Afghanistan and Iraq.

Then again with the Americans, there's the ability to move them to Landstuhl for them to be truly stabilized. Then there is the ability to partner with a civilian, usually teaching, tertiary care hospital.

That whole system chain has been phenomenally well done. When you're talking about 97%, I don't think we could have gotten any better.

One of the things you talk about in the military often is the so-called lessons learned. I actually don't talk about lessons learned because sometimes, regrettably, I think we learn very few lessons. We identify a lot of lessons.

To me, by definition, if you learned a lesson, you shouldn't make the same mistake again. We identify a lot of lessons, and then I think we sometimes put them on a shelf, and forget about them and re-identify them later on.

We've done phenomenally well at this campaign. Our challenge is, as the focus on Afghanistan potentially winds down and with the very budget and financial issues we have to deal with, whether we can make sure those lessons we've learned are cast in stone and we do not lose them.

[Chris Alexander, Conservative, Ajax—Pickering, ON]

This is the last question.

Tell us a bit more about stigma, because obviously a great deal has been done to address the issue for the Canadian Forces, but it's not even close to enough. There is the stigma of recognizing one is suffering, but then there is the question of getting those who need the care through the full cycle of care they need.

Tell us a bit about resilience. How much would more attention to building resilience help on the other end in reducing levels of PTSD and other OSIs?

[Cmdre Hans Jung]

As I said, I think the stigma has been reduced significantly. I know the military has taken a leadership role in trying to reduce stigma in general in Canadian society. A lot of that credit can be given to the senior leadership. General Hillier, General Natynczyk, and the commanders of the army, navy, and air force, and so on have done a tremendous job in that regard.

In terms of resilience, the answer is that nobody knows. No one knows whether you can actually instill resilience. We think intuitively that should be the case, but there is no research that says giving people resilience is going to actually help them in any way. Again, that's where the CIMVHR, the research, is really required to make sure we are in fact doing the right thing.

Let me again address one issue. I think in my mind that you as a committee may potentially aggravate that stigma. That is tragic, as people continue to suffer from severe consequences of PTSD. The fact they are continuing to suffer is not necessarily an indication that there's a failure in the system.

Even in the best hospitals in Canada there are people still dying of cancer and dying of heart disease. That does not mean those hospitals are incompetent. That is the best technology.

Regrettably, there will be people who will not get better from PTSD. Based upon our knowledge now, one-third of the people who are diagnosed with PTSD will never get better. No matter how good we provide the best technology, the best evidence, and the best resources we have today, they will not get fundamentally better. One-third will completely recover. The other third will have relapses, but they will be okay. They are not going to be perfect, but they will carry on. There's a third of the people who are diagnosed who are not going to get better. They can be here with tragic stories, and they are real, but that does not mean the system has failed them.

[The Chair, Conservative, James Bezan]

We have time for our last round, but I want to keep it to three or four minutes per party.

Mr. Harris, you can kick us off.

[Jack Harris, NDP, St. John's East, NL]

Thank you.

Commodore, I think I neglected to thank you for your service to the military. It's quite a remarkable period of time.

Just let me get to the question. No one expects miracles, obviously, and not everybody who is ill can be cured. What we're concerned about is making sure that those who can be cured, are cured.

One of the disturbing pieces of information we heard last Thursday was an individual, the bombardier, who said that he was diagnosed in the field in Afghanistan with PTSD. He was sent home on a civilian plane by himself, with no decompression and no accompaniment. That seems to be totally out of line with what everybody tells us happens to soldiers who come back from Afghanistan for any reason, even if they're perfectly healthy. They get decompressed. They come back as a soldier. They don't come back in a civilian aircraft by themselves with no support.

Does that sound even plausible to you? How could that happen?

[Cmdre Hans Jung]

Again, I think we have to be a bit careful with an experience that one individual has had. I'm sure that, from that person's experience, that's the way it was. I think you have to go a little deeper, and of course, given the confidentiality issues, you really can't do that. You have to really dig down for the real issues and the true diagnosis. What was the person's disability? What were tactical issues at the time that led to those decisions?

It would be somewhat irregular, and I don't mean to say that what the person said was not true, but to say that without knowing the full story behind it would be somewhat difficult. One thing I can say is—

[Jack Harris, NDP, St. John's East, NL]

You discount the story.

[Cmdre Hans Jung]

Well, you need more of it.

[Jack Harris, NDP, St. John's East, NL]

Well, is it possible that it could happen?

[Cmdre Hans Jung]

In the world, I suppose, if you want a yes or no, anything is possible. The decision to send somebody home unaccompanied would mean that there was a decision made in the theatre that they didn't have any concern that this person going home through civilian air would have any issue with that. If there were issues, they would have been accompanied.

[Jack Harris, NDP, St. John's East, NL]

Let me ask another question.

We talked about relapse, and that was raised last Thursday as well. One of the witnesses said that they were told by commanding officers or superior officers that if they had a relapse, they were going to be medically discharged. It was presented in the context of this being a way of suppressing, or has the effect of suppressing, someone actually getting treatment because they're afraid to go to that. Would you comment on that?

Also, the ombudsman talks in one section of his report “Fortitude Under Fatigue” about people being posted to the joint personnel support unit viewing it as the kiss of death from a career perspective. He says that as long as this perception persists, it constitutes a barrier to care.

Could you comment on those two pieces of information that we were given in terms of how improvements need to be made or what improvements can be made?

[Cmdre Hans Jung]

On the whole issue about JPSU, I'm not sure if there's an answer to that one. There are people who went to JPSU and say that it was the best thing that happened to them and their whole lives changed. There are others who say that as soon as they went there, it was the kiss of death. A lot of it is their own perception and potentially the micro-culture of the units they come from.

Remember that I said we've made major progress in terms of stigma from a senior leadership perspective. I think we still have significant challenges at the more junior level.

Here I will make a point, and I've made this many times to senior leadership, about what I call the self-stigma. Often soldiers are willing to give somebody else a break, but they stigmatize themselves quite significantly because they can no longer function in a certain way. The stigma is both external and internal. You have to know where the stigma is actually coming from. Is it from their buddies? Is it from the unit leadership. Is it partially from themselves? It may be a combination of all of those, depending on the micro-culture that exists in various places.

As I say, some people love JPSU, and other people are not so keen on it. What I can tell you is that the JPSU does deliver what I call one-stop shopping.

[The Chair, Conservative, James Bezan]

Mr. McKay, go ahead.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Along the same line of questioning; we were also told that when someone went to see the shrink, it was posted on the board, “so and so is off to see the shrink”. That's a bit of an issue for some people. I was kind of surprised that the military would actually do that. Is there an explanation for that?

[Cmdre Hans Jung]

I really can't explain that. I recognize that the units have to understand where their people are. For supervisors to know that someone is going to the clinic would be fine, but to say that someone is going to see a mental health practitioner, or shrink, or something like that, would be inappropriate.