National Defence Committee on May 12th, 2023

[James Bezan, Conservative, Selkirk—Interlake—Eastman, MB]

Thank you, Mr. Chair.

I want to thank all of our witnesses. I particularly want to thank Dr. Breeck and Senator Patterson for their service to Canada as part of our defence medical teams.

Senator Patterson, you talked about how things are paid for in the Canadian Armed Forces health care. We have universality of service that all of our troops have to meet, yet they don't meet universal health care.

Should part of the Canada health transfer be paid to the Department of National Defence and the Canadian Armed Forces or should the provincial health agencies quit charging our troops when they have to visit a provincial health facility?

[Rebecca Patterson]

Thank you, Mr. Chair.

That is actually a really pressing question because taxpayers want to make sure that their money is being used correctly.

I'm going to take this in two steps. The first step I'm going to talk about is how the CAF or the department pays for health services.

We have arrangements right now with each province, which are locally negotiated. Now, as we are excluded from the Canada Health Act there are times.... It comes into three buckets. There is an employer health tax, which is sort of a health transfer that a few provinces expect from the Canadian Armed Forces. We then have services for hospital type fees, which can be even $89 to step inside the door, as well as amplified service fees for using facilities. Then we have individual physicians providing care, which, as we all know, are negotiated with the provinces through their respective provincial organizations' associations.

I think the first thing we need to do, as part of the overall health transfer negotiations that are being opened with the provinces, is to say that the federal government runs a health care system—the deliverers of care. We need to have a seat at the table for those negotiations to deal with those rates.

In terms of a component of the health care transfers, especially potentially the one-time component, I think that is definitely worth consideration. What is going to be quite important is to understand that while health care is funded in the military, it is from a fixed budget within the whole defence department. If there isn't enough, as a baseline funding within health care, it comes from something else within the department.

We know that the Canadian Armed Forces needs more funding to do what they're doing—gas for tanks and health care. That's an oversimplification.

Thank you.

[James Bezan, Conservative, Selkirk—Interlake—Eastman, MB]

I appreciate that.

One thing that we haven't dove into yet is that our current defence team, of course, is treating our forces who are on training and on exercises, but not necessarily being exposed to a traumatic injury like we experienced when we were in theatre, like in Afghanistan.

How do we maintain that skill set within our defence team? How do we deal with surge capabilities in the case when we are deployed and in a hot conflict? Where do we find the personnel that are out there?

I know reservists could play a part in that. I just wanted to get both of your experiences on that side of it.

[Rebecca Patterson]

If you like, I'll start, and we can go from that point on.

When we're talking about surge capability, one way the health human resource component of the Canadian Armed Forces health services is structured is that you have a military-civilian mix of teams, meaning that the backbone was always intended to be civilian care providers, allowing uniformed personnel to maintain their clinical competencies. That costs money, by the way, that eats into that budget I was just talking about.

That is fine, but the challenges in that space right now are that there have been complaints about contracting within the department. However, if you cannot employ a health care provider through the public service because the salaries themselves are too low, there is no other choice, because to go without care means that you don't have people ready for deployment.

May I add that one of my recommendations to you is going to be that there is an urgent requirement for the public service to go through and review salaries of clinicians within the public service framework. This benefits more departments than the Canadian Armed Forces. The rates have to be competitive. This will then allow more military people to be able to surge forward and go elsewhere.

I might be out of time.

[James Bezan, Conservative, Selkirk—Interlake—Eastman, MB]

I have 30 seconds, so Dr. Breeck, I just want to switch over to your specialty in women's reproductive health.

You were saying that we don't have enough research here in Canada. Do any of our other allies have research that we can use as a baseline to start this discussion on how we protect women's reproductive health?

[The Chair, Liberal, John McKay]

Be very brief, please.

[Dr. Karen Breeck]

It's an extremely complicated area, and newer technology is required to even understand the baselines. Again, I do appreciate, especially for the unusual military environmental exposures, that our best bet is to work with our allies to start gathering the data so that we have higher numbers of women so we can start documenting and moving forward.

People look to Canada as leaders in this area, which is why I have more to do.

[The Chair, Liberal, John McKay]

Thank you, Mr. Bezan.

Mr. Fisher, you have five minutes.

[Darren Fisher, Liberal, Dartmouth—Cole Harbour, NS]

Thank you, Mr. Chair.

Thank you to all our witnesses.

I want to go to you first, Senator.

It is the end of Nurses Week. Happy Nurses Week, and thank you for your incredible service. You had the understatement, perhaps, of the day when you said, “I have quite a bit of experience.” I would say that's quite the understatement, based on your resumé, so thank you for your service.

You gave Mr. Bezan one of your recommendations. I am interested in all of your recommendations, and I feel that I want to take away as much of my preamble as possible and give you the floor. Can you speak from your own personal experience and tell us what we should be doing based on your experiences?

[Rebecca Patterson]

Thank you, Mr. Chair.

I'm going to approach this from our level as fellow parliamentarians. I'm going to break it down into buckets.

The first bucket is how we fund, because when you fund health care, you fund defence, which is key. That is why it's in my first recommendation. People may say, you know, $10 million here and $10 million there, it doesn't matter.... It matters a lot. My first recommendation is very much the biggest budget chunk. It's how we provide health care and how we purchase from the civilian sector, and I use the term “purchase” very deliberately.

My first recommendation is that, as part of the intergovernmental arrangements with provinces, federal health care very specifically is in there and is negotiated along with the transfer taxes, because the federal government delivers health care as well as pays for it. That is my first recommendation.

The second one that comes out of there—I'll pull up my little sheets here because of my age—is that we're looking at things such as an urgent replacement funding-wise to replace the health records that Mr. Booth very clearly talked about. We have a Frankenstein system that was one of the first medical health records in Canada and needs replacing. There are no more bolt-ons capable.

It is a patient safety issue to not invest about a half a billion dollars in replacing this electronic system. If we do this now—because process takes time—from an information passage you will be able to address everything from patient safety for serving members no matter where they serve to then moving them through to transition so that there is a seamless transfer of records between the civilian sector and the military into Veterans Affairs. That is another recommendation I have.

I'm trying to go faster for you, Mr. Chair.

The other thing we're having a look at is investing in infrastructure. It is a challenge throughout the department. I'm going to look at CMED here, which one of our honourable members who is here can really appreciate. That's the central medical equipment depot in Petawawa. It is an ancient building. The pandemic has shown us that multidepartmental relationships for unique medical procurement storage require a national solution and investment. It's important, but we can't get it across the start line: Invest in infrastructure within health care.

Do I still have time, Mr. Chair? Okay. I can get through these. I promise.

The next area is health human resources. This is a pan-Canadian health care issue, and this is very timely. If I focus very tightly on the Canadian Armed Forces, we are in direct competition with other sectors and the Canadian public, not only to find people who wish to wear uniforms but also to find public servants or even contractors to do that. In order to make it a career of choice—we can deal with the military side in a minute—I strongly recommend that some impetus be put behind the public service to do a review of all the occupations within the public service that deliver direct clinical care to make sure that salaries and benefits are competitive. Please keep in mind that whether I be military, RCMP, CBSA—you name it—I probably don't serve in a major centre but in a small and remote area of Canada. We also need bilingualism.

The next area is to look at federal health capacity.

I'm sorry, Mr. Chair. I can get it all in here. I used to own the official languages portfolio.

For the federal health capacity, when it looks at everything from day care to health care, I think we need to think differently about it—which the Canadian Armed Forces can benefit from—by looking at a federal health system that looks something like the public health care system down in the U.S., where you have licensure and federally regulated care providers at a national level. They become tools of the federal level, beyond the provincial jurisdictions, to very closely target care, whether it be health care for the military and the RCMP, perhaps, or day care—things that have become the barriers we meet all along. We need to be very progressive in looking at federally regulated, certified and transferable.... This is what we need to have a look at to determine if there is a better way of doing business. I do believe there is some work ongoing in other departments.

That's all. Thank you.

[The Chair, Liberal, John McKay]

Thank you.

Mr. Fisher, that was a brilliant question.

Madam Normandin, you have five minutes.

[Christine Normandin, Bloc, Saint-Jean, QC]

Thank you very much.

I thank all the witnesses, especially Doctor Breeck and Senator Patterson.

My questions are for you both.

Do the Canadian Forces give enough consideration to women's morphology when acquiring equipment? We know equipment that fails to consider it can cause medical problems.

Furthermore, during deployment, is there any disparity in medical treatment? When they're deployed, do women receive adequate services?

[Rebecca Patterson]

Do you want to start and I'll follow?

[Dr. Karen Breeck]

Thank you for your important question.

I think the Canadian Armed Forces has come a long way with the help of gender-based analysis, with doing the right thing moving forward for new procurements. Of course, a lot of the equipment in the military is old, though, so it has all of the older issues. We're looking at submarine accommodations, different kinds of accommodations on different ships. These things are already taken into account on newer ships, but we still have a lot of older equipment. That's one problem.

I do think we've done amazing work at places like DRDC, Toronto, for looking at different equipment pieces. That's still in evolution. We're still learning how to do it, but a lot of that is moving forward.

For me, the area that is still the most interesting is deployment. For me, there are three totally different types of medicine. There's the primary care where I'm your family doctor—normal medicine. Then there's the occupational medicine where you are employed, and I am the company doctor and ask how I can maximize so that you can work for me for 30 years. Then there's the deployment medicine, where I know you might be hurting yourself and I'm actually sending you out still, knowing you might hurt yourself. It's a very different type of medicine.

When we're deployed, there are many different ways that can be. It isn't just army. I came mostly by way of air force, so every time the wheels are up, we're deployed. There are many different ways deployment can happen, but we're often isolated by ourselves and we have to figure out how to do things.

If we look at something like a UN mission and start thinking with that women, peace and security lens, we are not necessarily with other Canadian resources or assets, but we're hoping for that equivalency. It's often quite hard to have that kind of equivalency for some of our UN missions. We, to my knowledge, don't have minimum medical standards of women's health training for the UN-level health. Often we'll say, “There's a U.S. base nearby, so we're good”, but especially on women's health issues, and especially even more so lately, there are still lots of different treatments and resources that might not be available in a U.S. location that would be in Canada.

We often still don't have basic basics in some of the UN kit, so things like birth control pills or the kinds of medications that would be needed after a sexual assault, vaginal infection information or even just a speculum, instruments to be able to properly examine a woman's vagina. That may not be available at that first stage, so suddenly something that really should be pretty simple to take care of becomes a big to-do. You have to leave the mission. Especially if you're in a conflict zone, even leaving the mission is actually quite dangerous. You're actually taking yourself out, and it could be a two- or three-day thing.

At one stage I was in Germany, and we would have women still having to come up from Afghanistan to Germany to get primary medical care that could have been ideally dealt with already on site if we all had a higher level of awareness of the right products, the right treatments and how to deal with common women's issues.

[Rebecca Patterson]

I've also realized I cannot hear simultaneous translation and the French.

That's a big problem for me.

I'm going to just build on what Dr. Breeck has said.

On the UN side, it is beyond Canada's control, because the UN provides the health care. However, what is really important is that through groups like the women, peace and security ambassador, we are trying to influence how women are included, whether it be the Elsie initiative that's within nations or also feedback that we're giving to the UN.

However, it behooves us as part of our planning process to ensure that there is a chain of care or evacuation should it need be.

The next thing will go more to preventative care and making sure that women have the right health before they go, so that is dealt with, with the exception of common episodic illnesses that are feminine in nature. It's investing in this women's health program and women's health research. How do we keep women healthy is where we're going.

[The Chair, Liberal, John McKay]

Thank you, Madam Normandin.

Ms. Blaney, you have five minutes.

[Rachel Blaney, NDP, North Island—Powell River, BC]

Thank you so much, Chair.

I want to thank all the witnesses testifying today, but a special thanks to Dr. Breeck and Senator Patterson for their service. I really profoundly appreciate it.

Dr. Breeck, I'm going to come first to you. We've had CAF officials at this committee, and there was some confusion on whether MST survivors can access OSISS and funded peer-support groups. I'm just wondering if you can speak to the significance of peer-support programs and how you think the programs should be structured.

[Dr. Karen Breeck]

Thank you for what I think is a really important question. If I can, it's very complicated, so I'll step back a little bit.

What problem are we trying to solve? To me, as a clinician, what you had is an injury in your workplace. I almost don't care what it is. You were injured in your workplace, so how can we help and support you. Whether that injury is from combat, whether that injury is from a sexual misconduct, you have an injury that is an occupational injury.

We now are calling a lot of these issues moral injuries and occupational stress injuries. The terminology, I think, we're still evolving and we're still learning. It's really important that we identify terminologies clearer, because it does cause constant confusion. What is an OSI, an operational stress injury and what is military sexual trauma? If I asked everyone here, I would guess I would get different answers from each of you.

I had an opportunity before COVID, where I had 10 generals in a room and I asked each of those generals the question: Is military sexual trauma an OSI, yes or no? Everyone had an answer, and it was literally straight down the middle. Five said, “Why are you asking me? Of course it is.” Five said, “Why are you asking me? Of course it is not.” That speaks to how we have the problems especially on the MST side, when a number of decision-makers assume that it's always included when we hear the words OSI, yet we have senior decision-makers that assume that it has nothing to do with it.

At the end of the day, my humble opinion here is that 10 years from now we won't be using this terminology at all. We'll be focusing on moral injury. We'll be focusing on where you go and what you need for help right now versus the hyperfocus on how you did the injury. We'll be focusing instead on the human and how we can help.

I think a lot of the issues on that day, in that moment, your genetics, your family history, your childhood, your health that day, your meaning, how that person looked like someone you knew, and you got overwhelmed from your trauma and you had a trauma response.... That's all we're talking about here. You had a trauma response. As we understand more now, I think we're finding very rapidly that if we can give you the right resources up front, you may not need medical care at all. You don't need to be medicalized. You don't need to be pathologized. You don't need to be medicationalized. You don't need a label. You don't need a diagnosis. You just need someone to say, “This is normal. You're having a normal reaction to an abnormal situation. Let me help you. Let me sit with you and tell you it's going to be okay. I will give you tools and resources.”

That's where peer support comes in. It's so important. Then we wouldn't necessarily need to go to VAC, because we can't go to VAC until we're already down the line. When we already have a diagnosis, when we already have major depression, anxiety, post-traumatic stress, that's when VAC picks up, yet the majority of people I know aren't there yet, so where do they go for help and support?

Peer support, if done holistically for everybody.... Right now, it's really a confusing area. Can I go to the operational stress injury clinic if I have military sexual trauma? Of course you can. Okay, so it is an OSI then. Because I'm going to the OSI clinic, it must be an OSI. I can go to the OSI social support program for me and my family. Oh, I can't. Why can I not? Why do we fit in one place but not the other?

There are a number of layers of confusion and hence that was a complaint that formally got brought to the veterans ombud and there is a report on it. We're still very much in the process of trying to find an equivalency for how to help everybody who has an occupational health injury, not preferentially just one group over the other. We need to help everyone, and peer support is a big part of that.

[The Chair, Liberal, John McKay]

Thank you, Ms. Blaney.

We have less than 15 minutes and 25 minutes' worth of questions. This is not going to work. It's three, three, one, one, three, three, and I'm going to be hard on the three.

Mr. Kelly, you have three minutes.

[Pat Kelly, Conservative, Calgary Rocky Ridge, AB]

Thank you.

Senator Patterson, we heard from the CAF ombudsman earlier about issues around attribution of injury, and then, once transitioning into Veterans Affairs, having to seek private diagnosis.

If a member has been certified by Canadian Forces medical personnel as unfit and unable to meet universality of service, is there any ethical reason, which has been raised, why that doesn't automatically carry through and enable a veteran to obtain appropriate medical support services?

[Rebecca Patterson]

I think that's a fabulous question. Just to let you know, I'm stuck right in the middle of it, personally, because I retired in January. I'm trying to figure the system out, and I come from a health background.

Just so you know, it isn't the medical services that declare you not universally fit. It's the CAF itself, and that is a technicality.

I think it's how we write our policies at a departmental level, in terms of what you're going to accept. I will try to give you something useful here. We need to have a policy—seamlessness between service and post-service time—where it isn't the member trying to navigate the system, which is what it is now. The whole burden is put on the member: “Find this. Pull that. Give that. Dig this up.” What we have to look at is not only policy changes that state, “If you have someone who has an expertise in military attribution—they did this while they were deployed in Somalia, for example—it doesn't have to be reproven for at least the initial stages within VAC.” We need to have a look at, through seamlessness, policy and mandate letters between, I'm going to say, departments, because that's always a unique space.

Secondly, how about making that health record seamlessly transferable? While there are some privacy technicalities that go in there, what you shouldn't have to do is an absolute complete review of everything that's ever happened to you. In order to leave the military.... Even if you leave without medical release, it's the same situation. You don't come out of this unscathed, unfortunately. When it has been attributed, why can't that be the first record already in the system in VAC, which starts the assessment before you? It's the same questions being asked again and again.

A seamless health record policy—to do that, as well as a mandate, would make it easier.

[The Chair, Liberal, John McKay]

Thank you, Mr. Kelly.

Ms. O'Connell, you have three minutes.

[Jennifer O'Connell, Liberal, Pickering—Uxbridge, ON]

Thank you, Mr. Chair.

Thank you for everyone's testimony. It has been exceptional.

Senator Patterson, thank you. You've done a lot of our work as well, I think. In your testimony, you've given us a lot,

With only three minutes, Dr. Breeck, could one of the problems be that, in dealing with women's health—even in civilian life—the needs of women's health care are still so misunderstood? There's a lack of expertise, again, even in civilian life. The stigma around talking about it—again, even in private life—could be part of the problem.

Then, there's a second piece to that: Are there not other industries that have come along further, in terms of dealing with non-traditional—even that is a ridiculous term—work for a woman who might be in a high-intensity or physical job in the private sector, so we could build upon reproductive health care and policies that could translate into military life? Obviously, travel, the intense schedule and things of that nature may not be completely compatible or comparable, but there could be some lessons learned even in the private sector.

Could you elaborate?

[The Chair, Liberal, John McKay]

There's a minute and a half.

[Jennifer O'Connell, Liberal, Pickering—Uxbridge, ON]

I'm sorry.