NDDN Committee Report

In any study of the Canadian Forces, it is important to recognize certain contextual factors affecting how the Canadian Forces is governed, organized, operated and adapted. These factors are important because they provide much of the rationale as to why some things are as they are and, of importance to this study, provide clues as to how improvements can be made.

PROFESSION OF ARMS IN CANADA

First among the principal contextual factors is the existence and influence of the profession of arms in Canada, which exercises the use of military force on behalf of government and people of Canada. All members of the profession willingly accept unlimited liability, the notion that they may be ordered into harm’s way in conditions that could lead to the loss of their lives. Their highest duty is to Canada and is embodied in the tenet, “service before self”. Canadian Forces members adhere to the principle of primacy of operations and military leaders are taught to act in accordance with the professional priorities of, “mission, troops, self”.[13]

Familiarity with the concept of the profession of arms in Canada is helpful in understanding why obligatory physical standards are imposed on military employment and in understanding why, if those standards cannot be met, military personnel must be reassigned or released from the Canadian Forces. In keeping with the tenet “service before self”, no Canadian Forces member is entitled to serve as long as they may want to, nor do they have a right to promotion. Continuing service and promotion are based on merit. That said, the Canadian Forces currently interprets existing regulations in a compassionate way to allow injured soldiers the time they need to recover or prepare for life after military service.

CHAIN OF COMMAND RESPONSIBILITIES

Command is the legal authority to direct action of subordinate units and issue orders to subordinate personnel. The military chain of command holds the professional, legal and moral responsibility for the care and well-being of military personnel under its command.[14] Chapter 4 of Queen’s Regulations and Orders, dealing with the general responsibilities of officers, specifically states that officers shall “promote the welfare, efficiency and good discipline of all subordinates”.[15] Officers in command of a base or other unit are expected to exercise command over all officers and non-commissioned members, at the base or other unit.[16] Commanders at all levels are required to be familiar with the personal and professional circumstances of personnel under their command,in order to control and administer them appropriately, in the pursuit of assigned missions.

The military chain of command extends from the Chief of the Defence Staff (CDS) down through all ranks, with two notable aspects. First, no chaplain shall exercise command over any officer or non-commissioned member. Second, “no officer who is not a medical officer shall exercise command over a medical officer in respect to his treatment of a patient.”[17]

COMMANDING OFFICER RESPONSIBILITIES   

Also in the context of this study, Commanding Officers have the following duties:

a)    to assist health care providers in understanding the performance requirements and conditions that normally apply to a particular military member, so that the most appropriate medical employment limitations (MEL) can be assigned;

b)    to inform health care providers when other employment exists within the unit that the Canadian Forces member may be able to perform in accordance with assigned MEL;

c)    to inform health care providers when assigned MEL appear vague or inappropriate in a particular working environment;

d)    to raise concern about imposed MEL with the health care provider or Base Surgeon as required;

e)    in consultation with a medical officer, to identify those unit supervisors who are authorized to receive additional information on MEL; and

f)     to ensure information about a MEL assigned to a Canadian Forces member is handled in confidence within the unit, without disclosure to unauthorized personnel.

CANADIAN FORCES MEMBER RESPONSIBILITIES

In the context of this study, we note that every Canadian Forces member has the following duties:

a)    to self-report as sick, without delay, when suffering from or suspecting he or she might be suffering from a disease;

b)    to report to his or her chain of command, any medically based inability to perform duties;

c)    to inform his or her chain of command, when required, any MEL specified by his or her health care provider;

d)    to follow those imposed MEL;[18] and

e)    to follow prescribed medication and treatment regimes.

Serving personnel also have a responsibility to convey information on available support facilities, programs and resources to their families.

CANADIAN FORCES HEALTH SERVICES RESPONSIBILITIES

The Chief of Military Personnel (CMP) is directly responsible to the CDS for the conduct and quality of health care in the Canadian Forces. The head of the clinical practice of medicine in the Canadian Forces is the Surgeon General, who has the right of direct access to the CDS on medical matters.

Also subordinate to the CMP is the Canadian Forces Health Services Group (CFHSG), sometimes referred to as part of Canada’s “14^th medical system”, the organization that actually delivers health care to the Canadian Forces and exercises command and technical control over all military health care facilities in the Canadian Forces.[19] It includes both medical and dental branches. CFHSG is composed of uniformed and civilian health care providers working in approximately 120 different units of varying sizes in different areas around the world. The units can range from a large group of about 300 health service personnel on bases such as Canadian Forces Base (CFB) Valcartier or CFB Petawawa, to two personnel providing health care support on any of Her Majesty’s Canadian ships (HMCS) or at Canada’s most northern military station at Alert.

Medical professionals within the Canadian Forces health services system are responsible to the chain of command for the quality of health care given to military personnel.[20] Their primary obligation to service personnel is to maintain their health and mental well-being, prevent disease, diagnose or treat any injury, illness, or disability and facilitate their rapid return to operational fitness. This is an important concept. Canadian Forces health care works to put soldiers ‘back into the fight’. The Canadian Forces health care system is not intended, nor is it fundamentally designed to provide continuing, long-term care to personnel who will never recover to the point of returning to full duty.

The obligation medical professionals have to the chain of command entails sustaining or restoring service personnel to operational effectiveness and deployability. Medical professionals are responsible for keeping the chain of command informed of the medical status of those under its command, to the degree necessary for optimal employment of those personnel in the attainment of assigned missions. While medical advice should always be treated with respect, the chain of command retains the authority and responsibility to employ personnel under command in a manner appropriate to the circumstances.[21]

Canadian Forces personal medical records are confidential, known only to a Canadian Forces patient and Canadian Forces medical professionals dealing with that patient. In keeping with Canadian privacy laws, military health care providers have a professional duty to safeguard patient medical information from inappropriate disclosure, but they must exercise due diligence in the context of supporting operational effectiveness, while respecting the legal and regulatory framework in which they work. While specific information such as diagnosis and detailed treatment should not be disclosed, an open dialogue, on a need-to-know basis, between medical professionals and the chain of command, is essential to maintaining the integrity of the Canadian Forces health care system and to ensure that neither the individual nor the mission is compromised.

Military health care providers have the following specific duties:

a)    To provide clear, detailed and relevant MEL information on sick report forms;

b)    to disclose to a Commanding Officer, limitations on a Canadian Forces member’s ability to use weapons, complex machinery or equipment;

c)    to disclose additional non-clinical information necessary for the Commanding Officer to assign appropriate duties to the psychologically or physically injured soldier;

d)    to disclose prescribed information to appropriate authorities when required by federal and applicable provincial laws; and

e)    to inform the Base or Area Surgeon when the health care provider has indications that a Commanding Officer is not providing the required support to the patient or is not respecting assigned MEL;[22] and

f)     to supervise Canadian Forces patients and ensure they follow prescribed medication and treatment regimes    .

FEDERAL, PROVINCIAL AND TERRITORIAL RESPONSIBILITIES

At the federal level, Health Canada’s responsibilities for health care include setting and administering national principles for the health care system through the Canada Health Act and delivering health care services to specific groups (e.g. First Nations and Inuit). Working in partnership with provinces and territories, Health Canada also supports the health care system through initiatives in areas such as health human resources planning, adoption of new technologies and primary health care delivery.[23]

The Canadian constitution does not address health and health care as a single subject nor does it explicitly allocate responsibility to one order of government or another. Both provincial and federal governments have varying degrees of jurisdiction over different aspects of the health care system.[24] However, through a number of court cases and legal interpretations, it is now well accepted that the provinces have primary jurisdiction over the organization and delivery of health care services in Canada. In contrast, Yukon, Nunavut and the Northwest Territories do not have formal constitutional powers over health care, although they have assumed these responsibilities.

While the provinces and territories have primary responsibility for health care delivery, the federal government has constitutional authority and responsibility in a number of very specialized aspects of health care (e.g. the approval and regulation of prescription drugs) and in critical areas of publicly funded health care, including the protection and promotion of health.

The Canada Health Act specifically excludes members of the Canadian Forces from the definition of “insured persons” and thereby effectively prohibits Canadian Forces personnel from care and benefits provided by provincial health care systems.[25] Responsibility for their healthcare falls upon the Minister of National Defence.

The Constitution of Canada bestows responsibility for “Militia, Military and Naval Service, and Defence” in the hands of the federal government.[26] The National Defence Act (NDA) assigns the Canadian Forces to the Minister of National Defence, who “has the management and direction of the Canadian Forces and of all matters relating to national defence.”[27] The CFHS provides health care to Regular and Reserve Canadian Forces personnel and represents the Department of National Defence in the Federal Healthcare Partnership (FHP), an umbrella group of federal departments and agencies that provide health services to specific groups of Canadians, including First Nations and Inuit peoples, members and veterans of the Canadian Forces and members of the Royal Canadian Mounted Police (RCMP).[28] Where medical treatment might not be available within the Canadian Forces, it can be acquired from the civilian sector. As explained by
Major-General Walter Semianiw, the Canadian Forces Chief of Military Personnel:

Canadian Forces personnel are offered a full range of health services, from health promotion and illness prevention to treatment and rehabilitation. If the health care clinic on a particular base cannot offer a required service, then that service is purchased from the civilian health care sector. Arrangements have been made across the country to ensure that regional care is provided close to the member's immediate family and support system, which is a foundation of the conceptual construct that we have in place.[29]

STATISTICS

To provide perspective on the scope of the issues being discussed in this report, the following statistics are offered. According to Department of National Defence information received in March 2009, the Canadian Forces casualty summary for Afghanistan in 2008 is as follows:

Table 1 — Canadian Forces Casualty Statistics as of December 31, 2008[30]

The Canadian Forces has deployed Rotation Number 7 (ROTO 7). There have been more than 27,000 Canadian Forces personnel deployed to Afghanistan since 2002. Applying the casualty statistics to that number produces the following death and casualty rates, as of the end of 2008:

a)    Killed in Action (KIA)                                   0.34% (1/3 of 1%);

b)    Non-battle deaths (NBD)                            0.05%;

c)    TOTAL DEATH RATE                              0.39%;

d)    Wounded in action (WIA)                           1.5%;

e)    Non-battle injuries (NBI)                             2.1%;

f)     TOTAL WOUNDED RATE                       3.6%

These statistics do not include psychological injuries, or OSI, the number of which remains largely unknown. However, to provide a general idea, Brigadier-General Hilary Jaeger, the Canadian Forces Surgeon General, told the Committee that the Canadian Forces now have results from over 8,200 completed screening questionnaires, which show 4% responding in a manner consistent with PTSD, 4.2% consistent with depression, a total of 5.8% consistent with either or both of these conditions, and 13% consistent with any mental health diagnosis.[31] Applying these percentages to the approximately 27,000 Canadian Forces personnel who have served in Afghanistan since 2002 it would seem that:[32]

a)    approximately 1120 Canadian Forces members could exhibit symptoms of PTSD;

b)    approximately 1176 Canadian Forces members could exhibit symptoms of depression;

c)    approximately 1624 Canadian Forces members could exhibit symptoms of either or both PTSD and depression; and

d)    approximately 3640 Canadian Forces members could exhibit some sort of mental health concern.

The Committee knows these statistics are not exact, nor are they precise enough to begin drawing any specific conclusions. The same individual may be counted in more than one category. Furthermore, symptoms of OSI or PTSD may not be a result of service in Afghanistan. Perhaps a trauma suffered years ago during a tour of duty in the Balkans, or Somalia, or Rwanda could be the root cause. But these issues might be beside the point. The numbers are presented here only to get a general feel for the size of the problem being discussed.

It must be noted however, that the overwhelming majority of Canadian Forces personnel are fit and healthy. They come through the rigours of difficult deployments without difficulty. As noted by Brigadier-General Jaeger, “…it is worth emphasizing that 87% of those screened reported doing well.” Nonetheless, this fact in no way diminishes the importance of addressing issues associated with those who have some degree
of OSI.

It should also be pointed out that the Committee realizes there are other Canadian Forces personnel suffering from some form of OSI, sustained at home, in other theatres of operation, or in conditions of work other than combat. In focussing on Canada’s military mission in Afghanistan we do not intend to neglect these other people who also require help. In fact, we feel that concentrating attention on Afghanistan-related OSI issues will inherently help all Canadian Forces personnel, including those who are veterans of past Canadian Forces missions, and their families who have been touched by any
injury—physical or psychological.

In the course of our efforts to understand the numbers involved, we persistently reminded ourselves that the real issue is one of people. Sailors, soldiers, airmen and airwomen and their families are the centre of gravity in this report. We recognize they need and deserve our attention, while they deal with injuries, both physical and psychological, and the effects of those injuries, no matter how large or small.