Military and Veteran Health Research

CANADIAN FORCES HEALTH SERVICES MISSIONAND ROLE The mission of the Canadian Forces Health Services (CFHS) is to provide full spectrum, high quality health services to Canada’s fighting forces wherever we serve. Given the exclusion of CF members under the Canada Health Act and the responsibilities of the Defence Minister under the National Defence Act, the CFHS Group constitutes a comprehensive health system to promote, protect, and restore the health of Regular and full-time Reserve CF members. In partnership with allies, civilian entities, the CF chain of command, and individual CF patients, it provides medical, dental, public health, occupational health, educational, regulatory, research, administrative, and advisory functions and services. It also fulfils command and control, operational planning, and other operational support functions by virtue of its mission to provide health service support to shield and sustain military operations. Like its civilian counterparts, the CF legally constitutes an independent jurisdiction akin to Canada’s 14th provincial/territorial health care system. The CFHS differs in mandate; however, as we must ensure that military commanders have a fit and healthy fighting force to employ in military operations. In essence, our responsibility differs from that of other health jurisdictions in that our primary role is to protect the health and well-being of military personnel and to promote a healthy lifestyle. Secondary to this is the provision of treatment services through a network of facilities in Canada, at sea, and abroad. The CF Health Services consist of over 6300 military and civilian health personnel from a broad variety of health professions. Our units are mostly static clinics, but include manoeuvre units such as our deployable field hospital and field ambulances, health services units deployed overseas, and special units with training, research, dental, operational, hyperbaric medicine, aerospace medicine, health protection and medical supply functions. All require continuous research and analysis to maintain capabilities at the best level of readiness and effectiveness. The CFHS is comprised of a national headquarters in Ottawa, 7 national units, 2 Health Services Group Headquarters, 43 static local units, 77 detachments, plus mobile deployable elements (Figure 1.1). C I M V H R • I C R S M V 3 Figure 1.1. CF Health Services Units1 CHAPTER 1 4 C I M V H R • I C R S M V Our role is not only to function as a military health organization, but also as a federal health organization. In addition to fulfilling military-specific functions such as personnel and administration, medical intelligence, operations, medical equipment and supply, plans, IM/IT, training, finance, public affairs, legal and research, the CFHS fulfils for the CF most functions of provincial/territorial ministries of health, the health-related functions of education and labour ministries, many functions of Health Canada and the Public Health Agency of Canada, industrial occupational health services, health research establishments, pharmaceutical and medical supply agencies, third party health insurers, workers compensation programs, and functions of organizations like the International Committee of the Red Cross with respect to our capability to rapidly deploy mobile field health capabilities anywhere in the world. Over 200 CFHS personnel are presently deployed on 13 missions across the globe. As our major function is to support deployed military operations, we have a large Operations directorate and staff integrated with Canadian, US, and British operational headquarters, intelligence agencies, or training organizations. For some humanitarian, domestic, and stability operational scenarios, the health response could be the primary supported military or diplomatic “pointy end”, such as our recent mission to Haiti and our annual deployment with the United States Navy on humanitarian assistance operations to South America & the South Pacific. In Afghanistan, for example, we provide mobile battlefield support integral to Canadian units. In 2006, we assumed leadership of the North Atlantic Treaty Organization ( NATO) field hospital providing tertiary care to all NATO coalition forces in southern Afghanistan for almost 4 years. Most staff were Canadians supported by allied staff from several other nations. Although it is now under US responsibility, the second-incommand remains a Canadian and we continue to provide about 30 clinical staff, as well as a much larger staff contingent to directly support the Canadian Task Force. By North American standards, the physical structure of the field hospital in Kandahar was very basic and cramped before a new state-of-the-art hospital was built last year, but the standard of care provided was extremely high and described by the current NATO force commander General David Petraeus as world-class combat medicine. During those 4 years, approximately 42,000 trauma patients passed through its doors. Over 4500 surgeries were performed, almost all of these as a direct result of the conflict. Most have been Afghans, but over 3000 coalition troops were treated in this humble plywood facility. CHAPTER 1 C I M V H R • I C R S M V 5 Of primary importance has been our mentoring of Afghan health care providers to improve Afghan health capabilities. Our performance generated tremendous praise from NATO and individual allies like the US, and although we do not have the resources of the US, NATO now looks to Canada as a leader in combat medicine and in leading multinational medical operations. In addition to our mentoring and combat medical roles in Afghanistan, 247 CFHS personnel from a variety of units deployed to Haiti on very short notice during this year’s humanitarian assistance mission. The Disaster Assistance Response Team ( DART ) deployed to Jacmel, providing outpatient and limited inpatient hospital care. Aeromedical Evacuation crews also cared for about 5000 Canadian entitled persons and Haitian casualties who were evacuated to back to Canada. These deployments demonstrate our flexibility and versatility in operating in very distinct types of operations in very different parts of the world. Notwithstanding the deployment of the DART, 1 Canadian Field Hospital also rapidly deployed with a 100-bed capacity. In addition to primary, surgical, intensive, and intermediate care with support services, it provided obstetrical, dental, and preventive medicine care. Between all CFHS element, about 22 ,500 patients were treated during this brief mission. What I have provided is a brief synopsis of our roles and responsibilities and is only a snapshot in time. Beyond the day-to-day activities, we must, as a military health care organization, look to the future. As a unique organization within Canada, we must increasingly strive for evidence-informed best practices through continuous advancement of knowledge and technology. For this reason, I am looking to both my own organization and externally to the Canadian academic community to support this effort. Our many challenges include an obligation to optimally support and treat CF members with mental health conditions, a burden which is expected to grow after the end of operations in Afghanistan. We must also maintain a robust rehabilitation capability, deal with health conditions arising from a progressively older CF population that reflects the lifestyle practices of society in general, and do so responsibly within national fiscal realities. A continual challenge given the changing nature of threats, missions, and medical technology is to maintain adequate leading-edge research to support the best possible capabilities in support of CF operations, particularly in combat casualty care, ChemicalBiological-Radiological-Nuclear (CBRN) medical defence, and other elements of military occupational and environmental health protection. CF commanders are responsible for the health of their subordinates, but military medical personnel must provide them with the advice and services necessary to CHAPTER 1 6 C I M V H R • I C R S M V promote, protect, and restore health. Clinical quality improvement programs, clinical research, and epidemiology in particular are fundamental functions of health authorities. This is supported within the CF by the Surgeon General’s Health Research Program, by various DRDC efforts, and by many other Canadian and allied partners contributing to military health research. CANADIAN FORCES HEALTH RESEARCH The Surgeon General Health Research Program is coordinated with the work of DRDC and our other partners. Most CF clinical and epidemiological research must, however, be conducted by CFHS staff who practice clinical and population health and have direct access to CF health information and a network of health institutional partners. The assumptions, conclusions and application of much military health research require a synthesis of many clinical, operational, privacy, resource, regulatory, and medico-legal factors that only come together within CFHS. This limits our military health research capacity since most of our clinicians and scientific staff have other military and clinical duties that limit the time available to conduct research. Our military medical roles are unlike anything experienced by our civilian counterparts. For example, the Medical Service has suffered the highest rate of casualties in Afghanistan after the combat arms. This highlights that our imperative to conduct continuous research to improve CF health capabilities is partly driven by our own direct application of what we learn to the health protection of CF members. Whatever the research area, CFHS clinician-researchers may well be personally applying their findings to CF members and casualties shortly thereafter, and I am accountable for the results. Hostile operational and environmental threats evolve constantly, and in order to do the best we can to protect our country and ourselves, a robust national military health research capability is critical. The past few years of intense operations have re-emphasized the operational and clinical importance of continuous military health research and scientific analysis. Combat operations with heavy casualties focus the efforts of those who must directly protect and treat our CF members. My mandates in this regard stimulated me to direct better formalization, coordination, and revitalization of the multiple Science and Technology ( S&T) efforts of my directorates and clinician-scientists, better coordination with external partners to maximize benefits derived from limited S&T resources, and better articulate my research program’s place within the broader Defence S&T enterprise. I therefore directed the development of a formal health research strategy, which was launched earlier this year and is now well underway in implementation. The mission of our research program is to direct, support and assist in the research, technology and analysis and the development, engineering and CHAPTER 1 C I M V H R • I C R S M V 7 evaluation of outcome-based science and technology initiatives that affect the performance, health, and welfare of ou