Response

We thank Dr Clark for his letter¹ and we appreciate the opportunity to discuss the issues that military families endure. We are always working to find the balance between recognizing the real effects of high mobility and relocation on the Canadian health care experience for military families without perpetuating the perception that military families are damaged.

Dr Clark raises some valid issues related to differences between the military operational demands and experiences across nations; however, he fails to consider the unique health care experiences of Canadian military families. In the United States (US), the military provides continuous health care for the families regardless of their location. For Canadian military families, 50% of whom move every 2 to 4 years, this is not the case. They must access civilian health care services across jurisdictions, starting from scratch every time. The issues raised in the vignette in our commentary,² when present, are amplified under these conditions.

We agree with Dr Clark that we cannot state that the issues highlighted in our vignette are common without supporting Canadian data. Recently published survey data from Canadian Forces Morale and Wellness Services suggest that, while this might be a common scenario for military families in the US or Canadian military families in need, most Canadian military families are doing well at any point in time.³ Military families in crisis are not the norm for the average family physician; however, when in need, these are commonly cited concerns and issues to look for, investigate, and ask about.

We also agree with Dr Clark that fly-in–fly-out resource extraction types of jobs are a close comparator for occupations that require protracted absences from the family unit. What this comparison does not account for is the interaction between separation and mobility that military families face. Many families of individuals employed in resource extraction remain in their communities and connected to their social, community, and health services in a stable and persistent manner. The workers often deploy on cycles of weeks, so relocation is not as frequent for those families. We also agree that more research needs to be done to understand the effect of occupation on health and social well-being at the family level to better understand how occupational mobility might affect continuity of care for other mobile Canadian families.

Dr Clark has also raised the point that many other occupations come with risks and that Canadian Armed Forces members experience lower mortality than the general population does.⁴ Individuals who join the military and stay in the military are by definition healthier than individuals in the general population, given occupational eligibility and operational requirements. Health effects of service and acquired morbidity continue after the period of employment, with an effect on families. While it is true that the risk of mortality might be lower in particular employed subsets who do not deploy to conflict zones, no other occupation requires the employee to legally sign off on the risk of death and injury.

Five years ago, there were virtually no Canadian data on military families. Since our commentary was submitted some 14 months ago,² the field of military family health research has surged forward.^3,5–10 We now know through the analysis of routinely collected health administrative data more and more about the differences between the children and spouses in military families and those in civilian families, and how they access and use the publicly funded health care system. This information, along with discussions with families themselves, can help direct thinking about the barriers military families face in accessing health care.

Dr Clark has also pointed out that we have highlighted programs run by for-profit companies for military families. Calian Canada is a company with strong ties to the Department of National Defence. They also have an active program to create primary health care access for military families; we also mentioned Operation Family Doc, which has a similar mandate. Rather than endorsing a single organization, we are outlining available supports for military families that family physicians can access while facilitating access to primary health care, so the issues described in the vignette do not evolve.

Most military families do well. Yet, like any population of patients, there is a small proportion who do not. We would like to ensure that the military lifestyle factors are recognized and addressed within the family physician relationship so that the concern that families are paying a price for the serving member’s service can be dampened.

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