Evidence of meeting #116 for Veterans Affairs in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was symptoms.
A recording is available from Parliament.
3:35 p.m.
Liberal
The Chair Liberal Neil Ellis
Pursuant to Standing Order 108(2), a study of the effects of mefloquine use among Canadian veterans today, we have Dr. Ritchie as an individual; and from The Quinism Foundation, Dr. Nevin.
We'll start with Dr. Ritchie. The floor is yours.
3:35 p.m.
Dr. Elspeth Ritchie As an Individual
Good afternoon, Chairman and members of the committee. It is a real pleasure to be here today.
I would like to share the perspective of a military psychiatrist, which is what I was for many years. I have been around mefloquine, and consistently been uninformed as to the toxic effects of mefloquine.
Normally, when I give a presentation, I start with World War I and roll up through World War II, Korea and Vietnam. In the interest of time I will truncate that today and I will start with Somalia, but all wars produce both physical and psychological reactions to a war, and we often don't know which it is. You remember shell shock from World War I, or the Gulf War syndrome more recently, with which we've gone round and round.
The short version of the presentation is that many things we have seen over the last 30 years that we thought were psychological we can now attribute, partially or completely, to the effects of mefloquine. With regard to Somalia, I deployed there early in Operation Restore Hope, as an army psychiatrist, a young major. I deployed with the 528th combat stress control team out of Fort Bragg. Our purpose was to diagnose, treat and evaluate combat stress control reactions.
We knew very little about mefloquine then. The day I got into the country a young solider was evacuated, acutely psychotic, we believe secondary to the effects of mefloquine.
I worked mainly with the American forces, although I was asked to evaluate Corporal Matchee after his suicide attempt. He was in a coma so I could not evaluate him.
During our time there we spent a lot of time discussing the dangers of malaria, and the neuropsychiatric short-term effects of mefloquine became apparent to us, but we did not think about the long-term effects at that time.
Fast-forward, we returned home. We were using less mefloquine. The murders, murder-suicides at Fort Bragg happened in 2002, shortly after we had gone into Afghanistan. I was part of a team asked to look at mefloquine; could this be related? At that time, again we didn't know very much about mefloquine. Various studies said one in 4,000, one in 10,000, one in 18,000 people may have neuropsychiatric effects from mefloquine. We were just told or knew about the short-term effects. We studied the indexed cases—you may or may not remember—Staff Sergeant Nieves, who killed his wife and then himself; Master Sergeant Wright, who killed his wife, hanged himself in a jail cell six months later, apparently hallucinating; and Staff Sergeant Brandon Floyd, who had been off mefloquine for six months when he killed his wife and then himself.
We looked at a lot of factors, but again, back then we didn't think about long-term effects of mefloquine. When you stop most medications, the effects go away. We found a combination of things responsible for the murder-suicides, which included marital fidelity and rapid operations tempo, but I got interested in mefloquine as a result of both those experiences. Back in 2004 I presented a paper on the neuropsychiatric effects of mefloquine.
Moving quickly through time, I retired from the army in 2010. Staff Sergeant Bales committed the atrocities in early 2012, and I immediately thought of mefloquine. During that intervening period the U.S. Army's use of mefloquine had declined precipitously, although it was still being used. Another factor was that headquarters repeatedly said we had to screen and document the screening of soldiers to make sure they didn't have mental illness or traumatic brain injury. Over and over again our systems found problems with the way we screened and documented soldiers for mental illness, traumatic brain injury, anxiety or suicide. Of course, during that time period from about 2004 to 2010, our suicide rate in the army doubled.
After my retirement, my most recent work has been with the VA as a psychiatrist. I cannot speak for the VA here, but I will say that we started to look through the risks at the War Related Illness and Injury Study Center. We looked at soldiers and other veterans in the U.S. who we thought may have suffered long-term effects from mefloquine. We found a variety of diagnoses. We found very seldom a clear picture, but certainly a lot of veterans who ascribed their symptoms to mefloquine.
Although I've been retired from the army since 2010, I've been very active in veterans' and military issues. I have followed the mefloquine controversy closely. Just last week one of my newest books came out, entitled Veteran Psychiatry in the US. We cover a whole range of issues for veterans, including toxic exposures. My colleague Dr. Nevin has a chapter on the effects of mefloquine.
I would like to leave you with a couple of thoughts. One is that, again, every war has produced physical and psychological reactions that we don't understand at the time. I think the last 20...or going back to Somalia or longer. After a period of time, there are both physical and psychological reactions. At the conference we just had on mefloquine, my colleague Dr. Kudler, who is a world-renowned expert in post-traumatic stress disorder, talked about how 40 or 45 years ago, nobody believed in PTSD, post-traumatic stress disorder. Later on, we had people who thought traumatic brain injury wasn't a factor. Over and over again, you hear case reports or discussions that gradually lead to recognition.
This question about the long-term effects is something that has puzzled me. Back when I was in Somalia or at Fort Bragg, and we were trying to figure out why Sergeant Floyd would have murdered his wife and then himself, being apparently very paranoid and psychotic at the time, we didn't have a mechanism to understand that. Now we have more ideas about how the drug may affect the brain stem and other parts of the brain to cause both neurologic and psychological problems.
I would like to close with an example that's very relevant to me in my current sitting. I'm chair of psychiatry at a hospital in Washington, D.C. I'm not speaking on their behalf, so I won't go into that in detail. As a psychiatrist, however, I work with a lot of patients who have been on antipsychotics in the past or who are on antipsychotics now. You're familiar with these medications—thorazine, haloperidol or haldol, risperdal, quetiapine and olanzapine; there's a range of them. We know they cause such short-term effects as dystonia, which is a rapid clamping of the muscle, or extrapyramidal symptoms, or akathisia, a lot of muscle movements. We also now know that they cause long-term problems such as tardive dyskinesia. You've perhaps all heard of that. That's TD, the oral buccal movements of the mouth or the tongue. If you go to a nursing home, you will often see the repeat movement. We know that these symptoms wax and wane over time, but when the medication is stopped, they may not go away. They may get worse. I'm not saying that the long-term effects of mefloquine toxicity are the same as tardive dyskinesia. Rather, that's a model that can be used. There are short-term effects that may stop when the drug goes away, but then there can be long-term effects.
As we move into the question and answer period, I know that you'll ask me many questions I don't know the answer to, because in many cases we don't have the science. We haven't done the studies. You might ask me how mefloquine affects women differently, to which I might say, “Well, I think it does; we have some studies...”, or you might ask why mefloquine toxicity is so prominent in veterans from Somalia and maybe less so in other conflicts. I have some hypotheses, but I don't have all the answers.
There are, however, a couple of things I'm very sure of. One is that in both the U.S. and Canada, we need to do a better job of screening veterans for exposure to mefloquine. That would be fairly simple.
Have you ever taken the once-a-week anti-malaria pill? As a follow-up to that, have you ever experienced a variety of symptoms that include dizziness and nystagmus?
The other question that I'm very clear on is that you have some percentage of your veterans who will have significant and permanent problems because of mefloquine. I cannot tell you the exact percentage and I cannot tell you who they are. Based on all of the work that Dr. Nevin and I, and others, have done, you have veterans who have suffered permanent injury. I think it is critically important for you all to identify those veterans.
As a psychiatrist I see a lot of people who are suicidal; that's my bread and butter. One of the things I've seen over and over with people suffering from mefloquine toxicity is they don't know where the suicidal feelings are coming from. They want to jump in front of a bus, they want to stab themselves or sometimes they want to kill their family. It can be just so helpful to them to know that this isn't just them; it's that they've been poisoned by a drug and that's why they're feeling this way. Just knowing about that exposure can be very helpful in having them say, “Okay, it's not just me. It's the medication.” The relief that veterans get is enormous.
With that, let me conclude my remarks.
I'll be happy to take your questions. Some of your questions I won't be able to answer because they're either outside my scope or we don't know, and some I may defer to Dr. Nevin to answer.
Thank you very much for your attention.
3:45 p.m.
Dr. Remington Nevin Executive Director, The Quinism Foundation
Thank you, Mr. Chair, and thank you, members of the committee, for inviting me here today.
I'm Dr. Remington Nevin, and I'm the executive director of the Quinism Foundation, which is a Vermont-based non-profit organization. Our mission is to support and promote education and research on the medical condition known as chronic quinoline encephalopathy, otherwise known as neuropsychiatric quinism. This is the medical condition caused by poisoning of the central nervous system by mefloquine and related quinoline anti-malarials.
I last provided evidence to this committee in December 2016 in the form of a written brief on the topic of mefloquine, and in that brief I commented in part on what were then the recent changes to the Canadian mefloquine product monograph updated in August of that year. The monograph was subsequently updated again in, I believe, September 2017, following the publication of both the Canadian Forces surgeon general report on mefloquine and the Health Canada report on mefloquine. It is the language from this most recent update that I will refer to in my testimony today.
The current Canadian mefloquine product monograph now warns physicians and other prescribers, in bold typeface, that:
Patients should be advised to consult a healthcare professional if any neurological and/or psychiatric symptoms occur during the prophylactic use of mefloquine
—for the prevention of malaria—
as healthcare professionals may have to discontinue mefloquine and prescribe an alternative medicine for the prevention of malaria.
The monograph further clarifies, in a boxed warning, that not only may mefloquine have to be discontinued, but that “mefloquine should be discontinued” and an alternative medication substituted if psychiatric or neurologic symptoms occur during prophylactic use.
The updated monograph then also makes clear that:
Psychiatric symptoms ranging from anxiety, paranoia...and depression to hallucinations and psychotic behavior...can occur with mefloquine use. Symptoms may occur early in the course of mefloquine use and on occasion...these symptoms have been reported to continue long after mefloquine has been stopped.
The monograph then also makes clear that:
In a small number of patients it has been reported that dizziness or vertigo and loss of balance may continue for months or years after discontinuation of mefloquine, and in some cases vestibular damage may be permanent.
There are several important points being made in this approved labelling, which has been approved by Health Canada and, therefore, presumably are being agreed to by Health Canada.
The first point being made is that there is an acknowledgement by Health Canada and the product's manufacturer that in some cases there are long-term psychiatric and neurologic symptoms that result from mefloquine use. The assumption in the labelling is that there is a likelihood of these symptoms being causal, meaning caused by the drug, and not merely associated with its use. To be clear, this causality is really not disputed by experts. There is broad consensus among international drug regulators on this fact. There's good evidence from the medical and scientific literature and from the accumulated pharmacovigilance data—meaning the adverse-event reports—that symptoms such as insomnia, abnormal dreams, nightmares, anxiety, depression and cognitive dysfunction, among other psychiatric symptoms, for example, can continue for years after use of the drug. That's the first point.
The second point being made by this updated language is that there's also tacit acknowledgement by Health Canada and the drug's manufacturer that to reduce the risk of these long-term symptoms, mefloquine should be discontinued at the onset of any psychiatric or neurologic symptom. This is made clear by the additional language in the monograph, that:
During prophylactic use, if signs of acute anxiety, depression, restlessness or confusion occur, these may be considered prodromal to a more serious event. In these cases, the drug must be discontinued and an alternative medication should be substituted.
It should be clear, given the other language in the monograph, as well as international drug labelling, that these specific symptoms—the acute anxiety, depression, restlessness or confusion—should be considered illustrative and not exclusive. For example, the European drug labelling makes clear that abnormal dreams, nightmares and insomnia should also require the drug's discontinuation. I believe this is clear from the Canadian product monograph language as well.
For the purposes of this committee’s mandate, these two points have profound implications for the care of Canadian veterans, tens of thousands of whom since the 1990s have been exposed to mefloquine, in most cases without the benefit of these enhanced warnings.
One obvious and profound implication is that for those Canadian veterans who were ordered to take mefloquine prior to these warnings appearing in the product monograph, and who were therefore not told to discontinue the drug at the onset of any psychiatric symptoms, there is an increased risk that they experienced the “more serious event” that these psychiatric symptoms are considered prodromal to. To be clear, this more serious event is in fact the development of the long-term psychiatric and neurologic symptoms that in some cases can contribute to disability.
This then raises the question: what is being done systematically by Veterans Affairs Canada and others to identify those veterans who did in fact develop these long-term psychiatric and neurologic symptoms as a result of their use of mefloquine? The answer appears to be nothing. As a result, in a recent letter to the former Minister of Veterans Affairs, we called upon VAC to implement a program to screen veterans for a history of symptomatic mefloquine exposure, meaning those veterans who not only recall having taken mefloquine but who recall having experienced those symptoms that are specifically listed as being prodromal to the more serious event, which we understand is a euphemism for the development of disability from the drug’s use.
Unfortunately, what we received in reply from the current minister was a very unsatisfying response, which suggests to us that VAC is not taking this issue seriously. I'd be happy to share this response for the record on request.
As we noted in our original letter to the veterans affairs minister, we believe that screening veterans “for symptomatic mefloquine exposure is a necessary first step to raising clinicians’ awareness of the prevalence of mefloquine poisoning among the recent Canadian veteran population”. We also believe that screening will permit VAC to more accurately and validly “estimate the total number of veterans exposed to mefloquine” and “how incomplete prescribing documentation may be”. We also believe that this will permit VAC to estimate “how many veterans may be suffering disability who may become eligible for disability compensation” as a result. As we noted in our original letter, our organization would be pleased to work with VAC to help implement such screening in this population.
That concludes my prepared testimony. I would be very pleased to answer any questions the committee members may have. Thank you.
3:55 p.m.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Thanks, Chair, and thanks to both of you for being here.
As you're aware, Dr. Nevin and Dr. Ritchie, we're now at a point where in Canada only about 5% of our armed forces are given this particular drug. Looking forward, and due to I think a great deal of pressure, the surgeon general and Health Canada have come around, to some degree, on these issues.
Our concern here is veterans who were forced to take this drug in the past. In your opinion, what should the Canadian Armed Forces be doing, then, specifically, in regard to assisting these veterans? As an example, are our one-hour mental health appointments at all effective? This is what's being given to our veterans in the early stages of PTSD, TBI or mefloquine poisoning. Does it go far enough? Do you have suggestions for programming for Canada that we should be investing in?
3:55 p.m.
As an Individual
I think we could each spend two hours answering that question. I think what might work is if I try and then turn it over to Dr. Nevin.
One of the things in the U.S. military that we've seen since 9/11 is that there are many programs trying to do early identification of post-traumatic stress disorder, traumatic brain injury and other psychological consequences of war. People get worried about their careers. We have not done—and on our part, this is a pity, in my opinion—a systematic screening for mefloquine as well.
I think it is important that you screen for all of those, as well as depression, which runs hand in hand with PTSD and isn't quite the same thing—also, of course, they're often comorbid with substance abuse—but by doing it in such a way that the service member honestly believes it will not impact their career. After they're off active duty, it's usually easier. When they're on active duty, they often are very determined, because they're so proud of their service and they really want to hold onto it.
3:55 p.m.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Okay, thank you.
Dr. Nevin, before you answer.... You're saying that this is a very limited response. Would you be able to write a report on that particular question and present it to the committee to be part of our records?
3:55 p.m.
Executive Director, The Quinism Foundation
Yes, I'd be happy to follow up my testimony with an additional brief.
Could you clarify precisely what the question is that I am being asked?
3:55 p.m.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Looking forward, we're seeing an improvement, not an admission of guilt of having done anything in the past, but less in the future. However, there are these individuals who were forced to take this drug and have faced great challenges with their health. What should the Canadian Armed Forces be doing specifically as far as programming?
You mentioned that right now we have one hour of mental health appointments, that type of thing. What should be done?
3:55 p.m.
Executive Director, The Quinism Foundation
To distinguish the military, the Department of National Defence, from VAC.... I have long stated that we will make the most progress on this issue with a simple acknowledgement in the United States, either by DOD or VA, that mefloquine is the cause of some degree of chronic disability among veterans. If a senior DOD leader in the United States were to acknowledge this in a memorandum or in a public forum, or if a senior official at the Department of Veterans Affairs were to make a similar acknowledgement, this would do more than anything else.
It's my belief that the clinicians in both of these organizations recognize the problems caused by mefloquine, but after 25 years of being told by senior leadership that this drug is not a problem, they are still somewhat reluctant to come forward and identify these problems in their patient population. What they need to see is a clear green light from their leaders that this will not result in any adverse impacts on either the clinicians' careers or the members' careers.
To address your question specifically, if the Department of National Defence would simply acknowledge what is obvious from the product monograph updates—namely what I discussed in my opening statement, that there is clearly some degree of chronic disability among Canadian veterans as a result of their use of mefloquine, particularly without the benefit of the updated warnings—that, I think, would do more than anything else.
From—
3:55 p.m.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Sorry.
Dr. Nevin, I'm sure that you're aware of the research that's been going on in Australia and of the 14 conditions that they have identified as related to having reactions to mefloquine. They have also gone so far as to say that they won't recognize the term “mefloquine toxicity”. It was two years ago when we started having these conversations, and now your term is “quinism”.
Can you talk about the difference between those two terms or what has developed since then?
4 p.m.
Executive Director, The Quinism Foundation
Our group was formed largely to advocate for and to support and promote education and research on this medical condition, which we have termed “quinism”. We chose this language very deliberately. We believe that quinism is a disease, that chronic quinoline encephalopathy is a medical condition caused by the poisoning of the brain by these drugs.
The symptoms that I have been describing, the symptoms that are acknowledged as being potentially long term in individuals who take mefloquine, are not just side effects. These symptoms are not just adverse reactions to the drug. These symptoms and the signs that accompany them are manifestations of an underlying disease that has been caused by the poisoning of the central nervous system by these drugs.
There are many reasons why we believe that. The symptoms and signs clustered together, for example, are evidence of a disease. However, we have an increasing understanding with time of the pathophysiology, meaning the disorder in structure and function, of the central nervous system that underlies these signs and symptoms.
When you have a putative pathophysiology, when you think you understand how the body—or in this case, the brain—is being disordered and you have consistent signs and symptoms, you have a disease. It's not merely a syndrome. These aren't merely side effects. It's a disease.
The term “quinism”, the disease quinism, encompasses the entirety of the symptoms that are experienced by veterans suffering from mefloquine poisoning.
4 p.m.
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
Thanks for being here, both of you.
I'm going to carry on with mefloquine toxicity. Perhaps I could ask Dr. Ritchie, what is the physical manifestation of the toxicity that we're talking about? It's confusing to us to determine the exact link in the conversation about the behaviours and acting out of these soldiers and the direct connection.
Does the medical literature define mefloquine toxicity in a specific way, as opposed to our attempt to determine what it is?
I'm not phrasing the question very well. I think I'm just asking the same question again.
How would you define mefloquine toxicity?
4 p.m.
As an Individual
You maybe asking the same question, but as a clinician and as a psychiatrist, let me say how I put it together.
There are lots of drugs, either illegal or legal, that cause things like hallucinations—things like LSD. There are things like PCP that cause hallucinations. PCP can also cause long-term problems. One thing that confused me initially when I was looking at it..... We knew about the insomnia, the bad dreams, the anxiety and the hallucinations. That was pretty obvious back then. More recently, we've learned that people will actually pop two or three of these drugs because they want the hallucinations. We knew about the technicolour dreams.
In the medical and psychiatric literature there is a lot of information about the neuropsychiatric side effects of all these things I'm talking about. What we are just beginning to put together in the literature are the neurological side effects and chronic psychiatric side effects specifically of mefloquine. Although, again, we know that with other things like PCP, you can have flashbacks and insomnia for a long period afterwards.
One thing that confuses many of us, perhaps, is that we got PTSD after the end of the Vietnam War. To remind you, we all know that the symptoms of that are flashbacks, the feelings of being numb and distant, and intrusive thoughts. What we haven't totally sorted out is that in Vietnam, many of our veterans were also on variations of the quinolones. We don't know if that actually confused the picture and we didn't recognize it back then. We labelled it all PTSD.
As I've gone along on this journey and learned more about the neurological side effects, the distinction between psychological and physical becomes blurry. It's all in the brain, whether or not it's the damage to the neurons, which we're seeing more and more of. Is it the psychological trauma? We're going down the road that this is really a toxin to the brain.
Did I answer your question?
It wasn't quite how you asked it.
4:05 p.m.
Liberal
Bob Bratina Liberal Hamilton East—Stoney Creek, ON
Thank you. You're helping me along the way for sure.
Are we ultimately going to try to determine that the use of this drug causes a physical manifestation such as a lesion on a brain stem?
What would those specific manifestations of the use of mefloquine be?
4:05 p.m.
As an Individual
Yes, I think we are. Our technology is fairly crude right now. We've gone from CAT scans, to MRIs to PET scans and SPECT scans. One thing we looked at in the study at the VA was some of the more sensitive ways of looking at things. They're sensitive, but we don't necessarily know what the answer is. Most of the research that has been done in the past has been done by cutting up rats, staining their brains and looking at them. We haven't done that yet.
I think the further we go down this field, the more we are going to find the anatomical lesions, whether we can just look and see the vacuoles—like we can in the rat brains—or whether they're smaller and harder to tease out.
I believe we will find damage.
I'm going to turn to Dr. Nevin because I have a feeling he will want to jump in here.
4:05 p.m.
Executive Director, The Quinism Foundation
Thank you.
So we know that mefloquine and the related quinolines are neurotoxic and we know that this neurotoxicity is demonstrated in animal models. It affects very specific areas of the brain stem and limbic system. As Dr. Ritchie was alluding to, on animal model studies, these drugs cause microscopic lesions in particular areas of the brain and brain stem, and based on our knowledge of neuroanatomy and neurophysiology, we would expect that lesions in those areas manifest as certain signs and symptoms.
For example, if there were tiny microscopic lesions in the vestibular nuclei in the brain stem that control the balance sense and that contribute to our orientation in space, such lesions would manifest as chronic disequilibrium, dizziness, a sense of vertigo and an abnormal gait. This is precisely what we see in veterans who complain both of psychiatric symptoms from mefloquine and of these symptoms.
These veterans who return home complaining of persistent nightmares, anxiety, depression and cognitive dysfunction, on careful examination by clinicians such as neuro-optometrists or neuro-otologists, are found to have evidence of central—meaning brain stem—visual or vestibular dysfunction.
We have a mechanism to explain this. It's not just PTSD. It's not just traumatic brain injury. The most parsimonious explanation for this is that they were exposed to a neurotoxicant that resulted in permanent dysfunction in their brain stem, and this explains the chronic disability.
4:05 p.m.
NDP
Rachel Blaney NDP North Island—Powell River, BC
Thank you so much for being here. I really appreciate the testimony.
I'm going to start with you, Dr. Nevin. One of the things that you talked about so clearly was the warning label, basically the monograph, which I think you referred to, that Health Canada now has on mefloquine. I'm just wondering if you know when that was actually added.
4:05 p.m.
Executive Director, The Quinism Foundation
Thank you. The product monographs for any drug are routinely updated on the basis of new safety signals and the need to warn the public of drug safety risks.
I am more familiar with the history of the U.S. label, but I believe the Canadian label language closely mirrors that of the United States. I can say that in general, beginning with the first availability of mefloquine in the late eighties, early nineties, the product insert should have said that if during prophylactic use of the drug—meaning for prevention of malaria—anxiety, depression, restlessness or confusion are noted, these either may or must be considered prodromal to a more serious event, and the drug must be discontinued.
In fact, in pretty much every jurisdiction where mefloquine, then marketed as Lariam, was available, this language existed in the product insert. We have known all along that mefloquine can produce a toxic encephalopathy that manifests with these symptoms and that the early manifestation of these symptoms predicts the development of more serious encephalopathy that can over time contribute to this risk of permanent neurotoxicity and disability. I think this is what permitted Roche—the original manufacturer of Lariam—to minimize their legal exposure such that they could with confidence market an inherently dangerous product. I think if you ask lawyers they will say that Roche has some very limited exposure, because they have warned all along that you are to stop taking this drug if you develop anxiety.
But the question remains. How is one supposed to use a drug in a military setting, a drug designed for military use, that has to be discontinued at the onset of anxiety? Isn't anxiety a ubiquitous emotion in deployed settings? How is one realistically to distinguish between anxiety from a toxic encephalopathy from mefloquine and anxiety from being deployed? It suggests the drug is inherently defective for the indications for which it was developed.
Now, that being said, that language was never emphasized. It was never understood by rank-and-file troops. It was never understood by military psychiatrists in the field, and certainly soldiers taking the drug were never told to discontinue the drug at the onset of those symptoms.
4:10 p.m.
NDP
Rachel Blaney NDP North Island—Powell River, BC
That is perfect for me because the next thing I want to ask is about informed consent. Right now about 5% of military personnel can get it if they ask for it or if they can't take something else. One of the concerns I have is, are they receiving the informed consent to take that?
The second part goes back to what you said about needing to let people know because a lot of veterans currently may or may not have any clue that this is what's happening to them. It concerns me deeply. I hope you can table with this committee that letter you received from the minister's office because we need to see that. That's so important because it's about letting them know.
My first question is about informed consent. What would that look like? What recommendation do we need to give to the current military personnel who are receiving that?
Second, what would you recommend in terms of identifying and helping veterans who may not know that this is one of the realities that they're living with?
4:10 p.m.
Executive Director, The Quinism Foundation
I believe, today, we have mostly addressed the problem of improper use of mefloquine. I would suggest that there are individuals out there who have taken mefloquine many times and, for whatever reason, they are simply not susceptible to the adverse effects of this drug. We don't know why some people are susceptible and some aren't. A sizable minority of us are susceptible to this toxic encephalopathy, the neurotoxic effects of mefloquine. The drug is what we call an idiosyncratic neurotoxicant, meaning some are susceptible and some aren't, and we don't know why that is. In due course we'll determine that.
Until we determine that, we have the next best thing. We have the development of prodromal symptoms to warn us who is susceptible. It could very well be that the 5%, or however many per cent, of the current force that is choosing mefloquine are individuals who have, through experience, determined that they are not susceptible. For example, I have many colleagues in the malariology community who have used mefloquine and they seem to be fine and they wish to continue taking it. I suppose as long as the drug is available and licensed for use, that's fine. I wouldn't recommend that someone who hasn't taken mefloquine take it for the first time, because there's always a risk—even with the very first tablet—that they could develop a permanent disability. I would ague that, even if one has tolerated it in the past, we don't know if certain environmental exposures or the taking of drugs or any number of things might introduce a new susceptibility. I think it's just an inherently risky drug that we probably shouldn't encourage the use of.
I think a case can be made that the current labelling, while not perfect, is far improved over what it had previously been. If the labelling is followed; if one does immediately discontinue the drug at the onset of psychiatric or neurologic symptoms, that should reduce the risk of long-term disability. I don't think it reduces it to zero, because again, there are reliable reports of permanent disability from even a single tablet, but there has been considerable improvement in the labelling in recent years.
4:15 p.m.
Liberal