Veterans Affairs Committee on May 1st, 2019

[Dr. Remington Nevin]

The simple answer is that it makes no sense.

Health Canada, one portion of your government, is very clearly stating that in some cases this drug is acting as a poison; it's causing permanent central nervous system dysfunction. It's very obvious from the product monograph and the implications of the updated language in the product monograph that we, the prescribers—the Canadian military, the U.S. military, travel medicine communities around the world—for many years were not using the drug in the most safe manner, and disability resulted as a result of that.

It's as clear as day to me. It would seem very straightforward for those in positions of authority to acknowledge that some damage has been done as a result of the use of the drug, that some disability—we don't know how much—has resulted from our use and misuse of mefloquine.

I suppose there are many reasons why it's very difficult in some cases to make that acknowledgement, and those circumstances will differ depending on the jurisdiction and the unique history.

[Phil McColeman, Conservative, Brantford—Brant, ON]

One of the things people continually talk about is giving our veterans the benefit of the doubt about whether or not their condition is related to something that happened during their service. We hear that over and over again. Yet, when it comes to something as serious as this—and this is very serious.... This is not something to just brush over and try to sweep under the carpet, saying, “Well, no, maybe you're suffering PTSD or something else that is not related to this.” That is absolutely.... I don't know the word to use. I'm lost for words.

I am very upset by this, because I can see things like anxiety and suicide—some of the worst things that these veterans have to deal with day in and day out. They are coming forth in good faith to say, “I had this experience with this drug.” I want to put that on the record, because this is, as you have said, “poisoning of the brain, and poisoning of the central nervous system”. This happened to certain individuals.

[Dr. Elspeth Ritchie]

Sir, obviously, your question is a good one, and somewhat rhetorical. I believe we would all want to do what's best for our veterans, and give them the benefit of the doubt.

One thing we haven't touched on here is the possible harmful side effects of the wrong treatment. We try to distinguish mefloquine toxicity, or quinism. What is PTSD? What's TBI? If we misdiagnose it as PTSD, for example, we treat it with selective serotonin reuptake inhibitors. Those are anti-depressants. They can be useful, but they have sexual side effects. I've seen suicides related to the sexual side effects. We might treat it with anti-psychotic agents, because we think it's a psychosis, and don't recognize that. The anti-psychotic agents also have their own side effects. It's really important to make sure that we are diagnosing as best we can.

Coming back to our theme of screening and diagnosis, you need to inform your providers to be looking for this, as well as the veterans themselves, to be able to come up and say, “Hey, doc, you said I have PTSD, but did you consider this?” That can take the conversation to a whole new level.

[Phil McColeman, Conservative, Brantford—Brant, ON]

Thank you.

[The Chair, Liberal, Neil Ellis]

Mr. Chen.

[Shaun Chen, Liberal, Scarborough North, ON]

Thank you, Mr. Chair.

I want to thank our witnesses, Dr. Nevin and Dr. Ritchie, for being here today.

From headaches and diarrhea to anxiety, hallucinations and depression—you've called it poisoning of the brain and poisoning of the central nervous system. Dr. Nevin, you said that 5% usage in the Canadian Armed Forces is tremendously higher than in the U.S. It's been pointed out that in the U.S., it's less than 1% usage.

In the Canadian Armed Forces press release, it says that “Mefloquine will now only be recommended for use if a CAF member requests it.” Why on earth would anyone request this drug? From your experience, can you speak to why this is? I know it's from the CAF. Why would it be given out? Why would somebody request this drug?

[Dr. Remington Nevin]

It's an excellent question.

The fact is there are individuals who, for whatever reason, and we don't understand why—are fortunate to have escaped the horrific adverse effects that other veterans and service members have experienced from this drug. Good for them. Thank goodness they haven't gone through what some service members have gone through. There are intelligent individuals, doctors and senior officers, who I think we can all agree have made a fully informed decision to take mefloquine. As I mentioned, the drug is licensed. It is approved by Health Canada for prevention of malaria, so there would have to be some sort of policy, and some very good reason, for that drug to be denied to service members.

I think a very strong case can be made that even if an individual states a preference for the use of mefloquine on deployment, and they have previously tolerated the drug—again, fortunately, for whatever reason—the residual risks to the military, and to that individual, from their subsequent use of mefloquine are simply too high to permit them to make that choice. A reasonable argument can be made for policy to restrict the use of that drug in operational settings.

I don't believe Canada has such a policy. At times, military organizations have implemented such a policy. For example, soon after the boxed warning in the United States in 2013, U.S. Army special forces, presumably on the basis of their long experience with bad things having happened from the drug, banned its use outright. I don't oppose those policies. I think those policies are quite wise. The drug simply isn't worth the risk in operational settings.

[Shaun Chen, Liberal, Scarborough North, ON]

If there are servicewomen and servicemen who can take the drug and not experience the potential adverse effects of it, Dr. Nevin, you said there is a risk with taking the very first tablet that there can be the development of a permanent disability.

[Dr. Remington Nevin]

Yes, that's correct. For someone who has never taken mefloquine, who has no experience with how they personally tolerate the medicine, or more specifically who has no experience with how susceptible their central nervous system is to the drug's toxicity, there is a very real possibility that with that very first tablet, which contains quite a bit of mefloquine—50 milligrams is a lot of mefloquine—the drug, for whatever reason, could accumulate in their brain and act as a central nervous system toxicant that could lead to permanent disability after that single tablet.

Those individuals who have previously taken mefloquine on deployments seemingly tolerated it well. Presumably, if they return for a second or third deployment and they take mefloquine again, they may presume that first tablet on second or third deployment not likely to be harmful. But you never know. We don't know. There have been cases that I'm familiar with. I have reviewed several cases where individuals who have deployed multiple times on mefloquine, for whatever reason, on a subsequent deployment experienced the very same symptoms, and subsequently suffered permanent disability as a result.

[Shaun Chen, Liberal, Scarborough North, ON]

Thank you.

Dr. Ritchie, in terms of the U.S., where there is less than 1% usage of mefloquine, can you speak to any information you have in terms of how the U.S. armed forces might better inform or educate members of their military with respect to the side effects? How do we account for the difference in usage of mefloquine?

[Dr. Elspeth Ritchie]

I want to jump in and talk about, coming back to your point, informed consent. I don't know whether that 5% is really informed. If you look at the Peace Corps, they traditionally have been offered their choice of medications, and more recently they're supposed to be warned about the side effects of mefloquine. But if you ask the average Peace Corps volunteer, they say they never really got true informed consent. I took mefloquine in Somalia. I did not know then what I know now. If I had known it then, I would never have taken it, even though likely I would have been court-martialled or at least restricted from deployment for not taking it.

I think one of the things that happened in the U.S. is there has been enough press, especially around, say, Staff Sergeant Bales, that people are really sensitive to not wanting.... There's also all the anecdotal information. It's widely known that the unit who took mefloquine on Monday would all have bad dreams and nightmares at night. It's not a secret. What I don't know, again, is with your 5% what are the reasons for choosing that?

[The Chair, Liberal, Neil Ellis]

Thank you.

Ms. Wagantall.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

Thank you.

Dr. Ritchie and Dr. Nevin, you're both aware of the circumstances around Somalia, where tens of thousands of mefloquine tablets were given to our Canadian Airborne Regiment. In 2017, in the Canadian Armed Forces surgeon general's report, he said, “The CAF members deploying to Somalia did not participate in the SMS study, since the guidelines of the study were not compatible with the operational requirement to deploy to Somalia,” and yet they still gave it to them. Not only did they give it to them, they were forced to use this drug. This has resurfaced since 2016.

Dr. Nevin, you know one of the Canadian airborne heard you speaking and the realization came to his mind that this is what impacted him. Since then, this committee has heard tons of anecdotal evidence, plus more than that coming to my office, of these individuals, but they continue to be ignored. We talk about anecdotal evidence. If you don't have it, you don't have a reason to do a study.

In my mind, why is it, then, that this was shut down in that inquiry? Why have VAC, DND and Health Canada refused to do what you are saying they fully need to do to deal with this issue, with the screening. No one has talked to our veterans since these changes came about with that report and with Health Canada's views on this. It's very frustrating to me, and I am not a veteran who was in those circumstances.

Again, with the benefit of the doubt for these individuals who have come forward, and with all the research taking place now, should they not be receiving proper screening, proper diagnosis, all these things that you're discussing?

[Dr. Elspeth Ritchie]

Absolutely they should.

[Dr. Remington Nevin]

The use of mefloquine in 1992 among deploying members of the Canadian Airborne Regiment to Somalia is extremely problematic. I don't understand the legal basis for the Canadian military's use of mefloquine in that population. Drugs cannot be prescribed or distributed without a legal basis.

The drug became available to the Canadian Forces under the guise of an existing small-scale clinical research protocol that, up until that point, had resulted in the distribution of the drug to dozens of Canadian Forces personnel after they had completed informed consent and after they had reviewed information that included the warning to discontinue the drug at the onset of symptoms such as anxiety.

Clayton Matchee and about 1,000 other deploying members of the Canadian Airborne Regiment received industrial quantities of mefloquine that were ordered under that protocol. The Canadian Forces readily admits they had no intention of abiding by the terms of that clinical research study. They were not victims of a botched clinical study. The clinical study was not being performed. The clinical study was the mechanism by which the Canadian Forces obtained industrial quantities of the drug that they otherwise could not have obtained.

The legal basis for the use of that drug has never, I think, been properly explored, but the consequences of not abiding by the clinical protocol have been profound to your country.

They have been profound because Clayton Matchee, for example, was never told that when he began to experience restlessness, anxiety and hallucinations he was to stop taking the drug. In fact, when he told others that he was experiencing those symptoms—when he returned home on leave, for example—and family members expressed concern, he said that he couldn't stop taking the drug. We all know what happened in subsequent weeks, don't we?

We know that led to the disbandment of the Canadian Airborne Regiment, which is something that could have been prevented had the Canadian Forces not taken what I think were extreme liberties with the law.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

Thank you.

[The Chair, Liberal, Neil Ellis]

Ms. Blaney.

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

We've had very powerful testimony today.

A couple of things keep coming to me. One of them is a comment that one of you made about how just knowing about the exposure can be a relief to the person. Realizing that there are veterans in this country who don't know right now why they have these symptoms, I'm very concerned about them receiving the wrong treatment that can perhaps aggravate it.

We also have heard from other testimony that the records are poor and that it's often hard for veterans to find out that information.

I want to go back to what we need to do for veterans in this country who have not been screened. Do we need to do an awareness campaign? I really want to make sure that there's a recommendation in this report that guides the next steps.

[Dr. Elspeth Ritchie]

We mentioned that we just had a symposium, and we had veterans from both Canada and the U.S. there. I don't want to name any names, but what several people told me quietly was that as a result of this, they had extreme homicidal thoughts about killing their most intimate family members. That they were scared to sleep with their wives because of fears that they would choke their wives, dreaming of bayoneting their babies, massacring their whole families.

This was very discongruent to them. How could they be thinking of this? The people who were there had not committed suicide but they talked of others who they believed had committed suicide rather than murder their families and those whom they loved.

That is just profoundly, deeply, morally troubling. So what could we do about it? Again, I'm from a different country. I can make only a few suggestions, but a public education campaign, using your media, reaching out, not being ashamed and trying to cover it up but rather saying, “Okay, we didn't know enough; in whatever happened, whether it was legal or not, we didn't do the right thing and now we want to make it right. So come in and talk to us.”

Again, it's also a provider education piece. Make sure that the psychologists, psychiatrists, primary care.... I'm a psychiatrist in my office. Somebody comes in to me with complaints of bad dreams from the war. My first instinct is to say, “Oh, it must be post-traumatic stress disorder”. Maybe I've read up and I know a little bit about people who get their vehicle blown up and they hit their head. So I'll do some screening for TBI. But what can you do to make sure?

This is medical school curriculum, as well as for advanced practice nurses, medics and physician's assistants, just so they all have the knowledge to at least ask the question, “Did you take anti-malarial agents?” Then if the answer is yes, either weekly dose or refer them to the next level of care. You can model it depending where they are. But a mass level of education, I think, would go a very long way.

[The Chair, Liberal, Neil Ellis]

That ends our time for today.

I'd like, on behalf of—

Yes?

[Phil McColeman, Conservative, Brantford—Brant, ON]

These are the experts who have come a long distance to be here. I know our committee meeting typically lasts two hours. Could I ask if I could get unanimous consent that we continue asking these experts questions up to the time that we exhaust everybody's questions? It's been limiting in terms of time for everyone, and I just think I'd like to ask the committee to consider and approve continuing this meeting.

[The Chair, Liberal, Neil Ellis]

Does anybody have any more questions, or is it just Phil? Also I see Bob and Cathay.

Okay, we'll just do a short round then of five minutes each.

[Phil McColeman, Conservative, Brantford—Brant, ON]

Can I start first?

[The Chair, Liberal, Neil Ellis]

Okay.

[Phil McColeman, Conservative, Brantford—Brant, ON]

I was searching my brain for a drug that was a cancer treatment. I googled it and I remember what it was. It's called vincristine. Have you heard of vincristine?