Veterans Affairs Committee on May 15th, 2019

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair, and thank you, Mr. Chen.

Dr. Libman, I'm going back to the Australian Senate report, which we've talked about before. This is from Professor Geoffrey Quail who's the president of the Australasian College of Tropical Medicine. This is based on well-conducted studies of over 360,000 U.S. military, which compared mefloquine with alternative drugs for malaria prophylaxis. It says that “long-term mefloquine toxicity is quite minor.”

Does that sound like a reasonable conclusion from the studies? You apparently read this report too.

[Dr. Michael Libman]

I agree that it's reasonable. Again, I think there's a little bit of mixing up between short-term effects and long-term effects.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Absolutely.

[Dr. Michael Libman]

I would agree with you completely that those studies of huge numbers of people suggest that long-term effects are either not distinguishable between the drugs or happen rarely with mefloquine.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

All right. Thank you.

This is going to seem like an overly simplistic question. If I say, I took this drug and then couldn't sleep, does that definitively establish causality between the drug and my inability to sleep?

[Dr. Michael Libman]

That's obviously one of the problems, particularly if there are other reasons you're not sleeping.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Precisely, yes.

If I were to tell you that last year in India my wife and I both took Malarone for malarial prophylaxis and for the period of a week had trouble sleeping and anxiety—which happened, by the way—someone might tell us...but at the same time, her mother had a respiratory infection and was in an intensive care unit in India. Perhaps that would account for our trouble sleeping.

Would you not agree that to say you took this drug and had these symptoms, you need to control for all other variables?

[Dr. Michael Libman]

I agree, though that being said, there are pretty good control data that in the short term things like difficulty sleeping happen more often.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Absolutely, in the short term, yes, I was just using it as an example of causality.

You are confident that the long-term neuropsychiatric effects of this drug, if present, are rare.

[Dr. Michael Libman]

Exactly.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

All right. Thank you.

I have no further questions.

[The Chair, Liberal, Neil Ellis]

Mr. McColeman.

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

Thank you, Chair.

Dr. Croft, when Mr. Eyolfson wanted to move on to another question and you did not have the time, you were explaining a story you started about two gentlemen in their forties. Could you finish that for us, please?

[Dr. Ashley Croft]

This was reported in February 1995 in the journal of the Canadian Medical Association. It's a report that would have been read by all Canadian doctors, including military doctors.

It was a case where two buddies were in a tent. One of them was taking mefloquine and the other was taking nothing, because he was a tough guy. They were prospecting for rocks in Tanzania. The guy taking mefloquine took it every Sunday, and everything was going fine. He was getting no side effects.

Then one day, three weeks into the trip, they shared a bottle of whisky on a Saturday night. The effect of that was to make the one who was taking the mefloquine psychotic, while the other one experienced nothing. He started getting auditory and visual hallucinations and was convinced his buddy was going to murder him, so he was going to murder him in exchange, but he controlled himself.

The next day he got very depressed for a day, and then he recovered. He felt a bit strange but by Tuesday he was all right, so everything was fine during the week.

The following weekend—this is all in the paper, by the way; these were Canadian geologists—exactly the same thing happened. They shared a bottle of whisky. The one taking mefloquine became psychotic and had hallucinations, was convinced his buddy was trying to murder him, and wanted to murder him in exchange. The next day, he took his mefloquine tablet and went into deep depression for a day, and by Tuesday was all right.

He decided it had to be the interaction between the mefloquine and alcohol. He decided to stop drinking whisky at the weekend and the rest of the trip he was fine. He came back to Canada and was seen at the Ottawa Civic Hospital. They said this looks like a serious interaction with intense alcohol exposure. They published the report, and of course, that didn't go down at all well with the drug company, because they didn't want a drug that was meant for tourists to have a precaution against alcohol with it.

They set up their own—what I call bogus—alcohol study, which they published the following year, which they carried out to discredit this very important, and in my view, very persuasive Canadian report. In the Dutch study, they got a population of 40 very healthy young people who were more or less teetotallers. They gave them a thimbleful of alcohol— 50 grams—in orange juice, over two hours. Some of them were taking mefloquine and some weren't, but they hadn't taken any mefloquine for a day. Then they put them out on the road and made them drive around and do some other tests and they published it as showing there was no effect of alcohol and mefloquine at all, at least not at low doses.

By that strategy, Roche were able to discredit this very important, in my view, hazard to taking mefloquine. It is one that the troops will inevitably face because that's the way soldiers drink. They don't drink moderately. They drink heavily once a week and if it happens to coincide with the day they take mefloquine, it seems to be a great risk, based on this Canadian study.

During my 20 years in the army I saw it again and again. It was very often the influence of taking alcohol at the same time as mefloquine that made soldiers act irrationally and completely out of character.

After some time, I persuaded to have a policy change in the British Army, which was introduced in December 2005. A policy letter came out: Soldiers taking mefloquine were not to take alcohol; female soldiers were not to take the oral contraceptive pill—it seems to have the same kind of effect— and they were not to take other prescription drugs.

That seemed to mitigate the risk. After that date we observed many fewer episodes of mefloquine-related events, if I may call them that.

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

Thank you.

You may or may not be aware, but there's a group of veterans who are currently in a lawsuit. They suffer from mefloquine toxicity and are suing the Government of Canada. The Government of Canada is going to court with them. They are what I would call veterans who have been honourable, who have served this country honourably and they are clear-headed individuals from the point of view of knowing that something went dreadfully wrong in theatre, particularly in Somalia. We have a senator, an ex-general who ran the operation in Somalia, who says that we should never be giving mefloquine to our soldiers.

That's the lay of the land here. Something is going on, although it is trying to be discredited by the government, as you can see through their questioning here today that the science isn't quite up to the standard that they would like to see. However, the reality is that we have disabled soldiers, veterans, who are looking to the government to do something, such as Australia has done, such as the United States has moved towards. We had our military witnesses here, and they also said, similar to Dr. Libman's testimony here today, that they are not totally convinced, so it still is an option for our troops.

I suppose that I just would like your reaction to those comments.

Dr. Croft, please.

[The Chair, Liberal, Neil Ellis]

We're running out of time, so make that quick.

[Dr. Ashley Croft]

If there was no reasonable alternative to mefloquine, then I would say that it would have to be given under careful supervision. However, because there are at least two drugs—I'm talking about doxycycline and atovaquone-proguanil—that are as effective at preventing malaria but that have a much better side effects profile, then, really, it makes no sense to give mefloquine at all, under any circumstances, to the troops. They're a vulnerable population and we need to protect them.

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

Thank you.

[The Chair, Liberal, Neil Ellis]

Ms. Blaney.

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

Thank you both again for this. I'm finding this to be very interesting testimony today.

Dr. Libman, you said in one of your responses that there are always ways to switch to other drugs. I'm just wondering if you could explain to me how that happens in the military. I've heard numerous testimonies about how, historically, they haven't necessarily had that option to switch their medication. In fact, if they come forward to disclose that they're having some of those concerns that the warning label tells them they might have—anxiety, a lack of ability to sleep and so forth—then that would actually potentially have an impact on their career moving forward.

When you say that there are always ways to switch to other drugs, do you have anything to support that in terms of medication that you get in the military?

[Dr. Michael Libman]

I'm going to have to apologize. I'm not a military doctor, so I can't really comment on when soldiers have issues with this drug or any other drug. I just can't tell you what the mechanism is for deciding what the right thing to do is in that case from a medical point of view.

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

Thank you.

Dr. Croft, with regard to that comment about how there are always ways to switch to other drugs, when you are serving your country, is it an easy thing to get your medication switched because of the way you're interacting with it?

[Dr. Ashley Croft]

I guess it depends where you are. If you're out on a front-line post in Afghanistan somewhere, where you're a long way from the medical aid centre—you might be 40 miles away—you're stuck with what drugs are there. It's not going to be possible to switch easily. That really is the difficulty in the military, that you often won't have access under operational conditions to a unit doctor. It will be difficult, quite apart from the fact we've already touched upon, that if you say, “Well, I don't like this drug because it's making me unhappy”, you're just going to make trouble for yourself because of the kind of stigma that is attached in the military to anyone who's reporting psychological unhappiness or distress.

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

I think there's a connection there with the reality that the people who are coming forward are actually veterans and are no longer serving.

[Dr. Ashley Croft]

Yes, indeed, they're veterans. Now they can say what they wanted to say when they were serving, but couldn't because of the constraints of being in service.