That's a good Scottish name, and the Ritchie side came over, and we were in Canada before the American Revolution, so my roots go way back with you.
But today I'm going to tell you a story. It's going to be a brief story, but it will cover some 25 years.
I was an army psychiatrist until my retirement in 2010. I now work for the Washington, D.C., Veterans Health Administration, its hospital, but I speak as an individual, not as an organization.
The themes I am going to touch on today, over the last almost 30 years, are the lack of informed consent around the use of mefloquine; the lack of screening for post-traumatic stress disorder, traumatic brain injury, depression, and other psychiatric illnesses; the lack of documentation around both giving the medication and any side effects; how you distinguish mefloquine use from post-traumatic stress disorder and traumatic brain injury—PTSD and TBI—and there are ways to do it, but it is not always easy; and finally, the intersection that we have seen through time with combat warfare and domestic violence.
So I'm going to pick three points. The first point is Somalia in 1993; the second point is Fort Bragg in 2002; and the third is the long wars in Iraq and Afghanistan, but focusing on the massacre of Afghan villagers by Staff Sergeant Bales in 2012.
I hope my tale will lead in to what Dr. Nevin and Dr. Passey will be testifying to.
I deployed to Somalia in 1993 as part of Operation Restore Hope. I was with the combat stress control out of Fort Bragg, North Carolina, the 528th—and if you're in the army at this point you say, “Hooah”; the marines have a different version. The first night that I got there, there was an army soldier evacuated out of Somalia, out of Mogadishu, who was totally psychotic. We later learned that he had probably taken mefloquine on a daily dose, rather than weekly as prescribed.
Back then, in 1993, we did not know that much about the neuropsychiatric side effects of mefloquine, and we sat in the circles with the preventive medicine officers and debated the risks and benefits of getting malaria versus using mefloquine, and we thought compliance would be enhanced by taking a medication that was once a week, rather than daily, as are Malarone and doxycycline.
So mefloquine was widely accepted—I took it myself—but there were, at that time, the beginnings of rumblings about “mefloquine Mondays”, or “psychotic Tuesdays”, or “rage Thursdays”; the days that the battalions would be administered in formation, and the bad dreams and the nightmares that followed. And then one day I was asked to do an assessment on Corporal Matchee. You know that story well. He had tried to kill himself the day before because of an investigation into the torture and murder of a Somali boy. When I went to see Corporal Matchee, he was comatose, essentially brain dead—at least we thought so at the time.
The rumours began to grow about the increased irritability and violence that mefloquine led to. And I'm sure you're going to come back to that time in Canadian history, because your military has never recovered from that investigation, that incident.
I'm going to go forward to Fort Bragg in 2002. At that time, 9/11 had happened and we were sending troops into Afghanistan; they were deploying.
In the summer of 2002, there were four murders of wives and two suicides at the same time. The staff sergeant was a cook named Griffin. He never deployed. He was not on mefloquine. The next three were Sergeant Nieves, Sergeant Floyd, and Sergeant Wright. I was part of a team that came down. I was working at the Department of Defense health affairs at the time. I went with an army team. We looked at the intersection of mefloquine and violence.
Again, a recurring theme here is that it's hard to sort out what is what, but let me tell you briefly about these situations.
Sergeant Nieves had just returned from Afghanistan. He was on mefloquine. He and his wife argued, and he shot her and then himself. Sergeant Floyd had come back six months before he killed his wife and himself. I thought at the time then, as did all of us, that if the drug did influence behaviour, that would have been six months ago. He was acting paranoid and weird at the time of the murder. Finally is the case that troubles me the most to this day. Staff Sergeant Wright was a high-speed, low-drag, special forces soldier. He had gotten promoted, and came back, and was on mefloquine. He either clubbed his wife to death with a baseball bat or a cup or strangled her—it's not clear—probably in front of his kids. He dragged his wife's body off to a shallow grave where he led police three weeks later. He went to jail. He was allegedly delusional, paranoid, anxious, and seeing and hearing things in jail. He hanged himself six months later.
Back then in 2002 we thought the incidence of neuropsychiatric side effects was very low, like one in ten thousand or one in sixteen thousand. The research done was often done on travellers from the Netherlands who were going to Thailand and taking hallucinogens, and how could they attribute this to mefloquine? But in the years since then, partly because of the work of my colleague Dr. Nevin and others, we've recognized the increased incidence of neuropsychiatric side effects, so most estimates are 25% to 50% of people on mefloquine have neuropsychiatric side effects depending on how we define the effects such as bad dreams or nightmares. Dr. Nevin's going to talk about this a little bit more.
I'd like to close with a couple of cases. In Iraq we were on mefloquine the first year we were there, but then it was found not to have much malaria there, and it was stopped. In Afghanistan troops were on it pretty much over the course of the long conflict, although over time we switched from mefloquine to doxycycline or Malarone because there was increased recognition of the neuropsychiatric side effects.
Having said that, there's only one suicide I know of that's directly attributable to mefloquine, Specialist Yuan Torrez in 2004, but the episode I'd like to close on is that of Staff Sergeant Bales. You may remember Staff Sergeant Bales. In 2012 he went out from his sleeping quarters, went to two different villages, massacred 16 Afghani civilians, wounded a number of others, and burned their bodies. He was apparently dressed in a bizarre fashion and having visual hallucinations.
When I first heard of this, I thought instantly that this was a mefloquine reaction, especially with the delusional paranoid behaviour—and you will hear about this over and over—and the visual hallucinations. As it turned out, Staff Sergeant Bales was on mefloquine in Iraq. He had a traumatic brain injury so he should not have been on mefloquine. It is still unknown whether or not he was on mefloquine at the time of this incident. He was prescribed doxycycline. We know he didn't take it. He was in an area where mefloquine was used commonly by special forces soldiers back at that time. It's not used by the special forces anymore. They have completely stopped using it.
What's most troubling about this case, whether or not he was on mefloquine or steroids and alcohol, as he seems to have been, is you have the same themes I talked about in the beginning, a lack of informed consent, a lack of screening for TBI, and a lack of documentation.
The Army never said whether he was on it or not, and I believe they did not know.
What is totally clear is the political damage this did to the United States military in our relationship with the country of Afghanistan. I will make the argument that it is too dangerous to put our soldiers and marines, who are handling weapons, may be stressed from other sources, may have post-traumatic stress disorder or traumatic brain injury, and are often in field situations where it's hard to do a good medical assessment.... I would argue that no service member at this time should be placed on mefloquine. The potential for violence is too great.
I see that the screen has just gone dead, so I will conclude my remarks here. I believe Dr. Nevin will talk about the “black box” warning that has been placed on mefloquine, again recommending against using it because of the multiplicity of neuropsychiatric side effects, including paranoia, irritability, delusions, and visual hallucination, which lead to the conclusion that it has severe neurological toxicity.
Thank you very much for your attention.