Veterans Affairs Committee on April 10th, 2017

[Col Rakesh Jetly]

It depends on the guidelines. If you're a pregnant woman or breastfeeding, it's probably the first line still, based on the CDC guidelines from a little while ago. So it gets down to these individual kinds of ideas. Of course, there's a lot of literature and a lot of concern about mefloquine right now. Say, we go to a patient or soldier who's going to a malaria endemic area, who sits down with a physician and asks him what he thinks because they need to pick something. If the soldier says, “Doc, I don't want that one I hear about on TV”, then we'll go somewhere else.

But there are other factors. Doxycycline is an antibiotic in the tetracycline class. If you have an allergy to that, that's out. If you have a G6PD abnormality, you take the other one out. There are reasons for using these drugs, and the ultimate reason should really be to prevent malaria in the safest way possible.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

I referred a few minutes ago to Brigadier-General Hugh MacKay's testimony to the defence committee. At that time he said there was no evidence of the relationship between mefloquine and suicide. In fact, as the usage of mefloquine declined, suicide has increased. Has there been no research linkage between the two?

[Col Rakesh Jetly]

There really hasn't been. We can argue, our colleagues Greg Passey, Cam Ritchie ...there's certainly a split within the community. People I respect hold one view versus the other. It's a contentious issue within medicine.

Again, suicide is extremely complicated. With our Afghanistan cohort, if you were taking mefloquine, if you were taking anti-malarials that was during the summer, the fighting season. If you try to study the group that had mefloquine or anti-malarials or not, you've also got the confounders of trauma exposure. The winter season—if you look at casualties killed in action, PTSD rates were in April and May on, in 2006 and 2007. I was there, There's a shift in all the other confounding factors; there's also permethrin in the clothing. People who have permethrin in the clothing may have had a higher rate of PTSD, and PTSD can certainly mediate in the suicide. I don't think it's as clear.... It would be an incredibly difficult thing to study because of all the other confounding factors and the trauma exposure and things.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

That's very helpful.

[Col Rakesh Jetly]

The jury is still out to some extent, I think.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

What about your experience with individuals who are assigned to the JPSU and whose conditions worsened? What systems are in place to identify a worsening condition, and is there some intervention at that point?

[Col Rakesh Jetly]

The JPSU is an administrative unit; it's not a health care unit itself. The JPSU staff themselves who are responsible from a leadership chain of command point of view do have training in recognizing people, recognizing difficulties, and bringing them within care.

The health care system itself is going to have a treatment plan in place for the person. It's not as if it ends when they are posted to JPSU. There's a chronic medical condition that needs to be monitored. There's also an individual responsibility. That's sometimes the part that gets challenging because you know the system exists, you have things in place, and that's where this safety plan comes in. If you're having difficulties, let us know. I think things are in place. It's a difficult time for people. It's a transition period, and we recognize that more and more. For some people it's no problem. This is a natural part of life. For other people there's a really strong loss of identity. How do we keep them connected to their units? The ideal JPSU situation is they're technically in the JPSU but let's do some work back in their company lines, their ship, back with their thing in the meantime. That connectedness is really important.

From my experience it's extremely difficult. Where a unit might call somebody once a week to ask how they're doing, one person appreciates it, the other person sees it as harassment. It's very challenging.

[The Chair, Liberal, Neil Ellis]

Thank you.

Ms. Wagantall, you have five minutes.

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

Thank you.

This is very helpful to me in understanding the bigger picture from the medical perspective, specifically on mefloquine. There's a lot of static around mefloquine. Part of that, I think, is significant in the fact that, even as late as Afghanistan, with individuals who have testified, what they took wasn't an option. Even Lieutenant General Roméo Dallaire said he requested the opportunity to not take it any....

[Col Rakesh Jetly]

That was a long time ago.

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

Exactly. That's what I'm trying to get at.

I think the concern around mefloquine is the recognition of what has happened in the past and the illnesses that have come from it, which very well might be a different dynamic. Now we know the use of it has gone down significantly over the last 10 years to 5%. I'm sensing from what you're saying they have the option as to which anti-malarial drug they choose.

[Col Rakesh Jetly]

That's right.

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

When did that start happening?

[Col Rakesh Jetly]

I don't know exactly. I know what the current policies are.

In my day, I didn't have a choice, I don't think. I was a doctor, and this is what we were taking as an anti-malarial. It was before the Internet. It was before lots of things. It was not as if you could.... That's the medication we took because of where we were going. We were going to Rwanda. A few people had adverse reactions, and they were switched to other medications.

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

Why wasn't the lieutenant general allowed to change when he was—

[Col Rakesh Jetly]

I have no idea. I didn't ask him.

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

These are the questions that make you say, “What?”

[Col Rakesh Jetly]

I was there, and I don't know. I don't know who he asked. I don't know what he said. Certainly we had a few young soldiers in Petawawa prior to going and a few in theatre who were having difficulty tolerating it, and we switched them to the other agent. It wasn't like “you will take it no matter what.” It wasn't that. I didn't sit down with a physician who said, “You're going into a malaria-infested zone. These are the choices. What are you going to take?” which is our current policy.

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

Okay, great.

[Col Rakesh Jetly]

We didn't do it then. I don't know why we didn't do it then, because I wasn't the decision-maker; I was the patient.

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

Okay, thanks. I appreciate that.

We're responsible, here in committee, for discussing issues with regard to veterans. It seems as though the mandate here is for the armed forces and veterans, but I'm hearing there's not a lot of follow-through on the veterans side.

[Col Rakesh Jetly]

For what? Sorry, I missed the—

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

I mean in your studies and in what you're dealing with right now.

[Col Rakesh Jetly]

With regard to the studies, part of why we're at the Royal, at the Institute of Mental Health Research, is that there's an OSI clinic there. We're doing studies on neurofeedback, and the EEGs, the psychiatric electroencephalography evaluation registry, PEER, to predict antidepressant use. We're going to be recruiting subjects from our military clinics and from the Veterans Affairs clinics.

The magnetoencephalography, MEG research we did, the neuroimaging studies we've done so far in Toronto and London, have always looked at veterans. We're looking at combat veterans, people who have been exposed to combat, from both Veterans Affairs and the military.

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

As far as CAF, DND, and Veterans working together goes, part of the challenge was to implement solutions to provide timely access for psychological and psychiatric assessments. That's something we hear a lot about on this committee too. As veterans, they're having trouble getting those assessments done. That's obviously not everyone, but there's a cohort.