Veterans Affairs Committee on April 10th, 2017

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

In my practice, a large portion were people who couldn't find a family doctor and got all of their primary care from the emergency department.

[Col Rakesh Jetly]

Yes, that's a huge problem.

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

I think there's a tremendous potential for uptake through this initiative.

[Col Rakesh Jetly]

Absolutely.

[The Chair, Liberal, Neil Ellis]

Thank you very much.

Ms. Wagantall.

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

Thank you, Chair.

Thank you very much for being here today.

I was reading the news release from December 2014 in regard to the announcement about the centre of excellence and your appointment. It indicated there are certain areas of focus that would be included, and I'll just quote it:

Conducting research on unique aspects of military and veterans mental health; Collaborating with scientific experts in academia such as through the Canadian Institute for Military and Veterans Health Research, government agencies, private sector laboratories, research consortia, and with NATO and other allies....

I was really pleased to see that. Our discussion today is about preventing suicide and treating people.

I'm sure you're aware that there's been quite a conversation around mefloquine as of late, the very clear reactions to it such as inability to sleep, hallucinations, nightmares, heightened anger issues, suicide ideations, and a number of suicides at this point can be attributed to it. Health Canada has updated the warning label and indicated that these conditions can carry on past the use as an anti-malarial drug.

In that regard, Germany, Britain, Australia, and the U.S. in the last couple of years have come to very determined statements and decisions in regard to mefloquine. It sounds like you collaborate with, and have a lot of information in regard to suicide from, our allies. Are we any closer to identifying this as a brain stem injury in Canada? There's no diagnosis and therefore no treatment, and we're still using it. Have you collaborated with NATO and our allies on this issue, and where are we at with it?

[Col Rakesh Jetly]

Within our sort of headquarters, it's more of a force health protection issue, so—

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

It's more of a...? Sorry?

[Col Rakesh Jetly]

Force health protection, sort of our preventative medicine. They're in the process, so I can't speak for.... We're in the process of revising our policies and things on that. It's exactly reaching out. It's not me doing it or my section, but our preventative medicine folks are reaching out to our allies and giving the surgeon general information. We're in the process of revising our policies, to the best of my knowledge.

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

You're not part of that conversation with regard to suicide?

[Col Rakesh Jetly]

My opinion would be asked from time to time, but really, when you're giving people treatment to prevent another illness like malaria, it becomes part of force health protection. They have expertise, and they have epidemiologists and scientists within their section.

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

Would you have an idea of a timeline on this decision coming?

[Col Rakesh Jetly]

The discussion is going on right now.

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

Okay.

[Col Rakesh Jetly]

It's a pressing issue right now, which we're working on.

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

A number of our witnesses have come forward who are still serving or have served, and they talk about the challenge with PTSD of those sudden crisis experiences that they have that we can't even imagine. It was brought up that they felt that they didn't get enough of that type of training in advance. There are some of those shows where you get to crawl amongst snakes—just things that I wouldn't do, but some people are capable of them—or even just, it was mentioned, having to crawl through pig guts—quite honestly I think was the term used—to get a sense of what you might experience. I wondered, I don't think we go to that extent when we try to prepare them—

[Col Rakesh Jetly]

You're hitting on one of the most difficult issues, historically, I think, because from speaking to many people who have developed PTSD, it's often your worst nightmare, and you don't know it's your worst nightmare necessarily.

So, clearly, let's work on sleep deprivation, let's work on getting shot at, let's work on crawling under barbed wire, let's work on people who speak a different tongue...the IED kind of scenario. But it's often something else. There's desensitization. There's training. There's stress inoculation. These have been used for many years, and the problem is PTSD has always been around. So back in the day, it was, let's go and watch animals being slaughtered, and let's do this. Around the Vietnam area that was popular. There was still an incredible amount of PTSD, and in fact, in 1980, the term PTSD was first coined to explain the phenomenon experienced by the Vietnam soldiers from the U.S. and Australia.

So, absolutely, let's stress inoculating people. Let's get them as desensitized as possible. But I still don't think that objectively exposing them to what you think is going to be stressful will help with what happens to the soul, the person with the moral injury, and the meaning of the actual trauma. We can set up all kinds of scenarios, and we should. We should exhaust people. We should wake them up in the middle of the night with flares. We should do all those kinds of things. I remember when General Leslie first brought the tanks to training, because he didn't want them to hear tanks firing for the first time once they were in Afghanistan, because we hadn't used them.

So, absolutely, I thought about what it would be like to have my best friend die, or to kill a child.

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

Absolutely.

[Col Rakesh Jetly]

We're not going to get there.

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

You're mentioning younger and younger, and I wonder about that whole training. At what point do you determine that too much would actually trigger potential PTSD—

[Col Rakesh Jetly]

There was something in the media today about some training in the eighties. I didn't read all of it, but there is a risk of harming people when you do certain types of conduct after capture and evasion training. You have to be careful about how far you take it, and not introduce illness, absolutely.

[The Chair, Liberal, Neil Ellis]

Thank you.

Ms. Lockhart.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

Thank you, Mr. Chair.

I want to go back to the mefloquine question for a second. I found a report here from the Case Reports in Psychiatry, from 2011. One of the statements says, “Prophylaxis against malaria still has benefits that frequently outweigh the risks, especially for deployed military medical personnel.” And it goes on. I know there are three drugs that we use.

Can you speak about how the transition has happened and what your feeling is on that statement?

[Col Rakesh Jetly]

I'm not a primary care physician prescribing this, but in my day, I took malaria, when I was in Rwanda, so I had a few nightmares, had a few things. For me, if I were to deploy again to Africa, I'd probably ask for mefloquine again, because I prefer the devil you know. Yes, I had a few side effects but the other medications.... Taking doxycycline for three months, six months, every day, doesn't appeal to me. There were the side effects.

So you're always balancing the risk to the individual of the medication versus the disease. Again, having been in Africa and having seen cerebral malaria, seeing people die from that, it's not a pretty sight. You want to stop malaria and then you want to give them the safest option for them to prevent the malaria, and then all of these agents are designed to kill an organism within your body, but not kill you. It's just like chemotherapy; it's this kind of idea.

Mefloquine is one of the options. Malarone is one of the options.

[Alaina Lockhart, Liberal, Fundy Royal, NB]

Mefloquine is the third-line drug. Is that correct?