Thank you very much, Mr. Chair.
My name is Dr. Remington Nevin. I'm a former U.S. Army physician and preventive medicine officer, trained in epidemiology and drug safety at Johns Hopkins. During my 10-year active duty military career, I conducted research and published extensively on various topics in military medicine, including mental health and malaria.
I now serve as executive and medical director of the Quinism Foundation, a charitable organization that supports research and education on the adverse effects of the class of anti-malarial drugs known as quinolines, which include the drug mefloquine or Lariam. For many decades in western militaries it was widely used to prevent malaria.
Malaria is, of course, a mosquito-borne disease that can infect military personnel deployed to certain tropical areas, particularly in Africa and the Middle East, where many Canadian veterans have served in recent decades.
It is this issue that I wish to speak to today, the prevention of malaria and the use of anti-malarial drugs in military women—particularly those of child-bearing age. This poses unique challenges, which, in my opinion, have not yet been adequately addressed by policy-makers.
Most of my testimony today is drawn from my chapter in the book Women at War, which discusses these issues in greater detail and contains references for many of the statements I make.
The primary point I make in this chapter, and which I wish to make to the committee today, is that the widespread deployment of women of child-bearing age calls into question western militaries' traditional one-size-fits-all policies for the prevention of malaria.
For historical reasons, most preventive anti-malarial drugs were tested predominantly among men, and therefore in many cases direct human safety and reproductive hazard data are not available to inform their rational use in women.
For example, the Canadian product monograph for atovaquone-proguanil, a popular anti-malarial drug marketed as Malarone, notes that “there are no studies in pregnant women”, and that the safety of the drug combination in pregnancy “has not been established”. Likewise, the Canadian product monograph for doxycycline, another popular anti-malarial drug, warns that it “should not be administered to pregnant women”.
These warnings are particularly relevant in that U.S. military experience has shown that women of child-bearing age are at high risk of pregnancy during deployments, where the use of these or other drugs has typically been mandatory.
For example, while in Afghanistan I and a colleague, Jen Caci, found that in an eight-month period in 2007, there were 49 pregnancies identified among 3,298 U.S. military women. That's equivalent to a rate of pregnancy of 22.3 per 1,000 women-years or over 2% of deployed women per year. For various operational and personal reasons, many of these pregnancies were not diagnosed until well into the first trimester and occasionally well beyond that.
If the Canadian experience is similar, this means that among Canadian military women, some degree of unintentional and potentially prolonged fetal exposure to anti-malarial drugs and other preventive measures, such as insect repellants, with unknown reproductive toxicity will have occurred. In many cases, such potentially toxic exposure will have occurred as a direct result of traditional one-size-fits-all policies that mandate the use of these measures under command direction.
The deployment of large numbers of women of reproductive age and the risk of pregnancy that accompanies these deployments provide an opportunity for western militaries to re-examine previous one-size-fits-all malaria-prevention policies and to consider adoption of malaria-prevention strategies that are customized to the individual.
As I describe in my book chapter, in many cases these can include a transition away from mandatory or command-directed use of anti-malarials and towards an emphasis on mosquito-avoidance measures. Such customized measures can reduce the risks potentially posed to the developing fetus while also reducing the risk that these measures may pose to the women service members themselves, such as we have seen, for example, with the mandatory or command-directed use of mefloquine.
Mr. Chair, thank you very much for the opportunity to address the committee on these issues. I'd be happy to answer any questions.