LARIAM – 27 October 2016
Relevant documents: Fourth Report from the Defence Committee of Session 2015-16, An acceptable risk? The use of Lariam for military personnel, HC 567, and the Government response, HC 648.
Dr Julian Lewis: It is right that the first three speakers in this debate should be the hon. Member for Bridgend (Mrs Moon), who has campaigned on this subject for probably the longest time; my hon. and gallant Friend the Member for Plymouth, Moor View (Johnny Mercer), who is an outstanding campaigner on behalf of anything to do with the welfare of veterans and current service personnel; and my hon. Friend the Member for Stafford (Jeremy Lefroy), whose unparalleled experience of malaria – experience of an unfortunately all too personal nature as well as professional experience – we have just listened to with great attention.
My hon. Friend the Member for Stafford asked whether the Committee had considered the question of mosquito nets impregnated with insecticide, and the answer is no. We were focused entirely on Lariam and our concern that it was being prescribed inappropriately. We said that the prescription of a drug known to have what were described as “neuro-psychiatric side effects” and to cause “vestibular disorders” without face-to-face interviews showed a lamentable weakness in the MOD’s duty of care towards service personnel. We are grateful that the Minister, who has an outstanding record of military service, made an apology to present and former service personnel when he appeared before the Committee on behalf of the MOD in relation to those who believe that they were prescribed this drug without the necessary individual risk assessments.
This is a slightly unusual case because, for once, nobody is pointing a finger of accusation at the drug manufacturer. Roche appears to have behaved responsibly in this matter from the outset. It always gave the clearest possible instructions that this particular drug, though it could be effective in some cases, could have dangerous side effects and therefore absolutely should not be prescribed without a face-to-face assessment of each individual first. It was good to receive a letter from the manufacturer, despite the Committee’s report being so critical of the drug itself and despite the adverse publicity that the drug inevitably received, stating:
“Your report has made a major contribution to highlighting the correct use of Lariam in the armed forces.”
That shows the strength of the arguments in the report and reinforces the importance of the MOD following Roche’s guidelines for use.
The hon. Member for Bridgend mentioned several of the people who gave evidence to the Committee. I would like to mention Mrs Ellen Duncan, who gave evidence on behalf of her husband, Major-General Alastair Duncan. Alastair Duncan was awarded the Distinguished Service Order while in command of the First Prince of Wales’s Own Regiment of Yorkshire, or 1 PWO. In May 1993, he took the battalion to Bosnia-Herzegovina under the UN mandate during the Balkans conflict. The Daily Telegraph described what he did in the following terms:
“The hostilities had escalated into a three-cornered fight between the Bosnian-Serbs, the Bosnian-Croats and the Muslims. In this dangerous environment, at great risk to himself, Duncan sought out the commanders of the belligerents in an attempt to broker a truce. In June, he was instrumental in the rescue of 200 Croats who had sought sanctuary from a violent attack in a monastery at Guca Gora. The citation for the award to Duncan of the DSO paid tribute to his courage, resolution and inspired leadership which, it stated, had saved many lives and had helped 1 PWO to win an outstanding reputation.”
He was subsequently awarded the CBE for his work in Sierra Leone.
Major-General Duncan suffered from post-traumatic stress as a result of all that he had seen and done, but his wife was absolutely convinced that taking Lariam destroyed his mental stability. He was sectioned many times. Our report was published on 24 May 2016, and I was truly saddened to read in the Daily Telegraph that he had died on 24 July 2016. He was a year younger than I am. It is a case of someone at the highest end of the Army whose life was wrecked by the inappropriate prescription of the drug.
I will touch briefly on a number of the Committee’s recommendations and the Government’s response. As we have heard, the Committee recommended
“a single point of contact for all current and former Service personnel who have concerns about their experience of Lariam”,
and the Government announced that that would be done. I would like an update on that, as I have heard suggestions that the advice people get when they ring the relevant number is very basic indeed, even on a par with “Go and visit your GP.” If that is all they are getting, we still have some way to go on that recommendation. We also said that people should be offered an alternative to Lariam if they are concerned about the risks, that this should be explained to them and that a box should be ticked to show that it has. I believe that that is now happening.
One part of the Government’s response was strange. They have alleged that they need to keep Lariam on the books because there are certain geographical areas where no other drug will work. The report disputed the Government’s assertion that geography was a valid factor. We therefore asked the Ministry of Defence to set out which geographical areas, if any, it believed to be resistant to each antimalarial drug it uses, and give us any accompanying evidence to support that view.
The Government’s response was:
“The MOD relies on authoritative external advice on the global distribution of antimalarial resistance.”
They provided us with a link to guidance from Public Health England. That guidance, which is 109 pages long, includes a table where areas of malaria risk are listed alongside the recommended antimalarial drug for that area. The table shows a dozen countries or areas for which only chloroquine is recommended, but by contrast, we could see no instances where Lariam was the only recommended antimalarial drug in any single area. [Interruption.] I am interested to see my hon. Friend the Member for Stafford [Jeremy Lefroy] assent.
The report questioned the feasibility of providing face-to-face individual risk assessments before prescribing Lariam in the event of a significant deployment, so we asked the MOD to set out how it would be able to do so, alongside an estimation of how much time it would take to conduct face-to-face individual risk assessments at both company and battalion level. I will not go into all the details of the MOD’s response, but I found one aspect worrying. The MOD acknowledged that if the operational imperative meant that the timing of a deployment did not allow for specific face-to-face interviews,
“an appropriately trained and regulated healthcare professional will review individual electronic health records and confirm that there are no contraindications to the recommended anti-malaria drug. It is estimated that this will take up to five minutes per individual, or approximately eight hours for a company, or approximately 50 hours for a battalion.”
Can the Minister explain – or, if not, write to us – exactly what that means? Is it predicated on the fact that people will have had a face-to-face individual assessment at an earlier stage in their career? In that case, there might be some argument for it, but if it is meant to be a substitute for individual face-to-face assessments, I am sure the Chamber will agree that that would be wholly unacceptable.
Ruth Smeeth: Is not one of the problems with Lariam that if someone has had a mental illness before, they may be more vulnerable? A lot of servicemen and women would feel uncomfortable admitting that, would be unlikely to have told anyone within their chain of command and may well not have sought guidance, so the idea that the medication could be used even with those measures is almost impossible.
Dr Lewis: That is probably the single strongest point that one could make in the course of this entire debate. Particularly in the macho military environment – I use that term in a non-sexist way – people are unlikely to disclose mental troubles in their past, meaning that either they may take a drug that is inappropriate for them or they may throw it away, rendering themselves vulnerable to contracting malaria.
Jeremy Lefroy: Did the Committee have any idea why there is such a particular emphasis on Lariam when other drugs are available, such as doxycycline or Malarone, that many of us take whenever we go to countries affected? The emphasis on Lariam seems to me extraordinary. I absolutely applaud my right hon. Friend’s point about the importance of encouraging Roche to continue its research in this area; we do not want it put off. Roche has been excellent in its clarity about what Lariam is about and what precautions need to be taken.
Dr Lewis: Other Committee members may correct me, but I have a feeling that we never quite got to the bottom of why the MOD is so fixated on that particular drug. What I am about to say is sheer speculation, but it could have something to do with the relative cost of different types of drug, or with concern about compensation claims. If the drug were given up completely, it might be easier to bring claims on that basis: “You don’t prescribe this drug at all now, so therefore you were wrong ever to have prescribed it.”
We sought to give the MOD a bit of wriggle room, for want of a better term, by saying that all we wanted it to do was designate Lariam as a drug of last resort. I do not see why it should not do that. It is obviously a drug of last resort, because the MOD accepts the fact that it should now be issued only under the most strictly defined conditions. What is that if not making it a drug of last resort? So why does the MOD not say so?
Similarly, there has been reluctance to acknowledge the experience of other countries. The MOD asserted that Lariam was
“considered by US CDC” –
the Centers for Disease Control and Prevention, which is the US equivalent of Public Health England –
“to be equally suitable (with an individual clinical assessment) as each of the other drugs”.
However, Dr Remington Nevin – one of the two doctors to whom we owe a great deal of gratitude for their consistent campaigning on this issue and for the evidence they brought to the Committee – described that as a “misinterpretation of CDC’s position”. The section entitled “Special Considerations for US Military Deployments” in chapter 8 of the CDC’s publication “Yellow Book” states:
“The military should be considered a special population with demographics, destinations, and needs that may differ from those of civilian travelers.”
In respect of the use of Lariam in other states’ armed forces, Dr Nevin argued that
“many of our Western allies have all but abandoned the use of the drug”,
and that the US and Australian military use it only for
“those rare service members who cannot tolerate…two safer and equally effective alternatives”.
That is why we made the point that Lariam should really be used only for such people, because we are not convinced that there is any geographical area where some other drug could not be used.
Dr Nevin also referred to the US Army Special Operations Command having taken the
“very wise step of banning it altogether”.
He said that the decision by the US military was made
“primarily on clinical grounds”
and was intended to
“decrease the risk of negative drug-related side-effects”.
The MOD’s response commits merely to updating the information held on the use by our allies of Lariam and other antimalarial drugs, including the extent to which Lariam is used and the circumstances in which it is supplied. It still does not appear to accept that its policy on Lariam is increasingly out of step with that of our allies.
We have made considerable progress by focusing on the terrible situation in which a drug designed for very specific issuing to very specific people after a very specific interview was doled out en masse as a routine prophylactic to our service personnel who were about to go to malaria-infested areas. That really was a scandal, and it would be another scandal if it ever happened again.
* * *
[Fabian Hamilton: ... The right hon. Member for New Forest East said that just five minutes’ assessment may be sufficient to ensure that individual Army personnel have the right prescription and are not forced to take Lariam when it is wholly inappropriate for their needs.]
Dr Lewis: May I correct that? I did not say that five minutes was sufficient. I said that the MOD was saying that.
[Fabian Hamilton: My apologies for that. I obviously did not write my notes correctly. I am sorry if I misquoted the right hon. Gentleman. ...]