Lariam

– in Westminster Hall at 3:15 pm on 27th October 2016.

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[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.]

Photo of Madeleine Moon Madeleine Moon Chair, Defence Sub-Committee 3:18 pm, 27th October 2016

I beg to move,

That this House
has considered the 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.

Before I turn to the overview of the report and the conclusions of the Select Committee on Defence, I want to put on record our thanks to those who gave us the impetus to investigate the issue and contributed their knowledge and their time. I apologise if I leave anyone out. Our thanks go to Trixie Foster and the retired Colonel Andrew Marriott for their persistence in raising the issue and co-ordinating a detailed submission; to defence correspondents who took the matter up; and to Forces TV whose work brought in more evidence. I thank the Library for its research and our Clerks, who do a magnificent job, as well as the witnesses who appeared at our three evidence sessions, including from the drug’s manufacturer, Roche.

I would also like to put on record my personal thanks to the Committee for agreeing to pursue the issue for the sake of the approximately 25% to 35% of personnel who have taken Lariam who have been directly affected. The Committee was determined to ensure that the Ministry of Defence would examine the damage to lives and the failure of the duty of care, and to make the necessary recommendations to protect our armed forces personnel in the future.

Lariam is one of several antimalarial drugs that the MOD uses to protect military personnel against malaria. None of the alternatives is without its problems, but Lariam has been the subject of concern for a long time. The inquiry set out to establish a clear picture of the impact of its use in the UK armed forces. I think it is fair to say that the Committee was shocked and surprised by what we found. I will leave others to go into details, as it is my role to give an overview of our principal conclusions and recommendations.

From the evidence we received from individuals and the statistics that the MOD provided, we were shocked that Lariam is still being used so often despite the well-known problems. We were told by the drug’s manufacturer that the MOD accounts for one fifth of all its UK sales. At a minimum, 17,368 personnel were prescribed the drug between 2007 and 2015. There may well be more, but one of our findings was the haphazard nature of MOD medical record keeping. Note to the Minister: it was particularly unhelpful when the MOD published its first 10-page statistical bulletin on Lariam on the day we took evidence from the Minister.

The MOD receives advice from the Advisory Committee on Malarial Prevention alongside the advice from the manufacturer. Roche is clear in its guidance that every individual who is prescribed Lariam should undergo an assessment with a medical professional to identify any contra-indications that might make them more susceptible to side effects. We questioned whether the ACMP’s advice was appropriate. It was clear to us that the general advice that it offered was not tailored to the specific needs and circumstances of the military. It fell short and put military personnel at risk. We concluded that the MOD should work with the ACMP to develop specific guidelines, similar to the US so-called “Yellow Book”.

Photo of Douglas Chapman Douglas Chapman Scottish National Party, Dunfermline and West Fife

Is the hon. Lady now confident that the MOD will be able to deliver on the duty of care and the commitment to proper prescribing of Lariam, especially when a large number of troops are leaving at the same time?

Photo of Madeleine Moon Madeleine Moon Chair, Defence Sub-Committee

If I am perfectly honest, no. I think that the medical care that is offered continues to fall short, but I hope that the Committee will be able to address the issue again in future and ask for further updates. Of course, we have the opportunity to hear from the Minister today what further progress has been made.

Alongside our findings about the ACMP, we looked at whether Lariam was appropriate to where personnel were sent and the work that they do. The Minister and the Surgeon General told us that geographical location was a consideration in prescribing Lariam. By contrast, other witnesses made it clear that there is nowhere where Lariam should be the preferred drug, particularly given that there is increasing resistance to it and there are alternatives available. Geography aside, and linked to our earlier concerns about the ACMP advice, we sought to clarify whether Lariam, given the known side effects, was appropriate at all in a military setting. A military deployment is a world away from a tourist sightseeing or sitting by a pool. The physical and mental strain of being deployed in stressful situations does not need to be exacerbated by the severe side effects that Lariam can induce.

Dr Nevin gave evidence of an alarming potential negative impact on military performance and operations. There were cases of service personnel experiencing

“episodes of panic resulting in abnormal behaviour” and incidents of servicemen becoming confused and being found “wandering aimlessly”. There were incidents of tension and anger, episodes of severe mental and physical exhaustion and nausea, lapses of concentration and episodes of short-term memory loss, ill temper, dangerous driving, confusion and suicide ideation. That is a grim picture of medically induced problems for military personnel on deployment.

We explored whether other nations gave Lariam to their armed forces. Our research uncovered a mixed picture, but a tendency towards either no longer using Lariam at all or using it only as a drug of last resort. That all added weight to our recommendation that greater clarity is needed in determining when to use Lariam, and that attention should be paid to whether it is appropriate for military personnel.

At the heart of our inquiry was the question whether the MOD was fulfilling its duty of care by following the clear guidance on prescribing Lariam. Did every individual undergo the Roche-required individual medical assessment prior to deployment? Was it realistic to think that the MOD could ensure that that happened, particularly for a large-scale, short-notice deployment? Alarmingly, there was evidence that individual assessments were not happening. Lariam was included in pre-deployment kit; it was handed out on parade; or the MOD relied on an assessment of medical records only for prescription. We felt that that was a fundamental failure in duty of care. We concluded that, aside from the need to consider the practicalities of arranging assessments, prescribing Lariam should only ever be a last resort bounded by strict conditions. Linked to that, we uncovered concerns about non-reporting of contra-indications; military personnel appeared unwilling to admit to conditions such as a previous history of depression, because of fear of a negative impact on their career. That underlines even further the need for individual assessments.

Several witnesses reported that personnel were so concerned by the reputation of Lariam that they discarded their medication and were potentially left with no antimalarial protection at all. That came even from the very top. I believe Lord Dannatt has announced that he refused to take Lariam and would throw it away. We were deeply disturbed by that and recommended that the MOD should monitor compliance rates.

Photo of Bob Stewart Bob Stewart Conservative, Beckenham

I recall that evidence that came to us, as hearsay, from Lord Dannatt. It really shocks me that he was Chief of the General Staff and felt that way and did not take action. I think that the Committee felt that too.

Photo of Madeleine Moon Madeleine Moon Chair, Defence Sub-Committee

We most certainly did; but that also shows the inertia in the Ministry of Defence. We heard from many personnel—either individually or as a Committee—at different ranks within the MOD. The matter was not something that was not known about, but it was not being tackled or recognised as a major problem for serving personnel.

Finally, and most tragically, we heard from many individuals who suffered severe long-term effects from taking Lariam. Long after leaving the military, they are still suffering such things as mental trauma, vivid dreams and suicide ideation. That is totally unacceptable. We sought to establish what support was on offer for them from the MOD as it became clear that arrangements were somewhat fragmented. We recommended the establishment of a single point of contact, which we felt was particularly important for veterans, some of whom have experienced mental health problems for years.

Having seen what happened in the previous debate, when the vice-chair of the Committee could not be called to speak owing to time restrictions, I shall now leave it to my colleagues to expand further on the report and evidence. We look forward to hearing from the Minister that further progress has been made.

Photo of Johnny Mercer Johnny Mercer Chair, Defence Sub-Committee 3:28 pm, 27th October 2016

I, too, want to thank the Defence Committee Clerks, who did a terrific job. We were presented with a wide range of evidence, some of which was reasonably scientific, and we certainly needed their help. I also pay tribute to our many witnesses, one of whom flew in from America to give us evidence.

The report has been an important one for the Committee. In the first 18 months following the 2015 general election we have produced three reports on the duty of care and how we look after people. It is an interesting time in politics, and there are diverse views on defence on either side of the party divide and in the SNP; that is great, but we have a duty to hold the Government to account. That is where Select Committees can come into their own, and we have had some success. The report speaks to the soft side of looking after people and why it is important.

Having served and so on, I know that the interesting side of the military is going on operations and all the things that come with that—shiny stuff, bombs and all the rest of it—but what we fail to get in this country is the importance to combat power of looking after people. I certainly would not hold the United States up as a bastion of getting everything right, but we have seen its forces go through a process so that they understand the whole force concept. They do not just talk about it doctrinally or write about it at staff college. They actually impose a whole force concept whereby looking after families, housing, accommodation, health, wellbeing and so on contributes to fighting power. The US has seen those rewards. We are slow to that game, but we are beginning to get there and we are making real strides, particularly under the current Minister.

In the challenging time we are going through with Brexit, which absolutely presents opportunities as well, it is important that we do not drop the ball on defence issues. As everyone will recognise, we have come out of a particularly tense time on operations. We must maintain our focus, as my right hon. Friend the Minister for the Armed Forces alluded to in the previous debate. People read and watch what happens in this place, and it means something to them, so I am pleased that we are having this debate.

Lariam can be quite a complex issue, but it comes down to one clear thing. There is a drug that is clearly very effective at fighting malaria, which is a killer—we should not lose sight of the fact that malaria still kills a lot of people worldwide—but any manufacturer will say that the drug should be used within the guidelines. Unfortunately, for one reason or another, we did not use it within those guidelines, and people were affected.

The matter can be viewed as being a bit niche. When I first brought it to the attention of the Ministry of Defence in August last year, I was treated as though it were a personal campaign of mine. I have never taken the stuff, so I have never experienced any of the effects at all, but the issue is not niche to those who have been affected. We are now doing so much better in this place when it comes to the problems caused by Lariam, as we are on other mental health matters. However, it is simply not good enough to understand it just because it happens to us, our family or someone close to us. We have to take these things seriously, and we must take responsibility.

Photo of Douglas Chapman Douglas Chapman Scottish National Party, Dunfermline and West Fife

The hon. and gallant Gentleman has been identified as being closer to the issue than most. Do his former colleagues in the services believe that things have improved or changed? Is there any evidence of more support being given to our armed forces who have been subjected to the drug over many years, and are there signs of improvement in the support they get?

Photo of Johnny Mercer Johnny Mercer Chair, Defence Sub-Committee

It would be hard for me to say, at the moment, whether there has been a shift. From the information I have been receiving, I understand that work has been done and it will take a little while to get the granular picture of that support. We have been given assurances that the report has changed things for people who are suffering.

We have to be mature and accept that, as an employer and a Government, we have asked young men and women to take medication to protect them from a disease in areas where we are asking them to operate, and we have not done so correctly. I welcome the fact that the report realises that. It is not in keeping with how we normally look after people. I know that, having served, I have come to this place on a bit of a mission, and that I get slightly carried away, as I did the other night, about how we look after people. However, one of the strengths of the military, including the Army, is that we do look after people. That pastoral care very much contributes to what we do, but the way in which we have looked after those who have taken this drug has been out of keeping with that.

Photo of Bob Stewart Bob Stewart Conservative, Beckenham

I thank my very good friend for giving way. I am slightly concerned by the third condition for prescribing Lariam, whereby the danger of the drug is explained to the soldier, sailor, airman or airwoman, and then the decision is down to them. In my experience, a lot of soldiers will say, “For goodness’ sake, tell me whether I should take it or not. Why do you give me that decision?” That condition worries me, because I think that most soldiers will say, “You tell me what I should take. I am not the judge of that.”

Photo of Johnny Mercer Johnny Mercer Chair, Defence Sub-Committee

I thank my hon. Friend, loosely speaking, for raising that point. He gets to the crux of the problem. Essentially in the military, we go on medical advice. None of us are scientists or doctors. If we get into the real detail of the issue, it is on that point that we get to the nub of what has gone wrong.

Photo of Madeleine Moon Madeleine Moon Chair, Defence Sub-Committee

Does the hon. Gentleman agree that the problem was that there was no medical advice? Often, a sergeant major would just walk down the ranks, saying, “Take these.” There was no assessment—nothing. It was just, “This is what we have in the stores. You take it.” There were no warnings about the side effects or about reporting them. That was, and remains, the failure.

Photo of Johnny Mercer Johnny Mercer Chair, Defence Sub-Committee

I absolutely agree that the single point of failure was that we had a drug that, like any drug—even paracetamol or Anadin—should be used within the guidelines set down by the manufacturer, but instead of people being given it carefully, in a medical fashion, with individual risk assessments as stipulated by Roche, Lariam was just handed out on parade. Clearly, that is not the way to do business. The hon. Lady is right. I am glad that we have identified that practice, and I believe that we have put a stop to it. That is a good thing to have come out of the report.

We now need to ensure that we look after those who come forward. There are conversations about compensation and things like that—I understand that that is the way of the world—but that is never the intent behind inquiries such as this. I am interested in looking after those who are going through the process. We must get those who come forward some sort of treatment. We must provide some point of contact that is not just known by me, other MPs and those within Main Building. Everybody should know where they can go to get help if they feel they have been affected, and we need to show them a clear pathway.

Ultimately, we need to pay people an interest and accept that something has gone wrong. There is a slight issue within the Department—I know that everybody, including the Minister, knows this—with accepting evidence of a problem. If I have seen that in my experience as a lowly Member of Parliament, I can only imagine what it is like for families who have an issue with the Ministry of Defence to come forward. I bring that point to people’s attention and ask that we never ignore evidence of problems. We all know what soldiers are like. They are fantastic people, although if they are not moaning, something is not right, but we need to be slightly smarter and understand what they are saying so that we can identify problems before they become as big a problem as Lariam.

Photo of Ruth Smeeth Ruth Smeeth Labour, Stoke-on-Trent North

I am loth to interrupt the hon. Gentleman when he is in such impressive flow, but I would suggest that the chain of command is a problem. Although soldiers may moan to one another—the hon. Gentleman will have more experience of that than I do—they are unlikely, at any point, to want to challenge. When soldiers are brave enough to say that there is a problem, that should be our priority and we should listen to them.

Photo of Johnny Mercer Johnny Mercer Chair, Defence Sub-Committee

The hon. Lady is right. That is a generic function of leadership, not one that is particular to this cause. Having that intimate relationship with our soldiers, or with those under our command, is something we work hard on at a junior level. At a senior level, it is desired. Whether the time is taken to do that is another matter. Across the military, we need to foster an environment where it is okay for a conversation to go both ways so that we can get on top of such problems.

I know that more Members want to speak, so I will finish soon. We need to change our view on having a softer side in the Ministry of Defence and understand how important it is to look after people. Whether we reconfigure what we do, or look into having a Minister for defence people or whatever as a No. 2 in the MOD, we need to bump that change up the priority list. I thank the Defence Committee and its Chair for letting us look into the issue. People talk about Parliament being so remote—that essentially, we just turn oxygen into carbon dioxide and no one really cares—but I hope that the people who have been affected by the issue see that Parliament does work for them and can take some comfort from that.

Photo of Jeremy Lefroy Jeremy Lefroy Conservative, Stafford 3:40 pm, 27th October 2016

It is a great privilege to speak under your chairmanship, Mr Rosindell. I congratulate the Defence Committee, under the excellent chairmanship of my right hon. Friend Dr Lewis, and all previous speakers in this debate.

I declare an interest as chair of the all-party parliamentary group on malaria and neglected tropical diseases and as a trustee of the Liverpool School of Tropical Medicine. I have a large MOD base in my constituency, MOD Stafford, which has three signals regiments and the RAF’s tactical supply wing. Many members of those units spend quite a lot of time on deployment in countries where malaria is a problem.

Malaria, as my hon. Friend Johnny Mercer said, is a killer. It used to kill well over 1 million people a year, but thankfully that figure is now down to 438,000 a year, according to the World Health Organisation in 2015. I hope the figure is still falling, but it is an awful lot of people. I have had friends die from malaria, which is a serious disease.

It is absolutely right that the Ministry of Defence should take every precaution to protect its personnel from the depredations of malaria, but the question, of course, is how to do it. I had experience of Lariam when I lived in a tropical country. I took it when I was diagnosed with malaria—I took it not as a prophylactic but as a curative—and they were four of the worst days of my life, and not because of the malaria. Lariam produces extraordinary dreams that leave those who take it completely debilitated. The next time I had malaria—I have had malaria four times—I took a different drug, artemether, and the experience was quite different. Within 12 hours I was back on my feet, back at work and able to continue. The side effects were almost zero.

We are talking about Lariam as prophylaxis, but several alternatives are mentioned in the report. There is Malarone, which for many years was quite expensive, but it is a lot cheaper now that it is off patent—that is the one I use whenever I go to tropical countries. There is doxycycline, which is effective and cheap, and of course chloroquine and proguanil, which have been used for decades. Those two drugs have some side effects, particularly proguanil, which can cause mouth ulcers if taken over an extended period—proguanil is also an ingredient of Malarone.

On the curative side there is Lariam, but artemisinin-based combination therapies are also incredibly effective and are the recommended curative drugs for malaria across the world—I will talk about those in my conclusion.

The Committee’s recommendations for using Lariam are spot on. First, the MOD should find out whether service personnel are unable to tolerate alternatives. Secondly, individual risk assessments should be conducted and, thirdly, the patient should be aware of alternatives. I am delighted that the Committee has come up with those recommendations, which are all absolutely right, but they need to be put into effect. I am delighted to hear that the Ministry of Defence has taken the report seriously.

I finish by issuing a warning. We think that we have come a long way with both prophylactic and curative drugs against malaria, and that is indeed the case. All the research funding over the past decade and a half has partially resulted in halving the number of deaths, although a substantial part of that is also due to the use of mosquito nets. Has the Committee looked at how many service personnel are provided with insecticide-treated mosquito nets? A recent study by Oxford University found that almost two thirds of the reduction in deaths from malaria since 2000 is the result of insecticide-treated bed nets, not the improved drugs.

Be that as it may, it is vital that research into improved drugs continues because, unfortunately, we are beginning to see resistance to the artemisinin-based combination therapies—ACTs are the best drugs available at the moment—in south-east Asia, particularly on the Myanmar-Thai border. The worry is that resistance to all the previous effective antimalarials, first chloroquine and then sulfadoxine-pyrimethamine, started in that same area. The fact that resistance to ACTs is starting there gives us great cause for concern. The Department for International Development is putting a lot of effort into research on that subject, which I welcome, but it is important that we continue to focus research on antimalarials both as prophylaxis and as curative.

I am grateful for the opportunity to speak in this debate, and I thank my hon. and right hon. Friends on the Defence Committee for their excellent work, which I hope results in better treatment for our servicemen and women across the world.

Photo of Julian Lewis Julian Lewis Chair, Defence Committee 3:46 pm, 27th October 2016

It is right that the first three speakers in this debate should be Mrs Moon, who has campaigned on this subject for probably the longest time; my hon. and gallant Friend 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 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 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.

Photo of Ruth Smeeth Ruth Smeeth Labour, Stoke-on-Trent North

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.

Photo of Julian Lewis Julian Lewis Chair, Defence Committee

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.

Photo of Jeremy Lefroy Jeremy Lefroy Conservative, Stafford

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.

Photo of Julian Lewis Julian Lewis Chair, Defence Committee

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.

Several hon. Members:

rose—

Photo of Andrew Rosindell Andrew Rosindell Conservative, Romford

Order. May I ask for brevity in the remaining speeches? I shall call the shadow Minister to speak next, because he has to leave a little early; I know that that is not regular, but we do not want Fabian to miss his train.

Photo of Fabian Hamilton Fabian Hamilton Shadow Minister (Foreign and Commonwealth Affairs), Shadow Minister (Defence) 4:03 pm, 27th October 2016

As always, it is a pleasure to serve under your chairmanship, Mr Rosindell. I thank Members for bearing with me; I know they will all get the chance to say their piece. I apologise to the Minister for having to leave. I have had to stand in at the last minute for my hon. Friend Wayne David, who has been taken ill, and I need to catch a particular train to get back to my party meeting this evening.

Like my friend—I hope he does not mind my calling him that—Jeremy Lefroy, with whom I served on the International Development Committee for three years, I feel a personal connection to the subject of Lariam. Unlike him I have never had malaria, but had I contracted it I would no longer be standing here, because it is fatal to patients who have no spleen—mine was removed some 20 years ago. I really feel very concerned about malarial areas. The hon. Gentleman knows how difficult it is for people who do not have a spleen to go to them because of the risks involved. Even the prophylaxes that he mentioned are not 100% effective, so even places where there is a tiny risk of contracting malaria are too dangerous. The Foreign Office advises all its asplenic personnel not to visit those areas at all. His personal experience has informed us greatly about the effects of Lariam, and the fact that he has taken it himself and knows exactly what its side effects can be has brought the issue to life for many of us.

I also pay tribute to my hon. Friend Mrs Moon, because she has pursued and pursued this. I am so glad that the Chair of the Defence Committee, Dr Lewis, and the rest of the Committee agreed that the issue of Lariam was so important and wrote this splendid and well written report with all the evidence that they accumulated. I congratulate them and their staff on it.

I feel huge sympathy with the 25% to 35% of Army personnel who have been affected by taking Lariam. My hon. Friend the Member for Bridgend mentioned that geographical location was a consideration when prescribing Lariam, and the hon. Member for Stafford underlined that with his point about the resistance that is now growing in south-east Asia. My hon. Friend the Member for Bridgend also said something very important that is contained in the report: military deployment is very different from tourism. While it is unpleasant to suffer the side effects as a tourist, it is dangerous if not worse for military personnel who suffer them on military duties.

The biggest scandal of all that has been revealed in the contributions to this debate, many from former serving personnel such as Johnny Mercer, is that there seems to have been no duty of care from the Army. 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.

Photo of Julian Lewis Julian Lewis Chair, Defence Committee

May I correct that? I did not say that five minutes was sufficient. I said that the MOD was saying that.

Photo of Fabian Hamilton Fabian Hamilton Shadow Minister (Foreign and Commonwealth Affairs), Shadow Minister (Defence)

My apologies for that. I obviously did not write my notes correctly. I am sorry if I misquoted the right hon. Gentleman.

As we discussed in the previous debate, we have a duty to ensure that people who put their lives on the line for the defence of this country, like hon. Members in this Chamber who have done so, do so in the knowledge that those who ask them to do it and who send them to dangerous places are looking after their interests.

We know that Lariam is the brand name of mefloquine and that it is used to treat malaria. It is most commonly administered as a prophylaxis, but the history of side effects, the evidence we have received and the evidence in the Defence Committee’s report make it clear that it is not necessarily the most appropriate prophylactic medication. I am glad we have made it clear that we do not blame the manufacturer, Roche, for the misuse of its drug. It is clearly an issue for the Army itself and we want the Army to get it right. That is why the Committee’s report was written in the first place. I myself have taken chloroquine and proguanil; I suffered some side effects, but nothing like those that have been recorded for Lariam.

We know that many countries’ military forces have used Lariam in the past, but that it is becoming increasingly uncommon because of its side effects. Some 17,000 British military personnel were prescribed Lariam between April 2007 and March 2015, and the reports of those side effects meant that many of them have discarded their Lariam tablets instead of using them. That makes them far more susceptible to malaria, which is extremely dangerous—as the hon. Member for Stafford said, it has killed 438,000 people in the last 12 months.

The summary of the Defence Committee report says:

“The evidence we received highlighted some severe examples of the possible side-effects of Lariam in a military setting. While they may be in the minority, we do not believe that the risk and severity of these side-effects are acceptable for our military personnel on operations overseas.”

When the Minister responds to the debate—I apologise that I will not be present to hear him—will he care to tell us about the handing out of Lariam to military personnel in future in the light of the report and the evidence contained within it?

In preparing for this debate, I sought the advice of a specialist—he has asked not to be named—who works at the London School of Hygiene & Tropical Medicine. His view was quite interesting. He made the point that Lariam is a cheaper medication than some antimalarials, and that it is very effective. That could be one reason why the MOD is maintaining its support for Lariam in the face of media controversy, the Defence Committee report and, of course, resistance from many military personnel. The specialist said that it is a good drug. He even gave it to his spouse when they went to west Africa a few years ago. He reported that she had had the most vivid and crazy dreams. Like most drugs, it is not good for some people, but it is good for others.

One thing in favour of Lariam is that it is administered once a week. Many other antimalarials are administered once a day. For someone in a military setting who is in a conflict situation, or who has been deployed in a remote area, it being a once-a-week drug will have a huge benefit for those administering it and those having to take it. A once-a-week dosage also increases the chances of compliance and of people actually taking the medication when they need to take it.

The specialist I mentioned noted that the number of tests on the effects of Lariam on Army personnel were small and were not done in an adequately controlled situation. I do not know whether my hon. Friend the Member for Bridgend would agree with that, given the evidence taken by the Select Committee, but there needs to be far more testing. There needs to be a much greater database of evidence to prove conclusively that so many people will not tolerate Lariam and that it should perhaps be replaced by other drugs, depending on geolocation and the individual assessment of military personnel.

Photo of Madeleine Moon Madeleine Moon Chair, Defence Sub-Committee

Is my hon. Friend aware that there have been episodes in which serving personnel have murdered individuals, and in which they have deliberately carried out inappropriate acts, all because they were under the influence of Lariam? That is part of the record that the Committee looked at.

Photo of Fabian Hamilton Fabian Hamilton Shadow Minister (Foreign and Commonwealth Affairs), Shadow Minister (Defence)

Yes, I was aware of that, but I am not aware of the details. I have heard anecdotal evidence, but it is important to hear about the actual cases and evidence.

I know that other Members wish to speak, and of course the Minister must respond, so I shall conclude. Paragraph 97 in the conclusion of the Defence Committee report states:

The Ministry of Defence has a duty of care to protect military personnel on operations overseas. It includes ensuring that they are adequately inoculated against disease. This will never be without the risk of detrimental side-effects, and we understand that the MoD must balance those risks against the health of our Armed Forces. However, in the case of malaria, we conclude that the MoD’s current policy has got that balance wrong.”

I hope the Minister addresses that point in his response.

Photo of Patrick Grady Patrick Grady Shadow SNP Spokesperson (International Development) 4:13 pm, 27th October 2016

It is a pleasure to serve under your chairmanship, Mr Rosindell. I shall be as brief as I can.

I have a couple of brief reflections of my own and from a constituent. I took Lariam prophylactically when I worked as a teacher in Malawi, and I certainly experienced what I later realised were its various side effects, including vivid dreams and a certain amount of paranoia. It was difficult to tell, though, because I had moved to a new context and was working in a stressful environment. It was not until some time afterwards that I started to realise that those side effects were the result of the Lariam kicking in. Mrs Moon was absolutely right to ask at the outset how much more difficult it must be for troops and service personnel, who are put into extremely pressurised situations, to try to deal with the consequences and side effects of these medicines.

I have heard from several individuals who have taken Lariam as part of their service. My colleague Feargal Dalton, a councillor for part of my area who also happens to be the husband of my hon. Friend Carol Monaghan, was a serviceman who served on Trident submarines and elsewhere. He described similar side effects which, fortunately for him, did not last after he stopped taking it. The point he made was that the drugs were prescribed and had to be taken under orders. If someone was to stop taking them, even if they were having side effects and making the person ill, they could be subject to military discipline. Many service personnel were put in a very difficult situation.

I was contacted by a constituent who was given Lariam while he was in Kenya for six weeks in the mid-’90s. Twenty years later, he continues to suffer from severe headaches and migraines, which are attributed to side effects of the drug. He has been given no compensation. He has also been told that the side effects are actually the result of post-traumatic stress disorder, but he has not been given any compensation for that either. The problems he faces are making it difficult for him to access work and, when he does, to maintain steady work. He has been told that his condition is not severe enough for him to be admitted to a treatment centre, despite his having approached various different charities. I wrote to the Secretary of State for Defence on 21 September but have not yet had a reply. I hope this debate will help to speed up the process.

There is clearly consensus in this debate. Lord Dannatt, who was quoted earlier, said:

“It is extraordinary that the MoD continues with this policy given the mounting evidence as to the harmful effects of Lariam.”

The Government have a duty of care to those who, like my constituent, have served in the armed forces. I call on the Government to implement the recommendations in the report and to provide the support needed by my constituent and many like him.

Photo of Kirsten Oswald Kirsten Oswald Shadow SNP Spokesperson (Armed Forces and Veterans) 4:16 pm, 27th October 2016

It is a pleasure to serve under your chairship, Mr Rosindell. I am aware that we are now very short of time, so I shall look for your guidance on when you want me to stop speaking so that the Minister can respond.

I thank Mrs Moon for opening the debate so thoughtfully, and the Defence Committee for its work. I endorse its recommendation that Lariam be retained for use by the Defence Medical Services, but it should be a drug of last resort, subject to the clear recommendations set out by the Committee. I would go further and suggest that those who are prescribed Lariam should be counselled about the potential side effects and the need to report them up the chain of command.

Once I had reviewed the Select Committee’s report, I was left wondering whether the level of debate and conflict on this issue was actually necessary—I shall try to return to that point at the end. I noticed from the departmental memorandum submitted to the Committee that the Ministry of Defence policy on preventing malaria is contained in a joint services leaflet called “Preventing Malaria in Military Populations”. I understand that the leaflet was made available to the Committee, but when I looked on the Government website, it was not there—it was released under a freedom of information request in 2013, so I was able to see it that way. The covering letter attached states that, in the interests of transparency, it should be published online. Had that happened and we had been able to see it, it would have been useful to a number of people. The sole reference in the leaflet to the use of Lariam and other antimalarial drugs is the statement:

“In the UK Armed Forces…policy is based on the guidelines at Footnote 1”,

which helpfully read:

British National Formulary (BNF). BMJ Group and Pharmaceutical Press Extant Version”.

As we have heard from several Members in the debate, information on the use of Lariam is sorely lacking. The only direct reference to it in the guidance was regarding its use by divers and aircrew, who are not to use it. There is considerably less information than I would have expected from a document that is described to Members of this House as the Government’s policy on the use of antimalarial drugs. It is exactly as my hon. Friend Douglas Chapman said.

Had the information been freely available, we would have seen a description of the briefing that is given to personnel receiving antimalarial drugs without an individual consultation. The only definitive items that have to be included in that consultation are dosage and frequency, and when to start and finish taking the drug. If that is the situation, advice levels clearly fall far short of what we would expect, as Dr Lewis said. There was simply no indication that Lariam should be regarded as any different from other antimalarial drugs.

Will the Minister address whether the document was published online? Will he tell us more about the advice the Government are seeking from Public Health England’s Advisory Committee on Malaria Prevention? Will he commit to a wider consultation on the version of the guidance that is currently being prepared? I also wonder whether he will commit to review the procedures for sharing and consulting on policy documents, which are so vital to the welfare of our armed services personnel, as Johnny Mercer told us.

The Government response looks too much like business as usual. The Committee’s report outlined the three stages when a risk assessment should be carried out: on completion of initial training; on being posted to a deployable role; and on receiving warning of possible deployment. Will the Minister clarify how the assessments will be made? Are they additional assessments, in which case how do we know what resources are needed to deliver them and are those resources in place?

As we heard from Jeremy Lefroy, the evidence provided by the Department in its response to the Committee reveals a significant difference in the nature of the side effects caused by Lariam and those caused by alternative drugs. We have heard significant detail about that difference today. As the right hon. Member for New Forest East said, the evidence that Lariam has such a clear link with adverse psychoactive effects suggests that the Committee’s recommendations about the use of the drug should be clearly heard by the Government, and it should simply be a drug of last resort.

Photo of Mark Lancaster Mark Lancaster The Parliamentary Under-Secretary of State for Defence 4:20 pm, 27th October 2016

It is a pleasure to serve under your chairmanship, Mr Rosindell.

We seem to have had something of a flurry of detailed questions towards the end of the debate, giving me little opportunity to address many of them in the nine minutes I have to respond to the debate. I will do my best, but at the start I simply commit to writing to any hon. Member whose question I do not manage to answer during that time.

Of course, I begin by taking this opportunity to thank the Defence Committee for its very thorough report on the use of mefloquine by service personnel, and I also thank the hon. Members who have spoken today, from the opening contribution by Mrs Moon onwards. I will address many of the points that were made as I go through, but on a specific point that she made, I absolutely regret the publication of the statistics on the day of the Committee hearing. However, she may not be aware that it is absolutely right that Ministers have no control over the collection or publication of statistics; it would be wrong if we did. So it was genuinely an unfortunate coincidence, and it would have been even worse if the statistics had been published the day afterwards.

I thank my hon. Friend Johnny Mercer for his passionate contribution, not least because every time he speaks in this House he seems to suggest that I should be promoted—so I thank him very much indeed. I also thank my hon. Friend Jeremy Lefroy, who gave an incredibly incisive personal account; it really was very powerful. Of course, I also thank my right hon. Friend Dr Lewis, who asked a number of questions, which I will endeavour to answer during my response to the debate.

We had other good contributions from the hon. Members for Leeds North East (Fabian Hamilton), who has had to leave us, for Glasgow North (Patrick Grady), and for East Renfrewshire (Kirsten Oswald). I will endeavour to address all the points that they made in due course.

The Government have considered our conclusions carefully, and I will outline the positive steps that the Ministry of Defence is taking to address the Committee’s recommendations. Before I do so, I want to nail one issue that floated around towards the end of the debate—that Lariam is somehow the MOD’s drug of first choice, and that cost is a factor in its use. According to the “British National Formulary” of March 2015, Lariam, at £14.53 for an eight-week supply, is more expensive than Paludrine/Avloclor, less expensive than Malarone but more expensive than doxycycline. So cost is not a factor, and we would never prescribe on the basis of cost alone.

Equally, mefloquine currently constitutes only 1.2% of all the antimalarial tablets held by the MOD, and in terms of doses for a six-month deployment—of course, doses for different drugs are given at different rates—it accounts for just 14% of the stock. So 86% of our stock is not Lariam. That hardly represents a reliance on Lariam or evidence that it is being used as a drug of first choice.

Photo of Madeleine Moon Madeleine Moon Chair, Defence Sub-Committee

I am delighted to hear about the low take-up of Lariam by the Ministry of Defence now. Does the Minister have the figures for what the take-up was in the past?

Photo of Mark Lancaster Mark Lancaster The Parliamentary Under-Secretary of State for Defence

Those figures give the current status, but I believe that the figures for the last eight years, which is as far as we go back, are similar. However, I am happy to write to the hon. Lady to give the exact figures. Of course, much of this debate is about how we move forward, as opposed to what we have done in the past, and I hope to demonstrate in my response over the next five and a half minutes that the steps we are taking are very positive.

It is important for me to state that we take the health and wellbeing of our personnel extremely seriously and acknowledge the duty of care to provide the best possible support to them. Malaria is a deadly disease, and we must protect our deployed personnel from it. The most effective way to do so is through the use of antimalarial drugs. However, as we have established, no antimalarial drug is 100% effective and risk-free. Indeed, all medications have the potential to cause side effects and adverse reactions in a small number of people. That is why the MOD needs to use a range of prevention drugs to protect our personnel and ensure that the treatment provided is the most effective for each individual. I should emphasise that despite tens of thousands of service personnel deploying to malaria-risk areas, no serviceman or woman has died from malaria resulting from an operational deployment since 1992, and cases of severe malaria are rare in the armed forces.

I turn to the two main recommendations of the Committee’s report. The first was that the MOD works with the Advisory Committee on Malaria Prevention to develop guidelines on mefloquine and other antimalarials, specifically regarding their use by military personnel. The MOD has always kept its malaria prevention policy under constant review, and I can confirm that a recently revised malaria prevention policy has been passed to the ACMP for its consideration.

The revised policy is based on three elements. In the first instance, at around the time when individuals complete initial training they will undergo a face-to-face consultation with a medical professional, to identify any adverse reactions to the five most commonly used antimalarial drugs. Secondly, after posting into a deployable role, armed forces personnel will undertake a generic face-to-face travel health risk assessment, again with a medical professional. Finally, once individuals are advised that they are likely to deploy, they will undertake a deployment-specific face-to-face travel health risk assessment.

The results of those assessments will be recorded in the patient’s electronic health record. Although the need for a risk assessment is not new—defence policy since 2004 has been clear on the requirement for such assessments—monitoring will now be better aided by an electronic records system. In answer to a question put by my right hon. Friend the Member for New Forest East, perhaps I can say that if the actions that he described need to be taken, in extremis, before an emergency deployment, they will be based on those three thorough, face-to-face, comprehensive interviews, as recorded in the electronic record.

On that point, I reiterate what I said when I gave evidence to the Committee. I recognise that anecdotal evidence submitted to the Committee suggests that, in a small number of cases, some people believe that their individual risk assessments did not take place in the past. I hope that the new system will prevent that situation from recurring. I encourage anyone who has concerns about the issue to come forward, in confidence, as there are established processes by which current and former members of the armed forces can be referred to medical staff to have such concerns investigated.

That leads me to the second main recommendation of the Committee’s report, namely that the MOD should establish a single point of contact for those who are worried about their experience of mefloquine. I am pleased to report that the mefloquine single point of contact has been set up and publicised widely through the chain of command, veterans’ organisations, military publications and GPs. As I sat here listening to the debate, I googled the advice about that single point of contact, and there it was on the gov.uk website. It was launched last month and is easily accessible. It is a confidential service for people to make contact by phone and email, and it is supported by other information on the Government website, as I have just said. Depending on their circumstances, individuals are directed to a range of information and services available to help them. That includes how service personnel and veterans can find out whether they have been prescribed mefloquine in the past. My right hon. Friend the Member for New Forest East has raised concerns about the quality of information being given on the helpline. I am more than happy to go and examine that, and I will write to the Committee with details as to exactly what advice is being given.

Again, I encourage anyone who is concerned about their experience of mefloquine and who has not yet gone to the single point of contact, including those who believe that their risk assessment did not take place, to contact the single point of contact or speak to their GP.

In addition to those two main recommendations, the MOD will conduct a prospective audit of returning travellers, to assess the impact of the new policy. That will be for any antimalarial drug that has been taken. The MOD will also continue to undertake post-deployment surveys, to enhance its understanding of compliance with the revised policy.

The Government informed the Committee that the MOD would undertake further research into the impact of the adverse effects of antimalarial drugs on the performance of military personnel. A research proposal is currently being considered by the MOD’s research ethics committee. The research will be in the form of a retrospective survey of soldiers deployed on exercise in Kenya who have been prescribed one of three antimalarial drugs. A questionnaire will seek information about risk assessments, individuals’ compliance with prescriptions, the incidence and prevalence of side effects of the drugs, and the impact of those side effects on functional effectiveness.

If there are any other questions, I will endeavour to write to hon. Members about them.

Question put and agreed to.

Resolved,

That this House
has considered the 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.

Sitting adjourned.