Brian Stanley (Laois, Sinn Fein) | Oireachtas source

I welcome the opportunity to speak on this very important issue and commend Deputy Aengus Ó Snodaigh and other Members who have raised the issue. There are many members of the Defence Forces living in my constituency of Laois-Offaly, particularly in Monasterevin. Many issues are faced by Defence Forces personnel in seeking access to negotiate terms and to address issues when they leave. I have come across various cases, of which the question of Lariam is a very serious one. I acknowledge the presence in the Gallery of members of the Defence Forces and their families, especially those from my constituency who have lobbied me on this matter, which I have raised with the Minister of State many times in the past. These people have risked life and limb to perform peacekeeping and life-saving duties overseas on behalf of the State and the United Nations. We should recognise that and treat them properly.

Ireland is one of the few states which continues to issue Lariam to military personnel. It has been estimated that over 7,000 Defence Forces personnel have received it. Major side effects and consequences are associated with the drug and these must be recognised. People in my constituency who have been pursuing this matter diligently have been affected by it. As with many things, the Government is behind the curve. I have heard the Minister of State say on many occasions that he is keen to be responsible for defence. He has expressed his gratitude to the Defence Forces. I do not doubt any of that, but there is a legacy and a prevention issue to be dealt with here. The legacy involves those who are suffering but we must also consider those who will be going overseas in future.

The side effects of Lariam include psychotic behaviour and, in particular, suicidal tendencies. The RTE investigation examined 28 suicides within the Defence Forces, 11 of which involved people who had taken Lariam. Of those, four had taken their lives within a year of returning from overseas duty. We have a high rate of suicide in the State, but that is abnormal and stands out. Studies have been conducted which found that those to whom the drug had been administered were at up to five times greater risk of suicide. A public inquiry in Britain recommended that the drug be used only as a last resort. In Britain, 1,000 armed forces personnel required psychiatric treatment as a result of the effects of the drug. The Defence Forces have received no fewer than 51 claims relating to Lariam.

The Irish Medicines Board first highlighted the risk of neuropsychiatric side effects in its drugs newsletter as far back as May 1996 but 21 years later we are still discussing Lariam. In the USA, for many years it has only been issued as a last resort. The UK's National Health Service recommends that civilians travelling overseas to sub-Saharan Africa or Latin America take alternatives to Lariam. Unbelievably, the Department of Defence has failed to comply with UN guidelines on the drug. Those guidelines set out the dangers of Lariam. Despite the evidence, our standing as one of the few military forces which still uses the drug, the potential side effects and the direct psychiatric and suicidal consequences to which the drug is linked, the Government continues, appallingly, to have the drug administered to Irish citizens performing a vital and honourable role on behalf of the State and the United Nations. That is the situation in respect of a drug which has been withdrawn from sale to the general public. It can be given to thousands of military personnel serving overseas while we turn a blind eye to the horrific potential consequences. That speaks volumes.

We should not put any citizen of the State at risk like this. The risks are serious and we have seen the consequences. I have met constituents who have been affected and Deputies Ó Snodaigh, Crowe and others have highlighted the issue. We should be taking the evidence on board and seeking the alternatives which exist to this potentially destructive drug. We must also consider generally the way we treat and support Defence Forces members who have suffered as a result of the administering of the drug. We must consider the treatment of current and former personnel who received Lariam and we must consider a public inquiry into the use and effects of the drug. We have a problem and we need to fix it. I ask the Government to listen to the evidence and examine the matter in a serious way. We have the reasons. Officials and senior military personnel will provide the Minister of State with plenty of reasons to continue doing this but I ask him to take a cold look at it himself. He should put to one side whatever departmental officials are telling him, cut straight to the chase and stop this practice. We are dealing with people's lives and it is time to put a stop to it.

I am delighted to address this issue and the Private Members' motion before the House tonight. Like Deputy Ó Snodaigh, I welcome the members of the Lariam action group who are here tonight. I have met this group of individuals previously.

While I appreciate that there are concerns with the prescribing of Lariam and that these concerns should be discussed, I will state at the outset that, as a High Court case is due to commence next week, I am restricted in what I can say on the record of the House. A total of 55 claims have been received and the first case is due for hearing next Tuesday in the High Court. There are elements of the motion that are problematic, particularly as they seek to draw out the defence that will be put forward in the High Court during the forthcoming case. As such, I am constrained in what I can say and there is a need to ensure that anything said in the House does not prejudice either party’s right to a fair hearing. I am mindful of not encroaching on the court's role in considering these matters. Members need to be very mindful of the separation of powers and the process in which the courts are already involved. This House should exercise caution before debating matters that are central to an imminent court case.

Let me make it very clear to the House that the health, well-being and welfare of the men and women of Óglaigh na hÉireann are high priorities for me, as Minister of State, the Defence Forces and the Department of Defence. The motion before us asks the House to direct doctors as to what medications to prescribe to members of the Defence Forces. Fundamentally, this is a medical matter that should be decided by qualified medical professionals and not politicians. In the Defence Forces, these are decisions for highly-qualified medical officers, having regard to the specific circumstances of missions and the individual members of the Defence Forces.

Deputy Ó Snodaigh has raised it, but let me be clear that cost is not an issue when deciding on what medications to prescribe to members of the Defence Forces. There are three anti-malarial drugs in use in the Defence Forces, namely, Lariam, or mefloquine, Malarone and doxycycline. The selection by a medical officer of the most appropriate drug for use is complex and dependent upon a number of factors. All of these anti-malarial drugs have contraindications and side effects. The World Health Organization, WHO, recognises this. In its International Travel and Health Handbook, it provides for a range of anti-malarials which include mefloquine. The WHO handbook notes that there are specific contraindications and possible side effects for all anti-malarial drugs.

It is the policy of the Defence Forces that individuals are screened by medical officers who will consider a number of things, including, for example, the medical profile of the individual and his or her suitability to take a particular medication, duration of travel, operational profile of the mission, dosing regimen and resistance in the region to particular drugs. It is wholly inappropriate that any Government would be called upon to instruct the military authorities to overrule the advice of medical professionals on what anti-malarial medications should be used in the Defence Forces. This is not a political decision; it is a medical decision. We should be very cautious about instructing doctors on what medications to prescribe. Patient safety and care is best left to the medical experts.

We are all aware that malaria is serious and can be fatal. The reason the Defence Forces prescribes malaria chemoprophylaxis in the first instance is to protect its personnel. In all the years of Defence Forces overseas service in areas where malaria is present, not one member has died from malaria. The WHO’s World Malaria Report 2016 indicates that there were 212 million new cases of malaria worldwide in 2015, with an estimated 429,000 malaria deaths. It is a serious threat to any military force operating in an area where the disease is prevalent.

I have indicated time and again that significant precautions are taken by Defence Forces medical officers in assessing the medical suitability of members of our Defence Forces to take any of the anti-malarial medications. In terms of the three anti-malarial drugs in use in the Defence Forces, I am advised there are specific reasons as to why Malarone and doxycycline are not prescribed for typical deployments in sub-Saharan Africa.

Doxycycline has to be taken in the absence of dairy products for maximum effect. It can cause troublesome, mainly gastrointestinal, side effects and it can also produce sun-sensitivity skin rashes in some individuals. This is particularly significant when used in very sunny climates. For these reasons, it is not generally prescribed for first line use by the Defence Forces in sub-Saharan Africa. Up to September 2012, Malarone was licensed for up to 28 days. This was removed in September 2012. However, I am advised by military authorities that there is limited evidence as to the safety and effectiveness of Malarone usage for longer periods. On this basis, the Defence Forces' medical policy to use Malarone up to the 27-day limit remains unchanged.

As doxycycline and Malarone have to be taken daily, there is an increased risk of missing a dose on operational deployments. Lariam has the advantage of being taken weekly and, on operational deployments, this reduces the risk of a missed dose exposing the individual to contracting malaria. I am informed that these are among the reasons why Lariam - as opposed to the alternatives - is usually prescribed to members of the Defence Forces on certain operational deployments in areas where the predominant species of malaria is plasmodium falciparum. In all cases, the primary focus is to protect personnel to the greatest extent possible from contracting malaria.

The medical procedures involved in assessing personnel before deployment are designed to ensure that a person who may be vulnerable to depression or other mental health issues is not prescribed Lariam. In general, where the Defence Forces' medical assessment is that Lariam is required to mitigate the risk of contracting malaria, those individuals for whom Lariam is contraindicated or not tolerated are generally not deployed. However, I am advised that in such circumstances there are occasions when alternative malaria chemoprophylaxis agents are prescribed. This can relate to whether the deployment of an individual is critical for the mission, where an individual has to deploy without sufficient lead time to take Lariam, or where an individual who is already deployed subsequently develops a sensitivity to Lariam.

A working group is currently examining issues arising in respect of the use of Lariam. In its earlier work in 2013, the group investigated all the various issues surrounding the use of Lariam and obtained advice from leading medical experts, both national and international. Those experts concurred with the practices followed by the Defence Forces in prescribing Lariam. The group is examining developments in the context of the Defence Forces' use of malaria chemoprophylaxis, with particular focus on updated patient safety information, changes to summary product characteristics, changes in product licensing and authorisation, identification of any new anti-malarial medications on the market and national and international expert advices on the use of malaria chemoprophylaxis and its usage by other armed forces.

Reference has been made to Dr. Croft and retired US Army major, Dr. Remington Nevin. Both accepted an invitation and made submissions to the second report of the working group. The group is continuing to engage with national and international experts and met again this morning. I anticipate receiving its report shortly. I understand that the working group is considering options to formalise the provision of ongoing external expert medical advice to the Defence Forces regarding a range of medical matters, including malaria chemoprophylaxis. I assure the House that when I have received the group’s report I will carefully consider its recommendations.

I also point out that there is a range of services, both medical and non-medical, available to Defence Forces personnel. These include access to Defence Forces medical officers, psychiatric, psychological, social work and personnel support services. A strictly confidential 24-hour help line, manned by trained counsellors, is also available to Defence Forces personnel.

For close to 60 years, our Defence Forces have played a vital role as peacekeepers all over the world, in Europe, Africa and the Middle East. At present, Ireland is contributing 657 Defence Forces personnel to ten different missions throughout the world, reflecting the Government’s continued commitment to our responsibilities in the area of international peace and security.

In conclusion, the Defence Forces have brought great honour on Ireland through their participation in peace support operations and have never hesitated to deploy into some of the world’s most dangerous conflict zones. In this regard, we should recall the 86 members of the Permanent Defence Force who have paid the ultimate price in the cause of peace. Our thoughts and prayers are with those peacekeepers and their families.

See this speech in context