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Foreign Affairs, Defence and Trade References Committee
01/09/2015
Mental health of returned Australian Defence Force personnel

McCARTHY, Mr Brian, Private capacity

McCARTHY, Mrs Lee, Private capacity

McCARTHY, Major Stuart, Private capacity

QUINN, Dr Jane Catherine, Private capacity

CHAIR: Welcome. Is there anything you would like to add about the capacity in which you appear?

Dr Quinn : I am here in a personal capacity as a survivor of a mefloquine related suicide but also in my capacity as a research neurotoxicologist investigating neurotoxic disorders.

Major McCarthy : I am a serving officer in the Australian Army, appearing in my private capacity.

Mr McCarthy : I have had a long career in education, and beyond education I was the CEO of two substantial state based not-for-profit health organisations. I am here to support Stuart and make my own case in relation to the need to bring about change in the ADF in relation to the attitudes regarding mefloquine.

Mrs McCarthy : I am here as Major Stuart McCarthy's mother but also to perhaps give you folk insights into how many mothers must feel.

CHAIR: Would one or all of you like to make a brief opening statement before we go to questions?

Major McCarthy : I will commence with a statement, and certainly it would be good if Dr Quinn were given a chance to make a statement as well. We are here to address the committee on the health impacts of the neurotoxic antimalarial drug mefloquine on ADF personnel. You may be aware that last week the Vice Chief of the Defence Force, Vice Admiral Griggs, publicly attacked my credibility for the so-called unsubstantiated claims in my original submission to this committee. If Vice Admiral Griggs was here, there are three falsehoods that I suspect he would try to tell you about his favourite suicide drug, mefloquine. The first is that this is a nonissue because so few ADF personnel are currently taking it. The second is that prophylactic use of mefloquine is perfectly safe. And the third is that the drug is not causing long-term harm. I am going to dispel each of those three falsehoods in a moment, but first I will give you some context.

As you will have read in my submission, mefloquine is one of a family of drugs—synthetic quinolones—that have been well-known for their neurotoxic properties since the 1940s. Mefloquine specifically was developed by the US military through the 1970s. The drug was initially tested on prisoners, soldiers and people in Third World countries, with the results of those trials being given to Roche as a free good. You will recall that Roche pays about 1c in the dollar in tax in this country. Mefloquine was inexplicably approved by national drug regulators in the late 1980s and the early 1990s, including the Therapeutic Goods Administration, in the absence of the necessary phase III clinical trials. Throughout the 1990s the drug caused such widespread harm that towards the end of that decade Roche wanted it withdrawn from the market. That is already on the public record.

Enter Timor-Leste and the Australian Army Malaria Institute in 2000 to 2002. The AMI has been directly involved with the development and research of this drug since at least the 1980s, in close cooperation with the US military and Roche. Vice Admiral Griggs may wish to play down the number of ADF personnel who have taken this drug with deceit about pharmaceutical records. It took me about two minutes to find mefloquine on my record from 2001, simply by asking my pharmacist. But let me explain the real issue when it comes to numbers. When the AMI conducted its unethical mefloquine clinical trials in Timor-Leste in 2000 to 2002 and cooked the books to falsely portray mefloquine as a safe drug, that safety recommendation from the ADF became the basis for the drug's continued use by many, many hundreds of thousands of coalition troops, possibly in the order of a million the world over. These men and women are our allies, and we lied to them—just as Vice Admiral Griggs is now.

Since then, this neurotoxic drug has been linked to multiple murders and multiple war crimes—for example, the murder of 16 Afghan civilians by a US soldier experiencing a psychotic episode in 2012. Then there are the countless suicides, among them Major Cameron Quinn, the late husband of Dr Jane Quinn. He took mefloquine in 2001, around the same time I did, and took his own life in the family home five years later. These many, many preventable deaths are the tip of the iceberg. Let's talk about the rest of the iceberg: a legacy of chronic debilitating illness affecting tens of thousands, if not hundreds of thousands, of allied and Australian veterans, including psychiatric disorders. Psychiatric disorders include anxiety, depression, mood swings, panic attacks, confusional states, hallucinations, aggression, bipolar disorder, psychotic disorder, delusional disorder, depersonalisation, mania, paranoia and suicidal ideation. Neurological disorders include dizziness, vertigo, tinnitus, hearing loss, balance disorder, somnolence, syncopy, convulsions, memory impairment, neuropathies, encephalopathies and vestibular disorders. The list goes on and on.

Vice Admiral Griggs cannot wash his hands of this, try as he might. The ADF caused it, to our eternal shame. The AMI and the authors of those drug trial reports—among them the ADF's director of military medicine, Colonel Leonard Brennan—bear direct responsibility for those deaths and the legacy of widespread chronic illness among coalition troops. Mefloquine was found conclusively to be neurotoxic in 2006. Concerns had been raised about neurotoxicity years before then. The researchers who made this finding in 2006 wrote that the drug causes lesions that are 'permanent in nature' in parts of the brain linked to the above disorders. These lesions resulted from mefloquine concentrations equivalent to those found in post-mortem examination of soldiers who had been taking prophylactic doses a decade earlier. Vice Admiral Griggs's two falsehoods about dosages and chronic illness were dispelled a decade before he even started using them.

Then what happened? Was their help for those affected? No. There was a decade of lies, denial, deceit and cover-up. For those who did try to help, there were threats, intimidation and abuse. The negligence of the senior leadership of the ADF in this scandal is breathtaking. There was a complete lack of oversight of the AMI for decades. The ADF's health system, which is supposed to provide for the health care of our 50,000 men and women in uniform, was instead co-opted to do the dirty work of the pharmaceutical industry—right under their noses. More recently, the previous Chief of Army, General Morrison, and the current Chief of Army, General Campbell, have both ignored repeated requests for help. Their integrity is now in question, just as vice Admiral Griggs's integrity is in question.

This is a national disgrace and the public now deserves to be told the truth. Those who have broken the law need to be held accountable. As I have recommended in my submission, there needs to be an urgent judicial inquiry into this scandal. That inquiry needs to investigate the AMI, the senior leadership of the ADF, Roche, the TGA and the Australian Defence Human Research Ethics Committee. More importantly, the veterans whose health has been affected by this neurotoxic drug, who have been knowingly neglected for at least a decade, should urgently be given the help they need and deserve. The chronic illness caused by this drug's injury to the brain is already well established in the scientific literature. No more begging to charity; we need fully funded research, toxicology studies, clinical guidelines for diagnosis and management, diagnostic test batteries and dedicated rehabilitation programs—for a start, and we need those things now. One of the people capable of taking a lead in these endeavours is sitting right here beside me. On that note, thank you and I look forward to your questions.

Dr Quinn : Thank you for allowing me to participate in this hearing. If those people who are left behind in the aftermath of a suicide are known as suicide survivors, then I am a mefloquine suicide survivor. My late husband, an officer in the British Army who served multiple tours in Northern Ireland as well as in the Second Gulf War, was given Lariam—its generic name: mefloquine—for an exercise in Kenya in 2001. During this exercise a number of soldiers, including my husband, suffered strange nightmares and some had visual hallucinations, but all of these events were shrugged off as being weird and slightly amusing.

When he returned he fell into a deep depression. He had never suffered in this way in his life before, and this was both extreme and alarming to both him and myself. I insisted that he stop taking mefloquine immediately and report how he felt to his medical officer. He did the former but not the latter for fear of the issues a mental health problem could cause for his career prospects. Over the next few weeks the severity of his symptoms subsided but the damage was already done. He continued to have Larium dreams and a changed personality right up to the night before the day he died. He took his own life in 2006—five years after taking mefloquine for that fateful exercise in Kenya—in an extraordinary manner and without any warning.

From the moment of his passing, I knew that mefloquine had contributed to his death. He had suffered mefloquine dreams the night before and was, as usual, in an extremely despondent state for that day, but I had no indication that suicide was imminent or even intended. The medical personnel who I dealt with after his death described this as an extreme psychotic episode. Similar psychotic episodes have been well documented in the literature in relation to mefloquine.

I felt compelled at that time to try to protect other army families from suffering the devastation that had been visited upon my family, so I wrote to the then Chief of the General Staff in the United Kingdom, calling for an immediate review of the use of mefloquine in the United Kingdom military and implementation of a mental health review program to identify others that could be affected by mefloquine toxicity. Although he paid deference to my call, he did not act, and nor have any of his successors.

A further 18,000 British troops have received this potent neurotoxic drug to date, with increasing numbers being admitted or treated for mental health issues. Although the numbers of personnel exposed in the ADF are smaller, the long-term side effects and health issues related to this drug are the same. I have been working with a small band of other mefloquine side effect survivors to have this potent neurotoxic drug removed from military use, to have the diagnosis of mefloquine toxicity formally recognised and acknowledged by the British military and to have appropriate screening and care available for mefloquine toxicity sufferers. The situation is the same here. We do not have that recognition for sufferers of mefloquine toxicity, and nor is there available and suitable help for that diagnosis.

In my professional life I am a neuroscientist and a research toxicologist working on the mechanism of action and potential treatments for neurotoxicities in both animals and humans. Mefloquine is well known to have neurotoxic effects. It causes cell death inside the brain and long-term cell damage, as well as causing abnormalities in behaviour, mentation, depression, mood, anxiety and other neuropsychiatric conditions, as Stuart has carefully defined. I am happy to share with the committee what I know of the cytotoxic action of this drug in the brain and how it can induce its acute, severe and long-term chronic effects.

Proper diagnosis is key. It is important that mefloquine toxicity is recognised as being a significant and identifiable neuropsychiatric disease state, because this has a severe impact on the way personnel need to be dealt with in terms of psychiatric treatment. Drugs that are administered for standard post-traumatic stress disorder can often exacerbate the clinical symptoms of mefloquine toxicity due to the underlying neurological damage. Therefore, a correct diagnosis is key.

Implementation of an institutional recognition of mefloquine toxicity in the Australian Defence Force is critically required and, further, a program to identify, assist and treat appropriately those who have suffered. Thank you.

CHAIR: Thank you very much for that. Would anybody else like to have a few words?

Mr McCarthy : Lee and I have deferred any opening comments that we might make to allow Stuart and Jane to have the maximum time in presenting to you. We will both be extremely happy to answer questions during the next few minutes or so. I ask your indulgence at the end just to make a couple of quite brief, but very appropriate, closing comments.

CHAIR: Thank you very much.

Senator FAWCETT: Just a couple of points of clarification, if I could, for a start—you said during your opening statement there was a complete lack of oversight of the AMI. You then went on later to talk about the Australian Defence Human Research Ethics Committee. My understanding is that that committee had oversight of the AMI and the trial they conducted. Is that correct?

Major McCarthy : Yes; that is the case. In fact, that was one of the points that the vice-chief made in the media last week. I know that those two particular trials that I am referring to—in fact, I have looked up on the annual reports from that ethics committee and, yes, they were approved by that committee. I made a supplementary submission over the weekend—a fairly short one, about four pages. One of the criticisms that was made of me, personally, last week was that I had not been directly involved in any clinical trials conducted by the AMI—which is not correct. One full page of that supplementary submission was my personal account of being subject to a separate clinical trial involving another quinoline drug, tafenoquine, which occurred in Bougainville in 1999. I am not sure if you had a chance to read that. I suspect not, because it was fairly late in the piece.

Senator FAWCETT: No, I have not seen that one.

Major McCarthy : I will leave you to read that in due course. The details are not so important. Certainly, in my view, it was unethical. But the point about tafenoquine is, even today, it is not approved by the TGA. It certainly was not approved by the TGA in 1999. To get back to the point, though, if the conduct of that trial is a reflection of the oversight that was provided by the human research ethics committee—I used, in that supplementary submission, the word 'disgrace', and I have no hesitation in using that word. If the conduct of that trial that I was subjected to is a reflection of that committee's work then that committee is a disgrace.

Senator FAWCETT: Sure. There are a couple of things we need to establish, though: one is the impact of the mefloquine itself; the second is the process by which it was trialled and brought into service. I guess it is that latter part I am trying to just establish at the moment. There is the research ethics committee that had oversight. They themselves are registered. I think it is by the NHMRC, the government body that registers ethics committees in a range of research fields.

Major McCarthy : I would have to take that on notice.

Senator FAWCETT: And then there is the TGA itself, which is completely separate from Defence, which has a role to look at both the efficacy and the safety of any drugs that are pharmaceuticals that are provided or allowed to be sold or administered in the community. My understanding is that mefloquine is still approved by TGA as an antimalarial.

Major McCarthy : Yes, it is. It is certainly approved.

Senator FAWCETT: So, taking that whole train of events, is it your contention that each of those bodies is somehow flawed?

Major McCarthy : Absolutely. To go back to the point that I made in my opening statement: mefloquine was approved by the TGA in the absence of proper phase III clinical trials. It is very unusual that that would happen. For that reason alone, to me, it warrants some very close scrutiny.

Senator FAWCETT: I am not an expert on the TGA, I would be the first to admit, but have they self-disclosed the fact there was no phase III trial?

Major McCarthy : It is on the public record. I made a longer supplementary submission—again, unfortunately, it was only fairly late last week. The main body of that submission was a forthcoming research paper. It is about 15,000 words, fully referenced. There are about 200 references in there. I went through the entire history of mefloquine—the regulatory processes. The conclusion that I have made publicly about the ethics of those trials specifically was with reference to the clinical guidelines that are mandated by the NHMRC Act. This is the sort of detail that I went into in that supplementary submission. If you want to follow my chain of logic in my criticisms of the TGA, then it is all laid out in that supplementary submission. But, to answer your question, it is a matter of public record, and a number of people have questioned not just the TGA but national regulators the world over. That criticism has been made for a long time by a number of academic authors.

Dr Quinn : Something that is worth adding to that is that mefloquine has a black box warning in the United States, so the FDA considers it to be one of the drugs of very last resort in terms of use as a clinical treatment. That occurred in 2013, and since the FDA withdrew its essential support for the drug the US military has ceased using it as any line of defence. So, there is historical precedence, which is based on published literature that it has a very significant incidence of side effects, particularly neuropsychiatric side effects, although there are others as well.

Major McCarthy : The particular significance of the US FDA black box warning is that one of the arguments that the manufacturer and various policy makers have made in relation to this drug—and this is one of the things I highlighted strongly in my opening statement—is that this drug can only have acute side effects while you are taking the drug, and those side effects will cease when you stop taking the drug. The significance of the US FDA's black box warning is that it recognises—as was recognised by the research findings from a decade ago—that it can cause long-term or permanent side effects. That has not been recognised by the TGA in Australia.

Senator FAWCETT: What is the normal cause and effect, if you like, if someone like the FDA, as a recognised world leader in this space, puts a black box warning on something? Is that normally then taken up by other regulators around the world?

Major McCarthy : I might start, and then maybe Jane could fill in the gaps again; her knowledge is probably better than mine. Again, I would invite you to look at some of the detail I put into that supplementary submission, because it goes into the decision-making processes generally speaking when it comes to risk-benefit analysis for pharmaceutical products. To answer your question, there are a number of sources of data that go into making those decisions. The first source is the clinical trials that I mentioned. In the case of mefloquine, long before I was even aware of any controversy surrounding the drug, academics were highly critical of what they called systemic underreporting of adverse events related to this drug. So, that is the first things. Clinical trials are one of the avenues of that.

The second one is what is called after-market adverse event reporting. If you or I purchased a pharmaceutical product and experienced some kind of adverse side effect, or if we were in discussion with our GP and we figured out that is was a side effect from that drug, then we could submit an adverse event report to the national regulator. The problem is that they are not linked. Although there are mechanisms for exchanging data, this appears to me to be a problem. Although the FDA has reached its determination, the TGA in Australia is not mandating a warning that reflects that this drug can have long-term side effects. Jane, do you want to add to that?

Dr Quinn : I think the important thing to add to that is that these drug administration agencies are targeting essentially a population that is the general public, so the risk-benefit analysis that is undertaken in order to determine whether a drug is suitable, safe or efficacious, or not, is within groups of healthy or appropriately disease-ridden individuals, looking at the risk-benefit of taking the drug versus suffering severe or other chronic adverse side effects. That is very different from a military population, where these drugs are mandated as part of the necessary OH&S procedures for deployment, for example. A number of questions have been raised around the East Timor trials as to whether these were actual volunteers, and the concept of what are called vulnerable subjects has been brought into play in terms of determining the role of military personnel in essentially commercial drug trials.

One of the key issues with mefloquine is whether the recognition of the very significant neurological side effects that can occur, even though they may occur only in a relatively small proportion of the population taking the drug, is a risk that outweighs the benefit of malarial prophylaxis for personnel who are under high-stress conditions already and dealing with live ammunition in large machinery—all of those things that would normally be contraindicated when taking a drug that can alter your mental status, your ability to make appropriate judgements and your ability to sleep normally. That is a very different ask to delivering the same drug to a relatively healthy middle-aged traveller who is travelling to Kenya on holiday, for example. So, it is the risk-benefit analysis specifically in the military environment that has really been brought into question, and it is for that reason that the US army has withdrawn use of that drug.

Senator LAMBIE: Are you saying it has a chemical reaction? When you feel really under the pump, there is a chemical reaction within the—

Dr Quinn : The parts of the brain that it works on are the areas of the brain that are affected in the chronic disease state caused by mefloquine toxicity, which can be described as a limbic encephalopathy, with vestibulopathy—if you will pardon the long terms. That basically translates to a disorder of the part of the brain that governs anxiety, fear and normal cognitive processing, associated with the part of the brain that deals with balance. A majority of symptoms that have been presented in long-term chronically affected individuals are rage, extreme anxiety, paranoia, auditory or visual hallucinations, vestibular disorder—balance disorders, tinnitus. In a military setting, a lot of those kinds of neuropsychiatric side effects really cross-reference very closely with those that present in PTSD, for example. There has been some concern in the medical profession that there is a subset of individuals whose clinical symptoms of PTSD are exacerbated by having taken mefloquine or that their disease state is actually caused by the drug they have taken and not by classic PTSD at all. It is a very complex neurological condition. It has only been well-characterised in the medical literature in the past eight years, I would say, but it is now well-characterised, and a diagnosis can be made.

Senator LAMBIE: How do you distinguish the difference? Is there neurological testing that you go through? Is it done through scans? Or is it just based on a psychiatrist making that determination? How is that determination made?

Dr Quinn : There is a set of clinical criteria from which a diagnosis of PTSD would be defined. Of those clinical criteria, 50 per cent of them can be attributable to cases of mefloquine toxicity, but 50 per cent of them are not. So, by taking a holistic view of the patient's history, of the neurological symptoms that are being presented, and by taking into account other factors—like traumatic brain injury—that could also impact on a diagnosis of PTSD, amongst other conditions, a diagnosis of mefloquine toxicity can officially be brought out. To date, in the United Kingdom there has been only one case—to my knowledge—where this has been a formal diagnosis in a serving officer in the British military, despite the tens of thousands who have taken this drug during its use in that particular military system. There is a general lack of acceptance that mefloquine toxicity exists, despite the fact that there is clear evidence in the clinical literature for it as a completely separate syndrome from both PTSD and traumatic brain injury. This is something that absolutely needs to be addressed in terms of the key criteria for diagnosis, both within a military setting and without it.

Senator LAMBIE: Is an autopsy the only real way to diagnose it? Is that what you are telling me?

Dr Quinn : No, diagnosis can be made prior to autopsy. For example, there are certain balance disorders, hearing disorders, nightmare states, psychoses and other extreme behavioural changes that are not necessarily commonly identified in cases of PTSD or traumatic brain injury but will be applicable in cases of mefloquine toxicity.

CHAIR: I am certainly not qualified. I can understand what you are saying, but I have no knowledge of the subject matter at all other than what we have in evidence, in the submission and our discussion here. Something I would like to move to is: you are senior-ranking Army personnel—a successful person—and you have presented with an injury. How have you and your family coped with that? What has the experience been like at your level, so to speak, Major McCarthy?

Major McCarthy : Perhaps I will start and Mum and Dad could add. In fact, I was just talking with Jane about this over lunch. I will not go into my whole history of experience with this drug, other than to say that the observation that I made to Jane over lunch is that my case is probably quite typical of those who have experienced mefloquine side effects over a long time and who have not understood them, not been able to attribute them to that drug, because the knowledge was not there. One short aside I will make is that one of the reasons for that is that the manufacturer's advice has always been, 'Once you cease taking this drug any side effects you have experienced will cease.' I believed that, so any of the side effects I subsequently experienced I have attributed to other things.

But to get to your point, I am an Army officer, so when I see that something has gone wrong and people need help my instinct is to step forward and try to address that. Once I came across the sort of evidence that Jane is talking about in the published literature last year, after going through this diagnostic process to try to figure out what had been going on, my instinct was to take that evidence to—among other people—Colonel Leonard Brennan, who is the director of military medicine in the ADF. He is effectively the most senior clinician other than the Surgeon-General. He blew me off. That was in the process of me not looking after myself, but in the process of me having put together a bit of a paper to say, 'Hey, we need to look after people.' Not only did he blow me off; I was then threatened in writing with disciplinary action for trying to implement the outreach program that I proposed. I have since been continually warned not to go to the media. Last week, after my evidence to this committee that was published on the committee's webpage six weeks ago was reported in the media, I was then subjected to intimidation by the second most senior officer in the Defence Force.

Mr McCarthy : Senator, could I make a small contribution to that. I am trying to avoid being personal about it. It does not look much to the point now, but Stuart has been very ill for a very long time thanks to the side effects of mefloquine. But it is to his credit that I put on the record a couple of things which I believe are very important. Naturally, Lee and I have a great relationship with Stuart, otherwise we would not be sitting here. But he has constantly said to me in emails and phone conversations: 'Dad, this is not just about me; it's about all of the other veterans who are like me who have no idea why they are ill, where they are going to get help and what the future might hold.' You might have gathered that Stuart has an intellectual capacity, and that led him to write substantial papers and it led him to write the submissions which brought him here. I stand in awe of what he has been able to do despite his illness.

But there is another thing that I would like to go on the record. When I read this in an email about six months ago I was reduced to tears: 'Dad, things are pretty shit right now, but I'm doing the best I can.' And he is still doing the best he can, despite adversity from the high command of the ADF, in particular the health section, in trying to bring about change which is important, surely, for him, but for many, many veterans who are out there coping with an illness which is not recognised or diagnosed appropriately. From my point of view, in total support, I have written to the previous Chief of Army, the current Chief of Army, the Assistant Minister for Defence and his chief of staff intelligent, sensible arguments about bringing about change, and I have met absolutely the same brick walls that Stuart is trying to climb over unaided by the ADF. I will make some closing comments later.

Mrs McCarthy : I have had 45 years in education, much of it in senior roles in early childhood. I have been to a few inquiries in Canberra with my work. I am retired now and I have more time, I guess, to think about things. But before this was all put into papers and documents I had this really, really frightened concern about Stuart's health and where it was heading. So what do you do then? You go for help. Where do you go for help? I could not find where. On two bases I rang and asked to speak to the padre, when I could find out how to do that, and on both occasions they said they would keep a watchful eye on him. But that was the only help that I could seem to get. In order to even get that I felt I had to be deceitful, because I knew, if I told Stuart what I was trying to do, that he would be angry. I know, since we have had a rough idea of what needs to be put in place, the number of brick walls he has faced, and all of this while he is having extreme nightmares that wake me in the night. I am on CPAP machine, so it takes a bit to wake me. I hear this awful dialogue going on in the room next door and go and find him perfectly asleep. Why isn't there some sort of social work, or some sort of part of the Army that would look after the families who go through this concern?

I have not said this to Stuart at all, but this can go on the record. Every day that we do not hear from him we have a concern about suicide. That is how bad this has been. It is not just his parents. It is his wife, his children and his wider circle. We all have this worry day by day about how he is going and how he is managing to crawl out of this heap. Certainly some assistance from the army would be great instead of these brick walls and—worst of all—his concern that after 26 years he will be tossed out of the army as a malingerer.

Maj. McCarthy : Perhaps I can directly answer your question. I am always reluctant to talk about my issues. I am very proud to have served in the Army for as long as I have. Generally, the Army has looked after me. The irony here is that I have served in the Army for 27 years, I have done six operational deployments, I have travelled all over the world and I have come through it. Despite the issues I have had with this drug, which are hard to pin down, the irony here is that I came back at the end of that to a home that I owned and a stable family 12 months ago. What brings me here now is a third depressive episode of the depressive disorder I have that I am now realising is a common side-effect of this drug. The third of those episodes is what led me to the research that brings me here. My efforts then in trying to get help for me and other people and the reactions to those efforts from the most senior officers in the Defence Force have destroyed my life, quite frankly.

Senator WHISH-WILSON: If you were to seek a medical discharge now—this is just theoretical—what do you think the diagnosis would be? Would they accept it, for a start?

Maj. McCarthy : I have been diagnosed with a series of things. If I were to be medically discharged, the main diagnosis would be a depressive disorder. From a perspective of being looked after by the DVA and so on, that is not so much of an issue. But correct diagnosis is an issue for all of the reasons that Jane mentioned. The risk of misdiagnosis and mistreatment and being subjected to further risk of contraindicated drugs, some of which are very dangerous, are the reasons we need to correctly diagnose.

The second issue—and it is only tangentially related to your question, but it is an important point—is that when the most senior military doctors in the Defence Force dispute mefloquine being a cause of chronic illness they are contradicting the Repatriation Medical Authority. You will see this when you have a chance to look at my longer submission. I went back and had a look at the various SOPs that reflected determinations made by the RMA. Mefloquine specifically and quinolines in general have already been determined to be causes of a raft of chronic illnesses that I have already listed. So the most senior doctors in the Defence Force are wrong. Their responses and threats of disciplinary action to me are in direct contradiction to the competent medical authority that makes these decisions. It is just staggering. It really is.

Senator FAWCETT: My understanding is there were about 1,300-odd people involved in the trial, and I understand Defence is saying there are 500 or 600 people who have subsequently used the drug outside of the trial. Is there any record that you are aware of of that ADF cohort of people who have reported problems that are traceable or identifiable as mefloquine sourced?

Major McCarthy : That is the problem. The first point that I would make in relation to numbers is that the numbers I have read on the public record, which Defence is stating reflect the overall numbers of mefloquine users, are post-2001. They are arguing that the electronic records only go back to 2001. Mefloquine was used for a decade prior to that and the ADF malaria policy states that somewhere between five and 10 per cent of the ADF population are intolerant of doxycycline, which is the first-line antimalarial drug. If you just do some number crunching on that decade prior to 2001, there would have to be several thousand people in there, I would suspect, who would also have used it.

But, to answer your question, that is the problem—there is no recognition of this. As Dr Quinn was saying, the simple recognition of the use of this drug in your history is an indication that there needs to be some further investigation. I have spoken to a number of veterans about this, even senior people. I spoke about this drug in particular with a Duntroon classmate who took part in those trials. This guy retired as a lieutenant colonel—not that I am necessarily saying rank is a reflection of one's intelligence. That is not the point I am making. He had no recollection of which of the two trial drugs he took, but it is on his record.

Going back to the various studies that have been done, there was the 2010 prevalence study. I forget the exact figure, but they made an estimate in that study that reflects what a lot of other witnesses were saying. There are people who have done multiple tours—and I am a reflection of this too—and they have had multiple exposures to not just psychological stress but all sorts of other factors. The thing with mefloquine is it is on your record. Why can't we proactively go and check those records and, if nothing else, rule that out as a factor? It is just the common-sense rule and it is just not being done. I do not know why.

Mr McCarthy : I would like to make a brief response to your question, because I have asked that very same question of two chiefs of Army and the assistant minister: how far back do those records go? In correspondence, some of which was included in my original submission, I have been quoted only the last five years of records. You heard Stuart say earlier today that he went to the pharmacist and he found this mefloquine prescription from way back—20-odd years ago.

I have constantly, seriously and sensibly requested information, because my concern is not just for Stuart but for all those veterans who have the same problem Stuart has who are not being recognised. In one piece of correspondence from the assistant minister's chief of staff, it was stated that even if we did have the records, the number of serving personnel and past personnel impacted is so small that we do not really need to care or worry. Yet here is a worry sitting right here alongside us. Here is the living evidence that the care is not there, the worry is not there and the concern is not there, and it appears that it is not going to happen unless this inquiry brings something positive about it.

Senator LAMBIE: Are there alternative drugs? There are obviously alternative drugs that they use.

Major McCarthy : Exactly. That is the whole point. Even prior to this drug's introduction, there were two very effective antimalarial drugs. Doxycycline has always—or certainly since the 1980s—been the ADF's first-line antimalarial drug. You probably recall taking doxy yourself; I am not too sure. There was a period of time when mefloquine was used as a second-line drug, but even then Malarone, which has become the second-line drug, was a very effective malaria preventative drug. One of the ironies here is that when I was a teenager we as a family lived in Papua New Guinea and we were taking Malarone. Since joining the Army I have never taken Malarone. I have taken the Army's various antimalarial regimens, I have still had malaria, and now I have a permanent brain injury. But, to answer your question, yes, there have always been alternative efficacious drugs, and there still are alternatives. The reason that mefloquine has been slighted as a preferential drug for the military is that it is taken once a week, but even then studies about whether or not people are compliant with the drug regimen really call that into question, at best—whether just because you are taking—

Senator LAMBIE: Do you know whether the drug is cheaper? Is it the cheapest alternative?

Major McCarthy : It is definitely cheaper, yes.

Senator LAMBIE: So it is the cheapest alternative, so Defence has picked it up and run with it because it is probably the cheapest alternative.

Major McCarthy : To be fair, I have to point out that is not used as the first-line antimalarial and never has been in the ADF. It has only ever been used as an alternative, and this is the reason that I took it. When I take the first-line drug, doxycycline, I get photosensitivity and so on. That is what led me to this drug. But, to be fair, I do not think that in the ADF it has been a cost calculus; it has just been more a question that we need to have other alternative drugs.

Senator FAWCETT: It is for a resistant strain, isn't it?

Major McCarthy : Yes, that is part of the question.

CHAIR: At this stage we have your submission, which is comprehensive, and also abundant evidence. One thing I would just like to draw your attention to is that in our opening statement we remind all witnesses that in giving evidence to the committee they are protected by parliamentary privilege. It is unlawful for anyone to threaten or disadvantage a witness on account of evidence given to a committee, and such action may be treated by the Senate as a contempt. That applies to your submission, which we have accepted and published. So, if you have a threat or an action against you, you should raise that in a very formal way with the committee.

Major McCarthy : Absolutely. I will do that. Would you like me to do that in writing to you?

CHAIR: Absolutely, if you could. Do you have any closing remarks?

Mr McCarthy : Just a couple of expectations that I have. Thank you for the opportunity, first, to make those remarks. I did not say earlier how grateful I was to be invited here today. It is quite substantial that three McCarthys can be here at the same time for the same cause. I have a couple of brief expectations, but they are very positive. I have an expectation that this inquiry will have such strong recommendations in its report that substantial, long-term change will be brought into the ADF in relation to the side effects of mefloquine and the great trouble that those side effects are causing for a substantial number of veterans.

The second expectation I have—and Stuart mentioned this in the closing comments to his opening statement—is that maybe the committee would seriously consider instigating a judicial inquiry so that allegations can be tested and, where appropriate, charges can be laid. I hope that it would not come to that, but in order to bring about change in the ADF in relation to mefloquine that may be necessary.

CHAIR: Thank you very much, Dr Quinn, Major McCarthy and Mr and Mrs McCarthy, for your evidence and appearance here today.