Anti-Malarial Medication: Motion

Deputy Aengus Ó Snodaigh

I move:

That Dáil Éireann:

acknowledges:

— the serious side effects of the anti-malaria drug Mefloquine (Lariam) on some Irish Defence Forces personnel serving overseas in peacekeeping missions in the sub-Saharan region of the African continent;

— that these side effects have resulted in serious and prolonged psychotic and psychiatric behaviour and suicidal tendencies, including the possible death by suicide of some military personnel;

— the failure by the Department of Defence to implement a comprehensive screening programme to monitor the effects of Lariam on the estimated 4,500 plus Irish Defence Forces personnel who have received it since it was made drug of first resort for sub-Saharan Africa in 2000;

— that most of the world’s major military powers have, on the back of overwhelming evidence, completely banned Lariam or use it only as a drug of last resort for their soldiers;

— that the Irish Defence Forces are now one of the few in the world to administer Lariam as the only drug of first resort for its serving overseas soldiers in areas where there is a high risk of malaria;

— that RTÉ’s Investigations Unit engaged international medical experts whose analysis in their report in 2013 concluded that Irish Defence Forces personnel who had taken Lariam were three to five times more at risk from suicide; and

— the findings of a public inquiry by the British military, led by retired Lieutenant Colonel Dr. Ashley Croft and retired USA military Major Dr. Remington Nevin, two world experts into the effects of Lariam, who recommend that Lariam should be a drug of last resort and that the prescription of the drug should only be made under the most rigorous supervision; and

calls on the Government to:

— instruct the military authorities to immediately cease administering Lariam to all Irish soldiers as the drug of first resort and to replace it with proven safer alternatives such as Doxycycline or Malarone, and Lariam should only ever be the drug of last resort where no suitable safer alternative is available; and

— instruct the Department of Defence, in conjunction with the Health Service Executive, the military authorities and in consultation with the representative bodies for serving and former soldiers, to draw up a plan of action to help alleviate and address the ongoing concerns regarding the anti-malaria drug Lariam issued to military personnel serving on overseas missions in sub-Saharan Africa in the past.

I acknowledge the presence of members of Action Lariam for Irish Soldiers, Mefloquine Ireland and the Wives & Partners of the Defence Forces, WPDF, some of whom are in the Public Gallery and have come from various places throughout the country as well as from Dublin to listen to this debate, which is important for them and for those who have suffered the effects of Lariam. I commend them in particular on their sterling efforts to ban the use of Lariam as the anti-malarial drug of choice for military personnel serving overseas. I also thank them for their encouragement, their advice and assistance which greatly aided me in the course of my work on this important matter. I commend the Opposition Deputies who have co-signed this motion. I know there are others supporting it who, thus far, have not signed.

I also acknowledge the importance my party has attached to this issue by giving me today's debate time.

To those at home watching this debate, and elsewhere, who are living with the effects of Lariam this is not only the issue of the day, it has been the issue of the day since they or a loved one first felt the full effects of a drug that was intended to protect not cripple. I hope I can do justice to the words and feelings that I have heard and felt since people first shared their personal stories with me.

For nearly a decade I have raised the dangerous and potentially fatal side effects associated with Lariam with successive Ministers for Defence. The value and respect rightly accorded to Irish military personnel is reflected globally. The courageous peacekeeping duties they have performed in some of the world's most dangerous conflict zones and their recent role in rescuing thousands of refugees in the Mediterranean have conferred upon them a reputation for bravery and professionalism that is unequalled. Unfortunately, the plaudits frequently lavished on the Defence Forces by Ministers on the floor of this House have not always been matched by their treatment of those men and women. Nowhere is this more starkly illustrated than in the inexplicable failure to replace the anti-malaria drug Lariam with a safer alternative.

For years, the plight of serving and retired personnel who have suffered the serious side effects of taking Lariam, which has been available since the early 1990s, has been ignored and dismissed. At a glance, this issue has been before at least eight Ministers or Ministers of State in the Department of Defence. There is a "hear no evil, see no evil, speak no evil" approach to the suffering of affected soldiers, whose plight has been ignored and whose scandalous treatment has been impossible to fathom. Indeed, I remember in April 2008 when the Minister of State, Deputy Kehoe's colleagues, former Deputies, Billy Timmins and Jimmy Deenihan, questioned the then Minister for Defence, Deputy O'Dea, about Lariam only to get virtually the same stock reply we have been given many times since, namely, "The drug in question is considered one of the most effective anti-malaria drugs ... The Military Authorities have assured me that they are fully aware of the drug's neuropyschiatric side effects." Deputy O'Dea's signature on this motion tonight shows that he is man enough to admit that the advice he was given nearly ten years ago was wrong. I hope the Minister of State and the military authorities today have the same humility.

The Ceann Comhairle, Deputies Clare Daly and O'Brien, an tSeanadóir Pádraig Mac Lochlainn and I have doggedly pursued this issue with the Minister of State and with previous Ministers since 2008, but without any hint of a change of policy. The purpose of this motion, when it is passed and I believe it will be, is to force the Minister of State to end his indefensible justification of the use of Lariam as an anti-malaria drug for soldiers.

In considering this issue, I want the Minister of State to try to imagine the life of a soldier who has volunteered to serve overseas, in the service of his or her country, and who succumbs to the effects of what is supposedly a life-protecting drug. The challenges for soldiers serving abroad, of performing their duties in a stressful and sometimes dangerous environment, are offset somewhat by the knowledge that, as peacekeepers, they are making a significant difference in a conflict zone and to the world. The pride that comes from fulfilling that challenging role wanes quickly when their lives are altered and no one seems to care. The change in their personalities happens slowly and is barely noticeable at first but it starts to be noticed by colleagues, family and friends. They become increasingly snappy and at times angry or depressed and experience occasional suicidal thoughts without any understanding of what is causing these uncharacteristic mood swings. They lose their appetite, become increasingly lethargic, demotivated and unable to concentrate. They find things to blame, maybe it is the weather, the long hours, arduous travel or the stress of serving in a country where they must remain constantly vigilant. When they return home, their loved ones are quick to comment on their change of mood, asking what happened during their tour of duty. Some blame it on post-traumatic stress disorder, PTSD, even if they did not directly experience the horrors of war.

They live in denial and refuse to visit the Army doctor for fear of being put on sick leave with no duties which means reduced pay, no allowances and the all-too-real risk of being considered too weak to serve overseas again. They might have seen this happen to their comrades who were stigmatised, sidelined and ridiculed for seeking help, with some even being drummed out of the service for being too sick to serve. The physical and mental problems continue to worsen and they cannot shake their malaise but the cost of attending a private GP is daunting, so they suffer in silence. They hear the rumours about the high rates of suicide among military personnel - for example, the 12 men who took their own lives after returning from UN peacekeeping missions in Africa - and recall the rumours about Lariam, the anti-malaria drug they were forced to take without question or protest on pain of being told their services would no longer be required and think it might be responsible for their problems. Nobody ever explained to them the possible side effects. They find out that the Brits, the Yanks, the Canadians and most other militaries have banned or greatly restricted its use. They read about three Fort Bragg soldiers suspected of killing their wives after they exhibited unusual anger and incoherence upon returning from Afghanistan where they were prescribed Lariam. Similar, seemingly inexplicable, brutal killings by Canadian Special Forces in Somali in 1992 or massacres in Afghanistan in 2013 have a common theme; those responsible were soldiers who were prescribed Lariam.

Closer to home, an "RTE Investigates" report into the use of Lariam in 2013 found a "plausible link" between the drug and the high rate of suicides among soldiers. An examination of 28 suicides within the Defence Forces, found that 11 of those involved had taken Lariam and that four of them had taken their lives within a year of returning home from overseas duty. Two of the world's leading authorities on the medication are on record as saying that the results of RTE’s probe require urgent investigation. Dr. Remington Nevin, an epidemiologist and former US Army major, is unequivocal in his view that Lariam is responsible for symptoms of mental illness, including anxiety and depression, and a strongly increased risk of suicide brought on by severe psychosis. In spite of what has been uncovered, the Government and the Irish military authorities seem oblivious to the approach taken by other countries, including the United States, which, since 2009, issues Lariam for military personnel only in the most exceptional of circumstances. In Britain, an estimated 1,000 plus former military personnel have required psychiatric treatment as a result of the after-effects of taking Lariam. That government was forced to act. In 2013, the British military authorities initiated a public inquiry that was damning in its conclusions about Lariam. In 2016, a report published by a House of Commons Defence Committee stated:

Lariam has a high risk profile and a minority of users experience severe side-effects. These side-effects are clearly highlighted by Roche, the manufacturer of Lariam. Our inquiry considered whether those risks outweigh the benefits of Lariam when other anti-malarial drugs, with a lower risk profile, are available to the MoD ... We also believe that if the MoD continues to prescribe Lariam, this must take place only after a face-to-face Individual Risk Assessment has been conducted.

There is overwhelming evidence of the dangers of Lariam, yet the testimonies of Irish Defence Forces personnel and the horror stories from other armed forces that highlight the drug's serious side effects have not, to date, been deemed serious enough to have it replaced.

When soldiers learn about Lariam's debilitating and dangerous side effects, it dawns on them that despite devoting a good part of their lives to the service of their country, they have been given poison which is likely to have compromised their mental well-being and physical health, possibly for the rest of their days. It quickly becomes obvious that the military authorities, the Department of Defence, the Irish Medicines Board and several Ministers for Defence have been fully aware of the major questions about this drug and have chosen to ignore the potential risks involved. It is simply not plausible for them to have been ignorant of the facts as the dangers associated with this drug are well documented and have been highlighted to them and their Ministers continuously by, to name but a few, the Action Lariam Group, Deputies and Senators who have continued to raise the issue, RTÉ's "Prime Time" and various newspaper articles.

The obvious question for the Minister of State is why members of our military have been given Lariam when there are safer alternatives available and why has the Department persisted in issuing to soldiers a drug that could poison their minds and destroy their lives. Is the Minister of State afraid, in the face of such overwhelming evidence, to admit that he and the military authorities are fallible and have got things badly wrong in respect of Lariam? Thus far, the Minister of State has dismissed the evidence and testimonies of serving and retired soldiers on the basis of cost, saying it would be more expensive to replace Lariam with a safer alternative. That suggests the lives of the few soldiers who are affected are less important in the wider scheme of things, particularly if that means being able to make budgetary savings. I hope the Minister of State will contradict that. The only way to do it is to change the way we approach anti-malarial medicines for the Defence Forces very quickly. The Minister of State has that opportunity tonight. He must be brave enough to admit he is and has been wrong on this matter so that we can begin to finally address what has been inflicted on the men and women who were forced to take Lariam.

The Minister of State must not only pass the motion, he must immediately replace Lariam with a safer alternative drug. I ask him to provide an assurance that the health and well-being of Irish soldiers serving overseas will be a priority from now on and that they will no longer be prescribed this drug. We must also begin to address the legacy of a drug which has left some men and women so debilitated that they cannot get out of bed in the morning and carry on their normal, day-to-day business while others are dead. The Minister of State has an opportunity to act in circumstances in which the motion has the backing of the majority of Deputies. The Minister of State can weigh in behind it and issue an instruction to the military authorities. Where other governments have learned of the horrors of this drug, they have taken the right and decent step of banning its use.

Deputy Brian Stanley

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.

Minister of State at the Department of Defence (Deputy Paul Kehoe)

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.

An Ceann Comhairle

I thank the Minister of State.

Deputy Paul Kehoe

I would like to finish. I pay tribute to those members. In conclusion, for the second time, this afternoon I was delighted to attend the launch by the Organisation of National Ex-Servicemen and Women, ONE, of its annual fuchsia appeal. The work of ONE is an important support in the lives of many members of the Defence Forces. I know that from speaking to ex-servicemen and women from my constituency in Wexford.

I reiterate the health and welfare of the Defence Forces is a high priority for me, as Minister of State, and the military authorities. This will continue to inform the approach to the issue of protecting our personnel from the significant risks posed by malaria.

An Ceann Comhairle

I thank the Minister of State. We were unaware in scheduling this very important debate that the matter was imminently before the courts. I advise Members to be conscious of that and to be careful in comments they make. Our next contributor is Deputy Brendan Smith, who is sharing time with Deputies Fiona O'Loughlin and Niamh Smyth.

Deputy Brendan Smith

One of the most regrettable realities of the past six or seven years has been the political neglect of our Defence Forces. Political leadership of the Department of Defence was first relegated to being a part-time role exercised by a Minister holding responsibility for another major Department and more recently to being a job handed out to a Minister of State. When the Taoiseach, Deputy Varadkar, came into the Dáil two weeks ago to announce the assignment of ministries, he omitted to tell us in the Chamber that he had taken responsibility for the Department of Defence himself. This level of political disregard for the Department and the Defence Forces is simply not acceptable. It does, however, help us to understand why problems and issues such as the one we are discussing have been allowed to run on for so long.

I represent a constituency, Cavan-Monaghan, that has had a long and proud association with the Defence Forces, the real and only Óglaigh na hÉireann, as an institution and as a family tradition. I know of many families in which two, three and more generations have proudly served in our Defence Forces and who cherish their service to the Defence Forces and to our nation. Even the shameful and absurd closure by the last Government of Dún Uí Neill Barracks in Cavan, one of the few new barracks built by the State, could not diminish that proud connection. Dún Uí Neill was a modern and very cost-effective military installation that is sadly no longer with us.

For these families and for many thousands of young men and women across the island, North and South, joining the Irish Defence Forces is their first and primary employment option. There is a myth abroad that young people join the Defence Forces because they have no other options but nothing could be further from the truth. Even at the absolute peak of the economic boom, the number of people applying to join the Defence Forces considerably outweighed the number of vacancies. If memory serves me correctly, in the early 2000s there were about 25 applications for every cadet recruitment vacancy and in the region of ten applications for every general service one. I make these points to stress the responsibility and onus on us to ensure that the people who willingly offer to serve their country at home and abroad in the most difficult of circumstances have the best equipment, training, conditions and supports.

As Deputy Micheál Martin pointed out on Leaders' Questions this morning, we are no longer offering these young men and women the best pay and conditions. As this Private Members' business motion highlights, neither are we offering them the fullest and best medical supports. As any of us who have had to go abroad on business will know, travel to certain parts of the world requires various medical vaccines and treatments. By definition, the places we send our Defence Forces personnel to as part of their UN-mandated peace support operations are in turmoil and pose many dangers. It is right and proper therefore that we put the best medical supports in place to minimise the risks to our personnel. We should never send them into these trouble spots without the right and appropriate equipment and training. Neither should we send them without the best range of modern and up-to-date medical supports and services. These include vaccinations and treatments. It is not sufficient to offer anti-malarial treatments; we must offer the best ones and the ones with minimal risks and side effects. The simple truth is there are real and genuine concerns about the continued use of Lariam as an anti-malarial. The stock response by the Government over recent years is no longer acceptable or sufficient. The answer appears to miss the reality that medical expertise on the use of Lariam is moving on as others here have mentioned. I refer to Dr. Humer in particular. There are more effective anti-malarial drugs available with reduced side effects and they are the ones we should be offering as standard.

This issue highlights the need for us to considerably review and overhaul the operations of the medical corps within the Defence Forces. As far back as 2008 and 2009, it was recognised that the Army medical corps needed an independent root-and-branch review after several recruitment campaigns, run here and abroad, failed to fill vacancies for doctors and other professionals. PA Consulting was brought in to do this review and made several recommendations. Several working groups were set up within the Department and the Defence Forces to identify the practical steps needed to implement that report. It is hard to identify what they did.

In 2012, we were told that a central medical unit had been formally established to enable the detailed structures, processes and personnel to be put in place to provide for the support, management and delivery of modern medical services for the Defence Forces. However, only a few years later Ministers were still coming in here to tell us the number of doctors in the medical corps was still way below established levels. In 2014, the former Minister, Alan Shatter, told the Dáil the medical corps had only 18 of the 32 doctors it required. It is no wonder that Lariam is an issue when the Government and Department are not treating the ongoing and sustainable delivery of full and proper medical services with the seriousness it deserves.

I am happy to support this motion, but it overlooks the key problem underpinning this and other problems, namely, the importance and significance we assign to our Defence Forces. As the Minister of State, Deputy Kehoe, knows, we have discussed this at the Oireachtas committee on defence. I welcome the representatives and people who have long advocated on this issue. Many personnel in Cavan and Monaghan, people who have served with distinction abroad, have told me of the side effects of having been prescribed that particular drug. It has had adverse impacts on the quality of their lives. Surely the least we could do is to eliminate the use of that particular drug and ensure that our personnel who, as the Minister of State said, do us proud in many countries throughout the world as well as at home, have the best medication available to them to ensure they are well-equipped for the difficult tasks they undertake in many troubled spots and in their routine duties throughout our State.

Deputy Fiona O'Loughlin

I hail from the heart of the Defence Forces in south County Kildare. The Curragh is home to 1,500 troops at any given time with practically every member of the Defence Forces receiving training in the Defence Forces training centre at some stage in their career and many receiving training prior to overseas deployment. We are extremely proud of our military tradition in my part of the country. There is not a family I know that does not have some connection or affiliation with the forces. The links and interactions with the communities right across the county are absolutely huge. It is incredibly difficult for me to reconcile the pride and honour we should feel for our Defence Forces with the disregard being shown for the health of serving and retired members by the continued use of Lariam. I have heard on many occasions from the Minister of State the line he trots out on the dangers of malaria in sub-Saharan Africa.

While we all understand those dangers, alternatives are available and I know the Minister of State used one of them. It is long past time he accepted the damage Lariam has wreaked on many soldiers and, indirectly, their families. The side effects of the drug are well documented and can be severe. They include anxiety, depression, paranoia and suicidal behaviour. Lariam must become the drug of last resort rather than of choice for soldiers serving overseas.

I am happy to support the Sinn Féin motion. We, in the Fianna Fáil Party, have long believed that the use of Lariam has caused serious problems for members of the Defence Forces, a view shared by current and retired members of the Defence Forces who have spoken to me. As far back as 2010, serious concerns were raised about the use of Lariam as an anti-malarial drug for members of the Defence Forces serving in Africa and other areas where malaria is a problem. There have been serious indications in the intervening seven years that the drug can increase the risk of mental health problems for those who use it. In 2015, the British Ministry of Defence acknowledged that 1,000 ex-servicemen and women were suffering severe psychiatric and mental health problems as a result of being prescribed Lariam. Similarly, an RTE "Prime Time" investigation broadcast in 2013 suggested the risk of suicide was between three and five times higher among Defence Forces personnel who were prescribed the drug than among those who were not prescribed it. A former British army chief has also apologised for its use. It is extraordinary that the Defence Forces continue to use Lariam given that the chairman of Roche, the company that manufactures the drug, has stated that the use of Lariam against malaria is no longer necessary owing to its side effects and the availability of other drugs.

The Action Lariam for Irish Soldiers group, whose members I have met several times, stated that new cases of serving and former Defence Forces personnel suffering ill effects after taking the drug, up to and including suicidal ideation, were continuing to emerge. The campaign against the indiscriminate use of Lariam has been raging for more than 20 years, yet the Department will not take responsibility and insist that the Defence Forces medical corps only use the drug when no alternative is available.

Successive Ministers have cited the fact that no member of the Defence Forces has died of malaria in the past ten years as a reason for the success of its policy. As recently as last month, the Minister noted that it is policy to have personnel individually screened for fitness for overseas service and medical suitability; in other words, a medical risk assessment for Lariam is carried out on an individual basis. The choice of overseas deployment is a medical decision made by the medical officers in the Defence Forces. While this policy may be practised, it is clearly not working. I know of serving personnel who will not admit to side effects caused by Lariam for fear they will be deemed unfit to serve. It is not, therefore, a fair playing pitch. Added to this, we have reports of Air Corps personnel being exposed to dangerous chemicals and a large number of soldiers at the rank of private - 20% of the total - having to claim family income supplement. These issues militate against recruitment campaigns to attract new recruits to the Defence Forces.

In recent months, I have met wives and partners of Defence Forces personnel and the general feeling among them is one of having been abandoned, let down and overlooked. The Minister must step back and consider the manner in which soldiers are being treated on a number of levels. Retention of personnel, as the Minister acknowledged, is at a critical point. Bringing in new recruits and having excessively large classes of cadets will not address leakage from the Defence Forces. Other options are available. For example, treating serving personnel with respect, having a duty of care for their health when serving at home and abroad and no longer having a dangerous drug such as Lariam being prescribed unnecessarily could go some way towards reassuring soldiers and their families that the State they serve has their back and cares. I commend the motion.

Deputy Niamh Smyth

The Fianna Fáil Party will support the motion to designate Lariam as a drug of last resort. For many years, serious concerns have arisen regarding the use of this anti-malarial drug by members of the Defence Forces serving overseas in Africa and other areas where malaria is rife. Side effects of Lariam include anxiety, depression, paranoia and suicidal behaviour, all of which indicate that the drug can seriously increase the risk of mental health problems for users.

We in Fianna Fáil believe the use of Lariam continues to cause severe and irreparable mental health damage to brave members of the Defence Forces. Current and retired members of the Defence Forces have expressed to us their grave concern regarding the drug. A total of 69 claims have been taken by current and former members of the Defence Forces who allege injury as a consequence of using the drug.

In 2015, the British Ministry of Defence admitted that 1,000 former servicemen and women who had been prescribed Lariam are suffering severe psychiatric and mental health problems. Moreover, an RTE "Prime Time" investigation broadcast in 2013 found that the incidence of suicide among Defence Forces personnel prescribed the drug was between three and five times higher than among those who were not prescribed it. Despite the decision last July by the manufacturer of Lariam to withdraw the drug from the commercial market in Ireland, it remains available and continues to be used in the Defence Forces. This is despite the assertion by the chairman of Roche, the company that manufactures Lariam, that its use against malaria is no longer necessary. Dr. Franz Humer is on record as stating science had advanced significantly since Lariam was first introduced. He has also stated there are now more effective anti-malarial drugs available, with reduced side effects. Two other anti-malarial drugs besides Lariam are in use in the Defence Forces. The decision on which medication is provided to soldiers is made by medical officers. Surely the Defence Forces should shift from using Lariam to using other anti-malarial drugs.

The Permanent Defence Force Other Ranks Representative Association, PDFORRA, argues that Ireland is not following a UN guideline that an alternative drug should be provided for personnel with a sensitivity to Lariam. Speaking about the side effects of Lariam, a former member of the Defence Forces, Anthony Moore, who is a member of the Action Lariam for Irish Soldiers group, stated: "Had we been informed, most of the lads would not have taken it." Servicemen and women in our Defence Forces deserve better. They have put their personal lives on hold and risked their lives and safety for the security of the country. The Government has done little to express its gratitude for their unbelievable sacrifice.

Unfortunately, Dún Uí Néill Army Barracks in my constituency of Cavan-Monaghan closed some years ago. As Deputy Brendan Smith noted, two and three generations of the Defence Forces worked tirelessly in County Cavan and must now commute to barracks in Dundalk and Athlone. Their accounts of what they must do during their working day do not bode well. These individuals are an integral part of the communities they protect and it is a sad state of affairs when one hears such accounts.

The Government must reconsider the use of Lariam in the Defence Forces because it is causing severe damage. Designating Lariam a drug of last resort would mean it could only be prescribed when no alternative is available. Based on the experience of this approach in the United States and Australia, fewer than 1% of people here would be considered suitable for Lariam, in other words, the drug would no longer be used by the Defence Forces. As a result, no other soldier would have his or her career and life ruined by the drug's adverse side effects.

The Government must address the needs of our servicemen, for example, those who need an effective but safe anti-malarial drug. If nothing is done, the Government will send out a clear message that the problems of the men and women who sacrifice everything for the protection of the State are but inconsequential to some elected officials.

Deputy Brendan Ryan

This issue has dominated parliamentary questions on defence since this Dáil came into being last year and, indeed, during the previous Dáil. It has been the primary issue during every oral parliamentary question session. The Minister of State is well acquainted with the political will on this side of the House to remove Lariam as the preferred malaria prevention drug of choice for our Defence Forces.

I will not go through the issues again tonight. Others have already done so. What we have before us is a clear, concise and strong motion calling on the Defence Forces to cease immediately administering Lariam to all Irish soldiers as the drug of first resort and to replace it with proven safer alternatives such as doxycycline or Malarone. I am sure that the Minister of State expected this motion at some stage, as defence spokespersons have spoken with him inside and outside the Chamber about finding a solution. The issue will not go away until there is a change in policy.

Lariam should only ever be used as a drug of last resort where no suitable, safer alternative is available. The potential side effects of Lariam can and have been devastating for some Defence Forces personnel. It has been over four years since an RTE "Prime Time" programme revealed research showing a higher risk of suicide among members of the Army who had taken Lariam during their deployments overseas versus those who had not. A leading doctor in the field of Lariam effects, Major Dr. Remington Nevin, who is referenced in the motion, describes Lariam as "a horror movie in a pill".

Most of the world's major military powers have seen the evidence and have either banned the use of the drug or use it only as a drug of last resort. The US military no longer uses Lariam as its drug of choice. The Irish Medicines Board first highlighted the risk of neuropsychiatric side effects in its Drug Safety Newsletter in May 1996. Information leaflets were updated in 2003 with details of reported suicides and suicidal ideation related to the use of the medication. However, the Defence Forces and the Minister for Justice and Equality state that there are no plans as yet to discontinue its use. We are not satisfied with the Minister of State's replies to date as to why this position can be justified.

The controversy around Lariam does not exist in a vacuum, as other Deputies have mentioned. It is just one of a number of issues relating to equality and fair treatment for members of the Defence Forces. The ongoing financial hardships affecting Defence Forces families were raised again during today's Leaders' Questions. The Labour Party has regularly sought an upgrade of the ability of Defence Forces personnel to negotiate their terms and conditions of employment. Such an upgrade would in turn have an impact on the ability to earn an income without having recourse to family income supplement. PDFORRA has long held the belief that, for truly effective and equitable negotiations to be undertaken on behalf of its membership, affiliation to ICTU is imperative. This would allow the Defence Forces to have access to the Workplace Relations Commission, WRC, for dispute resolutions and to be involved in national pay bargaining like other workers. Without recourse to the WRC, Defence Forces personnel are denied an avenue that is open to many other workers to have issues relating to their rights and equality to be heard. That is why this motion and the work of Deputies are so important for the Defence Forces when it comes to an issue like Lariam.

The Minister of State has heard the arguments for a long time. The facts are incontrovertible. He should accept this motion. It has support across this side of the House. It makes sense and will save lives. This is an opportunity to put new politics into practice. Please support this motion. Put the issue to bed once and for all. Acknowledge the scientific evidence. Get the issue off the agenda and move on to the financial hardships affecting Defence Forces members and their families. We as a party support this motion.

I draw the Minister of State's attention to an excerpt from his speech where he stated:

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 in this country are not experts in this field though. We need to take a lead from health experts across the world who are telling us something different from what medical personnel within the armed forces are telling us. I urge the Minister of State to reconsider and support the motion.

Deputy Mick Barry

I welcome the members of the Action Lariam for Irish Soldiers group, the Wives and Partners of the Defence Forces group and PDFORRA who are in the Gallery and watching this debate on television. I believe that a large number of people around the country are paying careful attention to what is being discussed in the House.

In light of issues of muscle ache, memory problems, mood changes, insomnia, anxiety, depression, hallucination and suicidal ideation, it is clear that Lariam is a little pill that can have big side effects. In 2013, RTE's investigations unit found that the members of the forces surveyed who had used Lariam were three to five times more likely than others to take their lives. The Minister of State reported that no serving member of the Defence Forces had died from malaria, but how many does he reckon might have died from this anti-malarial? That was a factor.

Information has been laid before the House about the number of military establishments around the globe that have either banned Lariam or made it into a drug of last resort. The US, the UK, Australia and Germany are among them. The UK's Defence Select Committee referred to Lariam as a drug with a high risk profile and that it should only be prescribed to those who were unable to take any of the available alternatives. The Ministry of Defence in the UK has acknowledged that 1,000 ex-military personnel are suffering severe psychiatric problems as a result of Lariam. The United Nations guidelines are clear and indicate that an alternative drug or drugs should be provided for personnel who are sensitive to Lariam.

I wish to ask the Minister of State a direct question. The next time that he visits troops in sub-Saharan Africa and is in need of anti-malarials, will he take Lariam? People who lead organisations should be prepared to do themselves what they expect the rank and file to do. They should not expect them to do what the leaders are not prepared to do.

I have a further question for the Minister of State. Is it the case that officers in the Defence Forces who go to sub-Saharan Africa and who are in need of anti-malarials are offered a choice?

Deputy Paul Kehoe

No, they are not.

Deputy Mick Barry

The Minister of State can confirm that in the House.

Deputy Paul Kehoe

I confirm that absolutely.

Deputy Mick Barry

Okay. We would not want a double standard within the Defence Forces in this regard. I note the assurance that the Minister of State has given the House. It is an important point.

A number of Deputies have stated that there is a bigger picture. I agree with that point. Members of the Defence Forces are denied trade union rights.

Not alone do they not have the right to strike, but they do not have the right for their representative organisation to bring cases to the Workplace Relations Commission and they do not individually have the right to bring grievances before the likes of a rights commissioner. In fact, as I have pointed out in the House before, they do not have the right to bring a grievance to a Deputy's clinic. It is inevitable that when workers do not have the right to join a trade union they will be more exploited than workers who have that right. The two things cannot be separated. We see it in the Defence Forces in terms of the low pay and the huge amount of annual leave which is built up, which is not carried over and for which people are not compensated. We see it in Baldonnel with regard to health and safety. We are seeing it here with regard to health and safety around the anti-malarial drug, Lariam.

I congratulate Deputy Ó Snodaigh and his party on tabling this motion. We will be giving the motion our full support. I recently noted a report in The Sunday Business Post, which quoted sources, which I believe may have been former senior personnel in the military, who expressed concern about the fact that issues were being brought to the floor of the Dáil by Deputy Ó Snodaigh, myself, members of the Sinn Féin Party and members of Solidarity. They were concerned that that was the case. I make the point to those sources that we are bringing up issues that, in the past, have been brought to the doors of the Minister's party and the Fianna Fáil Party. Those parties have not been as attentive to those issues as they could have, or should have, been. In fact, in some cases, a blind eye and a deaf ear have been turned. Is it any wonder that members of the Defence Forces and their families might come to the likes of Sinn Féin and Solidarity? Is it any wonder that they might knock on our doors and ask that we help provide a voice for them and bring their issues to the floor of the House? They will continue to do so, and even more so in the future, unless the likes of the Minister, his party and the Fianna Fáil Party start to listen to the genuine grievances and concerns of those members. One thing I am certain of from discussing this with members of the Defence Forces and their families over the last while is that the grievances are very significant and widespread. People have the bit between their teeth now. I do not believe they will let it go. The campaigns will continue, and we will continue to bring up the issues until such time as the Minister deals with them.

Deputy Clare Daly

I absolutely and wholeheartedly welcome this incredibly important motion which Sinn Féin has put forward. I thank it for giving up its valuable Private Members' business slot so that we could be here tonight. There is no doubt about it that this can be an incredibly frustrating place where one quite often thinks that one does not make a difference. In that sense, there are not many good days in here. I am probably the only one here, apart from Brendan, who is from a Defence Forces background. Many staff in the House are, and this is a very important day.

I am not in the habit of congratulating individuals on Private Members' business but Deputy Ó Snodaigh deserves a huge amount of credit for the patient work he has done on this issue. He has worked co-operatively behind the scenes without trying to steal a headline. It is because of this work that, when this motion passes, we will be one step closer to ensuring that no member of the Defence Forces will ever be forced to take the dangerous, neurotoxic drug Lariam again. That is incredible. It should not be, but it is because for years we have been listening to the same standard stock answers, which the Minister of State repeated today. He has said that nobody has died from malaria but was silent on the fact that people have died from Lariam. Tales of the precautions being taken by the medical profession are belied by the reality of life.

I welcome that, when this motion is passed, a majority of Members of this House will be acknowledging the horrific suffering of military personnel who have been given this terribly dangerous drug. Such an acknowledgement will not, of course, undo the damage that has been done to these men and women but we should still acknowledge it. It is the right thing to do because they have faced the most unspeakable intransigence and stonewalling from the Department in their quest to get justice over the years.

I disagree with the Minister of State's take on the legal action. The timing of this motion could not be more appropriate precisely because the first Lariam psychiatric damages cases are listed before the courts on Tuesday. The fact that they are set for a three-week hearing tells us all we need to know about what the State's approach will be. The Government intends to dig in, batten down the hatches, basically deny and probably employ very expensive legal counsel in order to bury citizens' attempts to get justice for the terrible wrong which was done to them. As far as I am concerned, this is one of the worst scandals in the history of the State and, let us face it, we have plenty of other scandals to compete with it.

We and the Department have absolutely clear, incontrovertible and undeniable evidence that Lariam is dangerous, damages the brain, its effects can be long-lasting or permanent, and it causes depression, hallucinations, mood swings, bipolar disorder, mania, paranoia, psychosis and suicidal thinking. I will not repeat the points other Deputies have mentioned but I will point out that the US Food and Drug Administration, FDA, is unequivocal in the wording in its safety report on Lariam in July 2013. It said: "Neurologic side effects can occur at any time during drug use, and can last for months to years after the drug is stopped or can be permanent." The European Medicines Agency is equally unequivocal in its conclusion. It says: "There is enough evidence from the presented drug safety reports, the submitted literature report and the FDA assessment report supporting a causal relationship between mefloquine and the occurrence of long lasting and even persistent neuropsychiatric side effects." The FDA statement is four years old and yet the Government is still forcing personnel to take this drug. Some 42 members of the Defence Forces have been prescribed Lariam this year. It is absolutely incredible. What does the Chief Medical Officer know that the US and British authorities do not know? He does not know anything different. His decision is backed up by stubbornness.

It is absolutely disgraceful, particularly when there are other drugs available. The Department's excuses do not hold up to scrutiny. We know that there is no reason for Malarone not to be used. Contrary to what the Department has said, the Health Products Regulatory Authority, HPRA, itself is clear that using it for more than 28 days does not go against the terms of its licence.

Other Deputies have said that country after country is ceasing to prescribe Lariam, yet we still threaten members of our Defence Forces with disciplinary action if they do not take it. Worse still, we have been told that they have to sign a waiver - and we have proof of this - before they start taking Lariam to say that if they so much as report experiencing intolerable side effects, Lariam will be discontinued and they will be considered forever unfit to serve in sub-Saharan Africa. This is so far away from the best medical ethical principle of "first do no harm" that we seem to have stepped into a different dimension altogether. It is completely unacceptable.

I was going to recount the story of one of our personnel and the drug's impact on him in the hope that the Minister of State might be listening, but I am not sure that he is. This man started taking the drug when he was in sub-Saharan Africa and almost immediately experienced problems. The problems continued with clinical depression when he returned home. He had many more physical problems but he put them down to other causes. He was never told the side effects. After collapsing with seizures, he stopped breathing. He knows he is not the only one. Hundreds have presented with problems. The doctor who examined him did not even know that depression was a side effect.

I salute the efforts of the people in the Gallery - the Action Lariam for Irish Soldiers group, Tony, Mark and their families who have had to put up with them through this battle for justice over the years - along with Andrew Bryce, Remington Nevin and so on.

Their efforts contrast starkly with the Department's intransigence. The Department insists that doxycycline is unsuitable for malaria because it cannot be taken in conjunction with dairy products. The Minister of State repeated that tonight. Is he even listening to himself? If that was the reason and was a valid concern, would it not be better to recommend to members of the Defence Forces taking the drug to protect their mental health but to give up milk while doing so? However, of course, we know it is not a valid concern because it is completely false. The Minister of State's assertion is incorrect because the HPRA has confirmed no advice is given to avoid the consumption of dairy products in the diet while taking doxycycline.

This debate has been riddled with falsehoods from the Department with enormous consequences for the health and well-being of the men and women in our Defence Forces and their long-suffering families. We will see what happens with the court action, but it is time for the Department to acknowledge the terrible wrong done to those harmed. The Minister of State should take steps to compensate them for that. We should not drag people through the courts when we know what the outcome will be. The Minister of State should hold up his hands and apologise, and let these men and women now move on with their lives.

Deputy Michael Harty

I welcome this motion and will be supporting it.

There is a well-known Latin tag used in the medical profession which is "primum non nocere" meaning "first do no harm". This applies to all interventions in medical practice, including prescribing when treating diseases as well as actions which are designed to prevent disease. Malaria is a very serious disease which can be debilitating, chronic, relapsing and fatal. Taking treatment to prevent its development makes perfect sense, therefore, and it would be negligent not to do so, but no treatment is without some risk. Where several treatments are available, choosing the most effective treatment, balanced with that which has the least side effects, is the best option.

Another factor that has to be taken into account when prescribing or offering any form of treatment or prophylaxis against disease is that of informed consent. Effectively, this means that the patients must have full understandable information given to them prior to prescribing the medication so that they can decide if they want to take it. Additionally, they should be informed of alternative treatments and the risk profile of those treatments. This can be a time consuming task, but it is absolutely necessary so that informed decisions can be made. It is best and safest to ensure that this has been undertaken and, for everyone's protection, signed consent should be obtained for a treatment that has controversial side effects.

Lariam - mefloquine - has several serious side effects which include depression, anxiety, hallucinations, psychosis, violence, suicidal ideation and possibly suicide. As some people are at greater risk of developing these side effects, a full face-to-face assessment should be undertaken to identify those who would be most at risk and to offer alternative medication. However, such assessments will not eliminate the development of side effects in all recipients. The lessons to be learned are that this drug, while being effective in preventing malaria, has a high risk-benefit profile. In the case of Lariam, mefloquine, this is a classic case of first do no harm, get informed consent and carry out a pre-treatment risk assessment.

There are several types of malaria and several treatments. Not all treatments are effective against all varieties of malaria so one has to balance the risk versus the benefits of each treatment. Medicine is not an exact science but safety must be a priority. There is a worrying trend in medicine which is to deny evidence of side effects of treatments until the evidence is overwhelming and obvious. We should have early-warning systems which pick up adverse reactions to medications early and then take appropriate action. I believe Lariam should be used as a drug of last resort and not a drug of first resort.

An Leas-Cheann Comhairle

I call Deputy Mitchell, who is sharing time with Deputy Buckley.

Deputy Denise Mitchell

I welcome the opportunity to speak on this important motion. I express my sincere thanks to the work done by members of our Defence Forces, particularly those young men and women, many from my constituency, who are serving overseas on United Nations peacekeeping operations. We all admire the fantastic work done by members of the Naval Service in the Mediterranean in helping to rescue those unfortunate people fleeing war and conflict across the Middle East and Africa.

For over 20 years, Lariam has been the first-choice anti-malarial drug given to Defence Forces personnel on deployment to sub-Saharan Africa. However, over the years there has been increasing focus on the side effects of this drug not just here in Ireland, but internationally. Research shows that the drug affects the limbic system, the part of the brain which control's a person's emotions and behaviour. The side effects range from very common symptoms such as insomnia to depression, anxiety, panic attacks, aggression, hallucinations and paranoid suicidal tendencies - the list is horrific.

The US Army Special Operations Force determined in 2013 that due to the warning of potential long-lasting serious mental health problems, it was ceasing using the drug, stating that "consideration must be made for the impact of this medication on our population". In Britain, a House of Commons select committee was very critical of the use of Lariam. Soldiers explained how they suffered memory loss, insomnia, mood swings and hallucinations. It is worth noting that restrictions on the use of Lariam in Britain, even before the 2016 report, had been placed on aircrews, divers and those operating heavy machinery. There are also serious concerns that the use of Lariam may present difficulties when it comes to diagnosing post-traumatic stress disorder.

As there are a number of safer alternatives to Lariam, it beggars belief that this drug should remain the anti-malaria drug of choice for our Defence Forces. Denmark, Germany, the Netherlands, France, the Czech Republic, Australia, Canada and Belgium all prefer their personnel to use an alternative to Lariam. Therefore, what is the justification for keeping it as the go-to treatment here? A year ago, the drug was removed from general sale in Ireland, yet it continues to be used by members of the Defence Forces for whom it remains available via wholesalers. The removal of this drug from the general market, coupled with its downgrading to a last-resort drug with other militaries, should have set alarm bells ringing. It is just unbelievable. Now that there are proven and safer alternatives, I see no reason that Lariam should continue to be the anti-malarial drug of choice for our Defence Forces. Instead it should be only used as a last resort, for those unable to tolerate any of the alternatives. I am also disturbed by reports from members of the Defence Forces who have stated they were not screened properly for this drug and were not told the full facts of the side effects. The State has a duty of care to all of its citizens.

Further to this motion, I hope the Government will ensure that all serving and retired Defence Forces personnel who have been given Lariam, will be provided with proper supports and counselling services to aid their recovery from the side effects.

Deputy Pat Buckley

I welcome the members of various groups who are in the House. I also thank Members from all parties, especially those who have committed in advance to supporting the motion. It is a great encouragement to the women and men of the Defence Forces who have been affected by this scandal to now see such support for measures to cease the administration of Lariam and to deal with the problems faced by many who were administered it while serving their country. We all know that Lariam was given to members of the Defence Forces when serving in sub-Saharan Africa. The problem is that the drug was supposed to protect against serious illness but has ended up causing serious illness. We all know about the psychotic breakdowns, suicidal ideation and other side effects. I could spend an hour and a half listing them out. The side effects have led to tragic circumstances and deep suffering for members of the families of those affected, the survivors and spouses.

The Minister of State said that this is not a political decision, but a medical decision. I am surprised by that because the manufacturers of the drug told the Government not to give Lariam to soldiers. One could not write it. It is now 20 years later. I cannot believe it. The Minister of State also mentioned experts. The survivors and their partners and those suffering from the side effects of Lariam are the real experts. They are the people to whom we should be listening. More than 4,500 soldiers were given this drug by the Defence Forces without any comprehensive screening. I spoke to many soldiers who can tell what happened. A former Deputy referred to Dr. Remington Nevin who described Lariam as a "horror movie in a pill". I would go so far as to say it is a horror reality in a pill for the people I heard today.

We all know that the US military discontinued the use of Lariam and the US Food and Drug Administration launched a full neurological review of the medicine. As early as 1996, the Irish Medicines Board highlighted the risk of the side effects of the drug in a safety newsletter. What was done? Nothing. It was a case of pushing it under the carpet, again. We are getting very good at sweeping in this country. The Government and the Defence Forces did nothing to protect military personnel from the serious side effects of Lariam. The administration of Lariam as a drug of first choice by the Defence Forces must end immediately.

I wish to refer to other issues affecting the mental health of members of the Defence Forces. We are very quick in this House to laud the work of those women and men when it comes to their heroics in peacekeeping missions around the world. This is rightly so, but we must do right by them as they have done right by the nation. Currently, many Defence Forces personnel are living from week to week and hand to mouth because of the disgustingly paltry rates of pay for ordinary soldiers. New entrants earn just €200 a week, and that increases to €350 a week in their second year. The wages do not increase much more after that. It is impossible in the long term for a person to feed, clothe and house a family on such wages. In 2003, a total of 49 people in the Defence Forces were in receipt of family income supplement and by 2016 the number had risen to 124.

I commend the families of Defence Forces members who have been campaigning hard on this issue. Often it appears that the Government has no interest in listening. Shelley Cotter of the Wives and Partners of the Defence Forces, and all its members deserve a very honourable mention in this House tonight. Hopefully, we will soon see members of the Defence Forces being allowed the proper rights of workers, namely, the right to argue for better pay and conditions, but until then the Government should step up.

Today, unfortunately, there was a need to launch another campaign of fund-raising for veterans of the Defence Forces who became homeless in 2017. One can hardly say it is a surprise when soldiers are treated so poorly and we have such a catastrophic homelessness crisis in this State which still rages on. I appeal to all Members in this House to please show a bit of compassion and to support this motion.

Deputy Tony McLoughlin

Malaria is a very serious disease and is a serious threat to any military force operating in areas where the disease is prevalent. First and foremost, the decision on which anti-malarial drug to use must be one for medical professionals. This House should not prescribe to doctors what medications they can or cannot provide to their patients. On such matters, the priority should always be the health and well-being of the men and women of the Defence Forces who serve Ireland with distinction.

The Minister of State, Deputy Kehoe, has outlined the significant precautions that are taken by medical officers in the Defence Forces when assessing the medical suitability of an individual to take any of the anti-malaria medications. It is the policy of the Defence Forces that personnel are individually screened for fitness for overseas service and medical suitability. The medical procedures involved in assessing personnel before deployment are designed to ensure that personnel who may be contra-indicated or sensitive to Lariam are not prescribed it.

The House has been informed that a working group is currently examining developments in the context of the Defence Forces' use of malaria chemoprophylaxis. The group is continuing to engage with national and international experts. Its second report is due shortly and I look forward to this report being provided to the Minister. I know that he will consider the group's recommendations. I welcome confirmation that the group is considering options to formalise the provision of ongoing external medical advice. That will ensure the Defence Forces policy on malaria chemoprophylaxis continues to be kept under ongoing review.

While speaking on this topic, I wish to take this opportunity to reflect on and acknowledge Ireland's contribution to international peacekeeping. We have a long and honourable tradition of supporting the United Nations in the cause of peace, stability and security. The Defence Forces have brought great honour to this country through their participation in peace support operations. I pay tribute to those serving and former members of the Defence Forces for the important role they have played in this country's contribution to peacekeeping missions and to remember the 86 members of the Permanent Defence Force who have paid the ultimate price in the cause of peace.

As a member of the Joint Committee on Foreign Affairs, Trade and Defence I acknowledging the valuable peacekeeping role that our Defence Forces play overseas. It is important that we do all we can to provide them with effective protection from any diseases they are likely to encounter in the course of their duties. I hope we do not underestimate the seriousness of contracting malaria. Anti-malaria medications remain in the formulary of medications prescribed by the medical corps for Defence Forces personnel on appropriate overseas missions to ensure that our military personnel can have effective protection from the very serious risks posed by malaria. The discussion of these matters in this forum when there is ongoing litigation and particularly when the first court case is due for hearing next week, certainly limits any discussion that may be had. I welcome the Minister of State's indication that the working group is considering options to formalise the provision of ongoing external medical advice. We should all be mindful that any decision on what medication to prescribe is a matter for doctors, not Deputies.

Deputy Donnchadh Ó Laoghaire

Malaria is a very serious disease that can cause severe complications and death. Tá sé tomhaiste ag an Eagraíocht Dhomhanda Sláinte go gcailltear thart ar 1 mhilliún duine ón ngalar seo san Afraic amháin gach bliain. Feictear ar mhaláire i gcónaí mar ghalar an-dainséarach d'fhórsaí míleata sna háiteanna ina bhfuil sí forleathan. According to the World Health Organization, WHO, in 2015 there were 91 countries and areas with ongoing malaria transmission.

Is féidir an mhaláire a leigheas agus is féidir cosc a chur ar tholgadh na málaire. Is dócha go bhfuil go leor réitithe do sin. It is in this context that no one can doubt the importance of safeguarding Defence Forces personnel against malaria and protecting them in the best possible way.

Lariam which contains the active ingredient mefloquine, has been associated with psychosis, suicidal thoughts, depression and hallucinations. These are very serious conditions that have long-term implications for family and loved ones also. The drug has been administered to Irish soldiers serving in Liberia, Chad and sub-Saharan Africa since 1994. Warnings on the use of Lariam go back to as early as 1996 when the UK Committee on Safety of Medicines issued a warning on the side effects of Lariam. In 2015, Roche Products announced it was ceasing production of the drug. I commend my colleague, Deputy Ó Snodaigh, and Wives and Partners of Defence Forces Ireland, WPDF, on their efforts on this issue and especially Deputy Ó Snodaigh on tabling the motion, which calls in the Government to ban Lariam. In September 2016 in advance of this debate Deputy Ó Snodaigh called on the Government to ban Lariam, adopt a programme of care, provide the supports to affected military personnel in the form of medical cards and other forms of compensation. All these measures should be considered.

Following on from tonight's debate on the motion, we would ask the Government to provide for the carrying out of toxicology tests on users, make the results public and provide a treatment programme for those who require it. Those who served in years gone by must also be given the assistance they require, to ensure the best quality of life as possible. This should be forthcoming from the State. Sinn Féin would also ask that the Government establishes an independent inquiry to look in detail at Lariam and its effects, a practice which has been carried out in other jurisdictions. In Britain, 1,000 former military personnel have required psychiatric treatment as a result of the after-effects of taking Lariam. The fact that Lariam has been withdrawn from sale to the general public in Ireland should have alerted the Minister of State to make a safer anti-malaria drug available for non-commissioned soldiers in the Army. It is vitally important to remember that Lariam was not the only option; other options were outlined by other Deputies. Deputy Clare Daly rebutted - quite effectively - one of the excuses used by the Minister of State and the Department for not using one of the products doxycycline, the excuse being that it had to be taken on a daily basis. There are many other aspects in the context of military logistics that I am sure also require that level of attention.

There is also the element of respect to be considered. Deputy Buckley, rightly, raised the issue of members of the Defence Forces who are really on the breadline. New members of the Defence Forces earn just €200 per week increasing to €350 per week in their second year. I know guys who joined the Defence Forces three or four years ago, fellas my own age, and they and many others are talking about leaving. It just does not pay. They are joining at the age of 22 and 23 and leaving when they reach the age of 28 or 29. It is simply not a viable career for people. The lack of respect that is shown to the Defence Forces in relation to pay is also reflected in the area under discussion now. I commend Deputy Ó Snodaigh on the motion and I commend all the Deputies who are supporting it. I call on the Government to recognise the reality and the threat this drug poses to the men and women of the Defence Forces and to ensure its discontinuation.

Deputy Aengus Ó Snodaigh

Ba mhaith liom ar dtús báire mo bhuíochas a ghabháil leis an 13 Teachta eile a thapaigh an deis páirt a ghlacadh sa díospóireacht tábhachtach seo. Measaim go bhfuil sé ceart agus cuí go bhfuilimid ag déanamh é seo anocht agus go bhfuil roinnt dóibh siúd a bhfuil an nimh seo ina gcoirp toisc gur bhrú na Fórsaí Cosanta orthu é a ghlacadh anseo linn agus a gclanna le roinnt dóibh. Tá sé ceart agus cuí go bhfuil roinnt clann a bhfuair a mac nó a n-iníon bás de thairbhe féinmharaithe anseo chomh maith mar tá na ceisteanna sin ar fad fite fuaite le ceist Lariam.

I am surprised at the Minister of State because I thought just by virtue of the fact that he did not table an amendment such as the Government would usually submit that he and the Department might have come to their senses. I knew nothing of the court case happening on Tuesday. It would not have swayed me one way or the other.

We are right to have a debate on Lariam in the House because we are not debating individual cases. It is important to note that, by chance, we are having the debate on the same day as fuschia appeal day, which raises funds for ex-service men and women. It is a coincidence because our Private Members' business comes up only once in a while. We were at the launch of that appeal for moneys and for help for ex-service men and women and now here we are in the Chamber to appeal to the Government to help those service men and women who are affected by the toxicity of Lariam.

The Minister of State's answer is the same palaver that we have had day in, day out since I have been raising this issue. I first raised it in 2010 along with Deputy Brian O'Shea, who had been the Labour Party spokesperson on defence. Quite a number of others also raised the issue, and I listed them earlier in the debate. All that we asked was that the Minister of State could have looked at report after report. This is why I have this wad of papers with me tonight. These are reports. I did not write them, I am not a medical expert and I do not know half of the words contained within them. I do know, however, what the conclusions are and every single one of them is very, very stark. They say that this is a poison and it is dangerous and do not give it to a child, a dog or whoever and definitely do not give it to a person who is going to be in charge of mechanical vehicles or guns. What do we do? We do just that and every time there is a detachment of the Defence Forces sent in to sub-Saharan Africa, or elsewhere, we are poisoning those who end up with the side effects. Luckily for us not everyone is affected.

There is the argument that we are not medical professionals and that we should not get involved but it must be remembered that medical professionals and some pharma industries have poisoned communities over the years and are not infallible. They make mistakes. We all make mistakes. Sometimes it is good for us to stand up and say we made a mistake, something is wrong and we cannot undo it but can stop it from happening to anybody else. Ultimately, that is the appeal in this motion.

The motion I produced previously was much stronger and went a lot further. It is still my view that all the steps contained in the motion, to which Deputy Ó Laoghaire alluded, are still required to happen. The motion before the House today is for the Minister of State. He has the power to instruct the military authorities to take decisions, which in this case would be to end the use of Lariam and also to set about trying to tackle the effects of the use of Lariam on those who have side effects to make sure they and their families have the required supports. In other cases, where major medical side effects were identified, such as in the use of thalidomide, it is considered that the State should step in and help those affected by a State policy. That is all we are seeking. We wish to ensure those men and women who are affected have medical cards and are provided with psychiatrists or whatever specialist is required.

I find the debate sad. I thought earlier when I was discussing the matter with the delegations which came to the House tonight for the debate that perhaps the Government would not oppose the motion given the fact that, thankfully, the Opposition, which is larger than the Government on this occasion is going to support it tomorrow because they have signed up to it. It appears that the motion will pass. Beyond that, if the Dáil directs the Minister of State to do something, he could take the required steps to instruct the military authorities to live up to the message we will send to them when we sign up to the motion tomorrow.

I thank everybody for helping me to get to grips with this over the years, especially those who shared quite traumatic personal details. All of us who have listened to their testimony have been affected by it. That is why I was adamant that I would bring this motion before the House at the earliest possible opportunity. A few years ago, I would not have had a chance of getting it passed. Thankfully, the groups I have mentioned have managed to persuade many other people of the rightness of their cause. I hope the Minister will see the light before too long.

Question put and agreed to.

Dáil Éireann debate - Wednesday, 28 Jun 2017

Anti-Malarial Medication: Motion

Dáil Éireann debate -
Wednesday, 28 Jun 2017