That's a good Scottish name, and the Ritchie side came over, and we were in Canada before the American Revolution, so my roots go way back with you.
But today I'm going to tell you a story. It's going to be a brief story, but it will cover some 25 years.
I was an army psychiatrist until my retirement in 2010. I now work for the Washington, D.C., Veterans Health Administration, its hospital, but I speak as an individual, not as an organization.
The themes I am going to touch on today, over the last almost 30 years, are the lack of informed consent around the use of mefloquine; the lack of screening for post-traumatic stress disorder, traumatic brain injury, depression, and other psychiatric illnesses; the lack of documentation around both giving the medication and any side effects; how you distinguish mefloquine use from post-traumatic stress disorder and traumatic brain injury—PTSD and TBI—and there are ways to do it, but it is not always easy; and finally, the intersection that we have seen through time with combat warfare and domestic violence.
So I'm going to pick three points. The first point is Somalia in 1993; the second point is Fort Bragg in 2002; and the third is the long wars in Iraq and Afghanistan, but focusing on the massacre of Afghan villagers by Staff Sergeant Bales in 2012.
I hope my tale will lead in to what Dr. Nevin and Dr. Passey will be testifying to.
I deployed to Somalia in 1993 as part of Operation Restore Hope. I was with the combat stress control out of Fort Bragg, North Carolina, the 528th—and if you're in the army at this point you say, “Hooah”; the marines have a different version. The first night that I got there, there was an army soldier evacuated out of Somalia, out of Mogadishu, who was totally psychotic. We later learned that he had probably taken mefloquine on a daily dose, rather than weekly as prescribed.
Back then, in 1993, we did not know that much about the neuropsychiatric side effects of mefloquine, and we sat in the circles with the preventive medicine officers and debated the risks and benefits of getting malaria versus using mefloquine, and we thought compliance would be enhanced by taking a medication that was once a week, rather than daily, as are Malarone and doxycycline.
So mefloquine was widely accepted—I took it myself—but there were, at that time, the beginnings of rumblings about “mefloquine Mondays”, or “psychotic Tuesdays”, or “rage Thursdays”; the days that the battalions would be administered in formation, and the bad dreams and the nightmares that followed. And then one day I was asked to do an assessment on Corporal Matchee. You know that story well. He had tried to kill himself the day before because of an investigation into the torture and murder of a Somali boy. When I went to see Corporal Matchee, he was comatose, essentially brain dead—at least we thought so at the time.
The rumours began to grow about the increased irritability and violence that mefloquine led to. And I'm sure you're going to come back to that time in Canadian history, because your military has never recovered from that investigation, that incident.
I'm going to go forward to Fort Bragg in 2002. At that time, 9/11 had happened and we were sending troops into Afghanistan; they were deploying.
In the summer of 2002, there were four murders of wives and two suicides at the same time. The staff sergeant was a cook named Griffin. He never deployed. He was not on mefloquine. The next three were Sergeant Nieves, Sergeant Floyd, and Sergeant Wright. I was part of a team that came down. I was working at the Department of Defense health affairs at the time. I went with an army team. We looked at the intersection of mefloquine and violence.
Again, a recurring theme here is that it's hard to sort out what is what, but let me tell you briefly about these situations.
Sergeant Nieves had just returned from Afghanistan. He was on mefloquine. He and his wife argued, and he shot her and then himself. Sergeant Floyd had come back six months before he killed his wife and himself. I thought at the time then, as did all of us, that if the drug did influence behaviour, that would have been six months ago. He was acting paranoid and weird at the time of the murder. Finally is the case that troubles me the most to this day. Staff Sergeant Wright was a high-speed, low-drag, special forces soldier. He had gotten promoted, and came back, and was on mefloquine. He either clubbed his wife to death with a baseball bat or a cup or strangled her—it's not clear—probably in front of his kids. He dragged his wife's body off to a shallow grave where he led police three weeks later. He went to jail. He was allegedly delusional, paranoid, anxious, and seeing and hearing things in jail. He hanged himself six months later.
Back then in 2002 we thought the incidence of neuropsychiatric side effects was very low, like one in ten thousand or one in sixteen thousand. The research done was often done on travellers from the Netherlands who were going to Thailand and taking hallucinogens, and how could they attribute this to mefloquine? But in the years since then, partly because of the work of my colleague Dr. Nevin and others, we've recognized the increased incidence of neuropsychiatric side effects, so most estimates are 25% to 50% of people on mefloquine have neuropsychiatric side effects depending on how we define the effects such as bad dreams or nightmares. Dr. Nevin's going to talk about this a little bit more.
I'd like to close with a couple of cases. In Iraq we were on mefloquine the first year we were there, but then it was found not to have much malaria there, and it was stopped. In Afghanistan troops were on it pretty much over the course of the long conflict, although over time we switched from mefloquine to doxycycline or Malarone because there was increased recognition of the neuropsychiatric side effects.
Having said that, there's only one suicide I know of that's directly attributable to mefloquine, Specialist Yuan Torrez in 2004, but the episode I'd like to close on is that of Staff Sergeant Bales. You may remember Staff Sergeant Bales. In 2012 he went out from his sleeping quarters, went to two different villages, massacred 16 Afghani civilians, wounded a number of others, and burned their bodies. He was apparently dressed in a bizarre fashion and having visual hallucinations.
When I first heard of this, I thought instantly that this was a mefloquine reaction, especially with the delusional paranoid behaviour—and you will hear about this over and over—and the visual hallucinations. As it turned out, Staff Sergeant Bales was on mefloquine in Iraq. He had a traumatic brain injury so he should not have been on mefloquine. It is still unknown whether or not he was on mefloquine at the time of this incident. He was prescribed doxycycline. We know he didn't take it. He was in an area where mefloquine was used commonly by special forces soldiers back at that time. It's not used by the special forces anymore. They have completely stopped using it.
What's most troubling about this case, whether or not he was on mefloquine or steroids and alcohol, as he seems to have been, is you have the same themes I talked about in the beginning, a lack of informed consent, a lack of screening for TBI, and a lack of documentation.
The Army never said whether he was on it or not, and I believe they did not know.
What is totally clear is the political damage this did to the United States military in our relationship with the country of Afghanistan. I will make the argument that it is too dangerous to put our soldiers and marines, who are handling weapons, may be stressed from other sources, may have post-traumatic stress disorder or traumatic brain injury, and are often in field situations where it's hard to do a good medical assessment.... I would argue that no service member at this time should be placed on mefloquine. The potential for violence is too great.
I see that the screen has just gone dead, so I will conclude my remarks here. I believe Dr. Nevin will talk about the “black box” warning that has been placed on mefloquine, again recommending against using it because of the multiplicity of neuropsychiatric side effects, including paranoia, irritability, delusions, and visual hallucination, which lead to the conclusion that it has severe neurological toxicity.
Thank you very much for your attention.
Thank you very much, Mr. Chair. It is a great privilege to be invited to address the committee today to discuss the anti-malarial drug mefloquine.
I'm Dr. Remington Nevin. I'm a former U.S. Army preventive medicine physician. I received my medical training at the Uniformed Services University School of Medicine, and I've earned master's and doctoral degrees in public health from Johns Hopkins University. I completed residency training at the Walter Reed Army Institute of Research, and I'm currently completing a post-doctoral fellowship in occupational and environmental medicine at Johns Hopkins University.
I have 14 years of active U.S. medical service, including overseas tours in malaria-endemic areas in Africa and Afghanistan, where I had the honour of serving briefly alongside Canadian Forces personnel at Kandahar.
It was in Afghanistan where I first became interested in mefloquine, particularly in the adverse mental health effects of the drug. In the nearly decade since, I have authored or co-authored three dozen book chapters, letters, and peer-reviewed articles in various scientific and medical journals on the topic of malaria or anti-malarial drugs, including mefloquine to include, with Dr. Ritchie, what was the first review in the forensic psychiatric literature of the drug's affects.
I've received a $264,000 grant from the U.S. Army to study the genetic basis of susceptibility to mefloquine's adverse effects, and I've undertaken a number of other pharmacovigilance studies of the drug, including a detailed analysis of reported adverse event data that is pending publication. My doctoral thesis from Johns Hopkins is titled “Pharmacovigilance of Neuropsychiatric Adverse Reactions to Mefloquine”.
In recent years, my research in this area has broadly informed the rapidly changing military policies on the use of mefloquine, as well as a recent regulatory re-evaluation of the drug in the United States and in Europe. For instance, I offered evidence to the U.S. Food and Drug Administration prior to its directing the edition of a boxed warning to the approved mefloquine drug label in 2013. My work also directly informed the prohibition on the use of the drug among personnel of the U.S. Army special operations command later that year. I've previously offered evidence concerning mefloquine to committees of the U.S. Senate and the U.K. Parliament. I've also been retained or offered evidence in a number of civil and criminal cases on behalf of clients alleging adverse effects from the drug.
I should emphasize that I have not accepted sponsorship or received any funding from pharmaceutical companies for my work, and the opinions I offer today are my own and not necessarily those of my employer, Johns Hopkins University.
Mr. Chair, I would like to offer members of the committee, to begin, a brief review of what is now known of the drug's chronic adverse mental health effects, and then describe how in certain other countries, including the United States, growing awareness of these effects has recently been informing improved evaluation and care of veterans who may have been prescribed or otherwise have been issued mefloquine during their military service.
For many years it was believed, erroneously, that mefloquine had no long-term mental health effects. It was believed that, once the drug was fully cleared from one's system, any adverse mental healths would resolve. However, as drug regulators in both United States and Europe have specifically acknowledged, in some patients, the use of the drug is associated with a risk of mental health effects that can last for years after use and in some cases may even be permanent. The reasons for this are not yet fully understood, but it is known that unlike some other safer and better tolerated anti-malarial drugs, mefloquine is a neurotoxicant, meaning that as with lead or mercury, it is a substance that is capable of causing serious disruptions in the function of cells in the central nervous system and potentially causing permanent injury to these cells. More concisely, the intoxicating effects of mefloquine can cause an encephalopathy and then a neurotoxic injury to the brain.
In retrospect, it appears this property of mefloquine has been known for some time. For example, ever since the drug's licensing in the United States, over a quarter of a century ago, in 1989, the original drug manufacturer, Roche, has alluded to this potential warning on the drug labelling that if certain so-called “prodromal symptoms” developed during use of the drug, such as anxiety, depression, restlessness, or confusion, the drug should be immediately discontinued to reduce the risk of what was euphemistically referred to as “a more serious event”. In extreme cases, this more serious event was even acknowledged as encephalopathy, and often manifesting as a deep confusion, or delirium, or severe amnesia, along with certain other severe symptoms such as psychosis.
As the boxed warning in the United States and similar warnings in Europe now suggest, this same encephalopathy is also now understood to carry a risk of much subtler but still lasting, and perhaps even permanent, alterations in mood, personality, cognition, behaviour, and sleep, including symptoms of insomnia, nightmares, anxiety, depression, and personality change.
Particularly among returning veterans, these lasting symptoms may risk being misdiagnosed, including as the effects of traumatic brain injury or post-traumatic stress disorder. However, as recent drug labelling changes in the United States and Europe should now make clear, in many cases these symptoms may actually have nothing to do with combat exposures, but simply reflect nothing more than the toxic encephalopathic effects of the drug.
For example, in one recent study of Danish travellers who had previously reported adverse effects while using mefloquine, 21% of those reporting nightmares and 33% of those reporting cognitive dysfunction while taking the drug identified that these adverse reactions as still persisting over three years after use of the drug.
Unfortunately, in Canada, veterans, physicians, and even government officials may not be aware of this. Unlike in the United States and Europe, Health Canada has not yet directed an update to the mefloquine drug labelling to reflect this new knowledge. Perhaps as a result, the , the Honourable Kent Hehr, recently informed a Canadian veteran, quite incorrectly, that there are no long-term effects from taking mefloquine.
In contrast, in a growing number of other countries, including the United States and Australia, these long-term effects are at least reluctantly acknowledged. Steps are beginning to be taken to care for veterans who may have been affected by them. In the United States, the U.S. Army special operations command issued an order acknowledging that the effects of mefloquine “may confound the diagnosis of PTSD and TBI”, and directed that commanders and medical personnel “address and assess the possibility and impact of mefloquine toxicity in their populations”.
The U.S. Department of Veterans Affairs is taking steps to begin to study affected veterans, and recently awarded the first long-term disability claim for symptoms, in this case chronic sleep impairment and frequent panic attacks attributed to service-connected use of the drug.
This year, legislation was introduced in the U.S. Congress to expand the mission of various centres, including the Center for Deployment Health Research, and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, so as to include the clinical evaluation, diagnosis, management, and epidemiological study of adverse health effects among U.S. veterans following exposure to mefloquine.
In Australia, their Repatriation Medical Authority, or RMA, has recognized a number of conditions as being potentially caused by mefloquine and for which disability benefits may be awarded. These include primarily lasting neurological disorders associated with use of the drug, but also certain psychiatric disorders, including depressive disorder and bipolar disorder. RMA is reviewing the role of mefloquine in anxiety disorder, panic disorder, and suicide and attempted suicide as well.
It is on this issue of suicide that I will conclude my prepared remarks.
Today we recognize that symptoms of severe encephalopathy that can occur most commonly during use of the drug may also carry a strong risk of suicidal ideation, completed suicide, and, in some cases, a risk of extreme aggression and even violence directed towards others. We are also beginning to recognize the role of this toxic encephalopathy in affecting the risk of suicide even many years after use. Almost all suicides need to be understood in a broader context of mental illness. As mefloquine increases the risk of lasting symptoms of mental illness, and as symptoms of mental illness are strongly associated with suicide, it should not be surprising that veterans who have been prescribed the drug appear to be at significantly increased risk of suicide.
However, we must also acknowledge how the potential mistreatment of mefloquine veterans may be further contributing to this risk. Although we know that some mefloquine veterans may be receiving care for their symptoms under a diagnosis of TBI or PTSD, we also know that many other veterans, including those without traumatic exposures or who had never suffered a concussion, and in whom these lasting symptoms may not be easily explained, have been accused of malingering, of having a personality disorder, or have been told it's all in their heads.
In some cases, these veterans have been discharged without medical benefits and left to fend for themselves. It should not be surprising to learn that some of these mefloquine veterans, mentally injured and cast out by the military that unwittingly poisoned them, would later take their own lives in desperation.
We have seen this, unfortunately, even in countries such as Australia and the United States where steps have been taken to recognize and acknowledge the problem. More needs to be done, and quickly, to acknowledge and better understand the lasting effects of the drug and how these effects may be treated, and to ensure that no veteran affected by these effects continues to suffer alone and without the care that they, through their service, rightly deserve.
That concludes my prepared statement and I would be pleased to take questions from members of the committee.
Good afternoon, ladies and gentlemen, and my fellow veterans. I greatly appreciate the opportunity to be able to speak to this committee.
To start off with, I'm going to just take you through a 40-year journey that I've been on since 1976 when I first entered into medical practice, eventually joining the Canadian Forces.
I started doing assessments and treatments for PTSD in 1993, and this was after research that I had done in 1992-1994 on one CER, 1 Combat Engineer Regiment; the 2nd Battalion of the Royal Canadian Regiment; and the 2nd Battalion of the Princess Patricia's Canadian Light Infantry that were deployed to the former Yugoslavia. At that time we basically found that about 15% of our UN peacekeeping troops coming home were showing signs of post-traumatic stress disorder.
Over the course of my career, I've managed to assess and treat veterans, as well as serving members, from World War I, World War II, Korea, Vietnam, Cambodia, Central America, Haiti, the former Yugoslavia, with Srebrenica, the Medak pocket, Sarajevo, Cyprus, the Golan Heights, etc., up to and including Afghanistan and both Gulf wars.
In 1993, as a result of my initial research, I had recommended to the Canadian military that we develop multidisciplinary mental health clinics at the brigade level to deal with the predicted significant increase in mental health casualties. General Dallaire's advocacy and support in the late 1990s resulted in the creation of the operational and trauma stress support centres in the Canadian Forces at the major bases across Canada. Eventually, this evolved into the Veterans Affairs-funded operational stress injury clinics.
I was part of a mental health team that deployed to Rwanda in the latter part of the summer of 1994. We were sent there as a result of my initial research with the Yugoslavian veterans, with the prediction that in Rwanda we'd have increased casualty rates.
It was interesting that while we were there, the rates of things like PTSD and depression were next to zero. There were, however, a lot of symptoms—and it was like, and was called, Nightmare Friday—like very serious and vivid dreams every Friday when we were taking the mefloquine. I originally deployed with the expectation that we would follow up on these troops at six months and a year later, but the Canadian military decided not to do that. This is unfortunate because there were medical personnel who had deployed on that tour who I knew personally who ended up committing suicide in subsequent years. My assumption was always that it was PTSD because I, like everyone else at that time, did not feel that mefloquine would be a problem once it was stopped.
I witnessed first-hand members of the mental health team I deployed with become paranoid, isolative, and inappropriately threatening, while taking mefloquine, to the point that one of the members pulled out a knife beside me at a team meeting and was playing with it in a threatening manner.
After our team redeployed home, a Canadian Airborne Regiment member, Corporal Scott Fraser Smith, committed suicide by a C-7 gunshot at the Kigali Stadium in Rwanda on December 25, 1994. An investigation into this suicide never really determined what caused it. Was it PTSD from his Gulf deployment, his deployment to Somalia and Rwanda and the expectation that the unit was to deploy to Croatia after in 1995? Was it the mefloquine? Was it a combination? Was it that combination in addition to the alcohol, because we were allowed to drink back then? Were there other stressful situations going on? We don't know.
In 1996, January I believe, I forwarded a letter to the committee members. I wrote a letter to the Somalia Inquiry wishing to testify and inform the inquiry, as well as members of government and the Canadian Forces medical system, about the effects of mefloquine, and my thoughts that it was affecting the Canadian Airborne Regiment members and their behaviour in Somalia, up to and including the death of Shidane Arone.
It was interesting because at that time, prior to my going to testify, my commanding officer came into my office and actually was giving me crap, saying that I shouldn't have volunteered to testify and that the Surgeon General at that time, General Wendy Clay, was quite upset that I had volunteered.
It was very interesting that approximately one week before my testimony the inquiry was shut down. At that time, in 1996, neither the government nor the Canadian Forces ever had an opportunity to look at this and do something about it.
I also forwarded a letter from 1998 to the committee, which I wrote through my chain of command, expressing my concern about the Canadian Airborne health issues. I requested a medical follow-up of all members of that unit, but it was never acknowledged and never attempted.
The lack of support from the government and the Canadian Forces, and the way the Canadian Airborne was treated upon their homecoming and their regiment's subsequent disbandment, guaranteed that there would be medical casualties up to and including suicides.
I want to change direction here just briefly. I'm not an expert on mefloquine. My area is PTSD, but I want to talk a little bit about brain disorders.
There is a great overlap between post-traumatic stress disorder; other anxiety disorders; major depressive disorders; mefloquine, both long-term and short-term; and traumatic brain injuries. We don't know exactly what is happening. We do not know the electrical physiology, and we do not know the physiology of what is happening. What we do know, with more modern techniques like the quantitative EEG analysis, which gives a three-dimensional electrical view of the brain, and functional MRIs, is what areas of the brain are affected.
The problem is that it would be like your saying you have chest pain and therefore I am going to diagnose you with chest pain. Well, there are a whole lot of things that cause chest pain.
In the brain, where we are right now is where medicine was with the rest of the body a century ago. We're just starting to have the technology to move forward so that we're more accurately able to diagnose. The DSM-IV and DSM-5, which psychiatrists use, is a descriptor. It does not give you the actual pathology. Like any descriptor, it can encompass a whole lot of things.
We have soldiers coming forward suicidal, with bad dreams, irritability, aggressiveness, and anxiety. That can be any number of diagnoses. There is a huge overlap.
I want to mention our current treatment techniques. Pharmacotherapy as well as the talking therapies have significant failure rates. There is nothing that treats any of these disorders to a large extent beyond about 60% success.
Dr. Mark Gordon is an interventionist endocrinologist who specializes in traumatic brain injuries as well as PTSD, and he is looking at blood chemistry and hormonal and neural steroidal abnormalities. For instance, we now know there are certain metabolic pathways that are abnormal as a result of TBI, PTSD, and, I think, chemicals such as mefloquine.
Dr. Marty Hinz is another gentleman in the U.S. who is using transmitter precursors rather than antidepressants. It's interesting because antidepressants long-term can actually deplete neurotransmitters, and when you try to take someone off an antidepressant, all their symptoms come back.
For just another moment, if you can bear with me, I want to talk about the unknown fallen. These are our military members who return to Canada, retire, or are medically released and then eventually die from their medical disorder, whether it's a physical or brain disorder, or by suicide months or years later. They are often unnoticed, not acknowledged, and frequently alone. They receive no mention in the Hall of Honour, yet they served their country and ultimately died as a result of their service.
Briefly with regard to suicidality, suicide certainly increases with a diagnosis such as PTSD; 49% will think about suicide. Mood disorders, TBI, mefloquine, complicated diagnosis, PTSD, TBI, chronic pain, alcohol: I don't see very simple cases. Most importantly there's a perceived lack of support whether that's at the military unit, the government unit, or with Veterans Affairs. Denial of claims has a huge impact and increases suicidal risk in veterans. I can spend the better part of an hour giving you examples of the denials and subsequent suicides that I've been aware of.
I'm aware of the time. I've forwarded a copy of this to the members of the committee, and I'd be happy to discuss any of the issues I've listed.
Maybe I could take that question.
First of all, there is absolutely minimal research done, so we can't tell you the sample sizes. A lot of the research that was done initially was rat research. By the way, it was done on male rats, so if we talk about female service members—which is a whole different discussion about effects on pregnancy and reproduction—we have no information.
At this point, it is not ethical to do a perspective study, because we know mefloquine has serious neuropsychiatric side effects. What we are beginning to do at the VA in Washington, DC, in what's called WRIISC, the war related illness and injury study center, is look at people who say they've been exposed to mefloquine and try to characterize their symptoms. At the moment, we have 51 people who have self-identified.
If you start expanding this—I think this has been part of Dr. Nevin's experience, and it is part of my experience, too—you would very quickly get many service members who come in and say, “I have some symptoms. Study me.” That's probably a reasonable first step for our northern neighbours, to look systematically at the people who come in.
Often these people feel like they've been blown off by the military and nobody has taken them seriously. Just to be studied.... We can tell you a little more about how we do it and which studies, whether it's an MRI, a PET scan, vestibular testing—which is one of the things we are starting with—neuropsychological testing, or looking at effects on reproduction. That's a growing science. That's where I would begin—look at the sailors, soldiers, and airmen you have now and see what their symptoms are.
The medication that you're referring to, Chantix, has been associated with a lot of neuropsychiatric side effects; another one, Zyban, or Wellbutrin, much less so. I don't prescribe Chantix to my psychiatric patients because they're coming to me because they have suicidal thoughts and ideation.
Going back to your other question, are there other medications that have this many side effects, if you look at the medications that are the top 10 in side effects, and neuropsychiatric side effects, just about all of them are psychotropic drugs, they are antipsychotic medications or antidepressant medications or medications for bipolar disorder or seizures, which are often the same. So mefloquine is up there. I think if we had any other medication that caused this many side effects, it would have been pulled from the market a long time ago.
One historical piece that we did not mention is that mefloquine, which was developed by the Army and Hoffmann-Laroche, did not have post-marketing surveillance, by that I mean after it was put on the market nobody was gathering the side effects, unlike other medications that were done in a more conventional way. That is part of the problem here, and Dr. Nevin can elaborate on that.
One other piece I wanted to mention that I think is very important is we've briefly said this drug causes toxicity in the brain stem and in the limbic system. We see that when we look at rats and chop off their heads and look at their slices. They have vacuoles, places where the mefloquine has poisoned the brain stem, and the brain stem is what causes your balance. The problem with it is the dizziness, the nystagmus. Dr. Nevin mentioned the limbic system. The limbic system is where our emotions are, that lead to the amygdala, which is affected by post-traumatic stress disorder. The hypothesis—again, not proven—is that these changes to the limbic system are what leads to this intense aggressiveness and anger, and that's what I think makes this medication so dangerous.
Why do some people react to it and some not? It could be genetics. A theory of mine is that in Somalia it was very hard to get hydrated, to get enough water. That was a very primitive environment. I remember the truckloads of water that we'd all be scrounging for. It was hot and people didn't drink enough. I think the damage to the veterans in Somalia was greater than, say, to those in Iraq or Afghanistan, where there was a mature theatre and people got more water. Again, that's a hypothesis. Another piece is that some people have changes in the blood-brain barrier. They metabolize agents more. It is clear that while some people are severely affected, others are not affected at all, and that's led to some of the questions of, this is just an hysterical reaction on the part of the journalist, because I took mefloquine and I was okay. I did take mefloquine and I was okay, but I was also in a medical unit, so could get water. I'd be curious about Claude's experience, whether he was able to stay hydrated. Similarly with the Canadian Airborne Regiment, I believe they were in primitive conditions.
Finally, what I often see with mefloquine is it's the straw that breaks the camel's back. You're in nasty, difficult circumstances, you are irritable, the food sucks, the water sucks, there's not a place that you can go, excuse my language, and take a dump so you're irritated about that, your wife is going to leave you. But then you have this pill on top of that that just revs up your rage, and you hear it over and over again, and you have these crazy bad dreams, these vivid dreams, nightmares, and you just snap.