On 24 May 2016 the House of Commons Defence Committee released its report ‘An acceptable risk? The use of Lariam for military personnel’. Having heard evidence from witnesses including senior medical experts from within the military, as well as written evidence from people with personal experience, the Committee’s considered response was a resounding ‘no’.
Lariam (generic name Mefloquine) is one of a number of an anti-malarial prophylactics which may be used to protect people travelling to malarious regions. Lariam comes with a warning from its manufacturer (Roche) that it must not be used “in patients with active or a history of psychiatric disturbances such as depression, anxiety disorders, schizophrenia or other psychiatric disorders”, along with a clear statement that an individual risk assessment must be carried out before Lariam is prescribed.
Side effects reported by witnesses, set out in section 4 of the report, included: episodes of severe mental and physical exhaustion and nausea; severely broken sleep patterns; nightly periods of insomnia interspersed with hallucinogenic dreams; significant lapses of concentration and short term memory loss; vivid and dark dreams; extreme mood swings and episodes of poor judgement; uncharacteristic, unpredictable outbursts of verbally and physically aggressive behaviour; acts of violence, ill temper, dangerous driving, confusion and expressions of suicide ideation.
Given these potentially serious side effects the Committee was troubled by reports of Lariam having been provided to military personnel without individual risk assessments having been performed; there were reports of packets of pills being handed to personnel along with other items of kit and with no specific warnings. In such cases, not only were the risks not assessed – there cannot have been informed consent.
The Committee concluded that Lariam should only be used within the military as a last resort and then only after a face-to-face individual risk assessment, including an explanation of the possible risks and the alternative drugs that are available.
The concerns raised by the Committee in relation to military personnel are all too familiar to those of us who work with people in immigration detention, since despite the serious risks and contraindications Lariam is regularly given to pregnant women in detention.
Fewer anti-malarials are acceptable for use in pregnancy (Doxycycline is contraindicated and there is a lack of evidence on the safety of Malarone). This leaves just two: Chloroquine/Proguanil and Lariam (or Mefloquine as it is referred by the Home Office). Sub-Saharan African strains of malaria are resistant to Chloloquine.
Therefore, Lariam – even with its risks of adverse psychological effects and the advice from Roche against its use in pregnancy (in particular in the first trimester) – is the drug of choice for the Home Office seeking to remove pregnant women to sub-Saharan Africa.
In their September 2015 review the Royal College of Obstetrics and Gynaecology recognised that female asylum seekers are a “highly vulnerable and socially excluded group of women, often with complex medical histories and psychological needs” who “can have complex mental health needs due to the experiences which caused them to leave their home countries, including post-traumatic stress disorder” and in respect of whom the “risk of postnatal depression is high”. These women, therefore, are likely to have pre-existing mental health issues or may be at risk of developing mental health problems after giving birth. In either case Lariam is a reckless choice. Add to this language difficulties, and the stress and trauma of detention with the prospect of being returned to a place they fled, and it is difficult to envisage circumstances giving rise to informed consent. Indeed, in the experience of many of us who have worked with pregnant women in detention there has been no informed consent; Lariam has often been prescribed without individual risk assessments being carried out and without any of the risks being explained. There have been cases of acute psychosis as a result, including in respect of one woman whose case is being pursued in the High Court (by someone acting on her behalf, given her continued mental incapacity).
The risks to pregnant women of contracting malaria are stark so the option of removal without prophylaxis is unacceptable. In its 2015 Guidelines for malaria prevention in travellers from the UK, Public Health England says that “Pregnant women are advised to avoid travel to malarious areas. In the event that travel is unavoidable, the pregnant traveller must be informed of the risks which malaria presents and the risks and benefits of antimalarial chemoprophylaxis. Pregnant women have an increased risk of developing severe malaria and a higher risk of fatality compared to non-pregnant women”.
Medical Justice, the charity working for health rights for detainees, has raised concerns over a number of years about the use of Lariam in detention, including in its 2013 report ‘Expecting Change’ , which was based upon an audit of medical records of 75 pregnant women who had been detained between 2005 and 2011. Their findings were damning. In each case where anti-malarials were offered to pregnant women there was a failure of the staff to follow the relevant medical guidance. There was an absence of any evidence of informed consent in the medical notes in almost all of the cases. The scandal is that this situation continues in spite of the shocking findings of Medical Justice three years ago.
In its opening memorandum to the Defence Committee Inquiry the Minstry of Defence confirmed that its takes claims from service personnel of adverse side-effects “extremely seriously” and made reference to a process whereby current and former members of the Armed Forces can have their cases investigated in confidence.
The Government’s response to the report is awaited. However, it is difficult to envisage anything other than a wholesale overhaul of the use of Lariam amongst service personnel given the many serious issues raised. In the light of these findings and the existing evidence from Medical Justice the prescription of Lariam to pregnant detainees must now end.