Letter to the Editor

In   Issue Volume 26 Number 3 .

Dear Editor,

THE AUSTRALIAN ARMY MALARIA INSTITUTE AND THE MEFLOQUINE CONTROVERSY

In JMVH 26(1), January 2018, you published a letter from Dr Remington L. Nevin, Executive Director of the Quinism Foundation in Vermont, USA. Dr Nevin’s letter commented on aspects of an article of mine, ‘Australian military malariology comes of age’, which appeared in JMVH 25(3), July 2017. His comments focused on the final section of my article headed ‘The Australian Army Malaria Institute under attack: the mefloquine controversy’.

Dr Nevin’s letter contains a number of assertions which I refute.

Firstly, my article was not a ‘historical review’ of thedebate over the use of mefloquine and tafenoquine by the Australian Defence Force (ADF) and research on these antimalarial drugs by the Australian Army Malaria Institute (AAMI). The article was the fifth and concluding instalment of a five-part series tracing the history of Australian military malariology from 1885 to 2015. The series outlined that history biographically, profiling some twenty medical specialists and malariologists whose work on malaria had contributed to the evolution of malariology in Australia.
Of necessity, my article referred to the formation and subsequent development of the AAMI. It did so only briefly as this topic was already comprehensively covered in a seven-part series titled ‘Army Malaria Institute: Its Evolution and Achievements’, appearing in JMVH between 2012 and 2016, the co-authors of which were present and former AAMI staff members.

My observations on the mefloquine controversy were included in a section at the end of my article. Seen in that context, they were certainly not an ‘historical review’ of the debate over mefloquine use. Indeed, the section made the point that a history of the mefloquine debate is not yet possible because the debate continues. As Dr Nevin will possibly be aware, at present, the Senate of the Australian Parliament is conducting an inquiry into the use of mefloquine and tafenoquine by the ADF. If he knows about that inquiry, he will also know that it was prompted by the persistent demands of particular interest groups within, what may be loosely described as, the ‘Anti-Mefloquine Lobby’ (AML).

Secondly, Dr Nevin seems to have inferred that I am some kind of mouthpiece of the AAMI. Such is not the case. I am an impartial and independent practising historian who wrote a book about the Australian Army’s experience of malaria. (Released under the title An Unending War: The Australian Army’s struggle against malaria, 1885–2010, it was published in 2016 by Big Sky Publishing Pty Ltd.) A chapter of that book dealt with the AAMI, tracing its development against the background of catastrophic epidemics of malaria suffered by the Army in overseas deployments from World War I to the engagement in East Timor in 1999. While I appreciate the AAMI’s historic achievement in having saved thousands of ADF personnel from potentially fatal episodes of P. falciparum malaria infection, I am entirely independent of the AAMI and am certainly not a spokesperson for them or the ADF.

Thirdly, Dr Nevin suggests I am conducting ‘an attempted rearguard defence’ of the AAMI and its mefloquine and tafenoquine research programs. Again, his inference is wrong and unequivocally denied. The AAMI does not need me to defend it against the often intemperate AML fulminations. It is quite capable of doing that itself, as it will no doubt do so before the present Senate inquiry.

Fourthly, Dr Nevin states that I have trivialised ‘the concerns of antimalarial drug safety advocates’ by writing that ‘all antimalarial drugs have unwelcome side effects’. I reject this suggestion. Dr Nevin’s letter does not acknowledge the fact that mefloquine was used because some people could not take doxycycline, the ADF’s ‘front-line’ antimalarial drug. For some ADF personnel, doxycycline has serious side effects. Indeed, about one in eleven or nine per cent of people cannot tolerate doxycycline. For those people, using mefloquine as a ‘second-choice’ antimalarial drug may well have been lifesaving.

This brings me to another issue which Dr Nevin’s letter conveniently ignores. A reality that some former ADF personnel within the AML do not acknowledge is that mefloquine, tafenoquine and doxycycline might actually have saved their lives. By not acknowledging this, they nullify their own arguments against the AAMI. Here I draw Dr Nevin’s attention to the highly malarious places in which these former soldiers served —Timor Leste, Bougainville and the Solomons. They are regions of malaria endemicity where the often fatal P. falciparum form of the disease is common and still causes mortality. Without the AAMI-devised malaria treatment and prophylaxis regimens, multiple deaths of ADF personnel from P. falciparum malaria could well have occurred. The point here is that for the ‘consumers’, in this case ADF members serving in a malarious region, the choice is stark: either take an antimalarial drug and accept the risk of side effects or not take it and risk dying from P. falciparum malaria.

Yet another reality avoided by Dr Nevin and the AML is the widespread use of mefloquine by Australian civilians travelling overseas to malarious areas. As my article pointed out, between 2010 and 2015 almost 85 000 prescriptions for the drug were filled in Australia. Are any of those consumers clamouring for compensation because of the ‘psychoneurosis’ they might allegedly have suffered? Is it only people associated with the AML who have purportedly suffered from mefloquine toxicity? If so, why? These are questions that Dr Nevin and his supporters might care to answer honestly in submissions to the present Senate inquiry.

I wish to conclude with one final point, one made in my article relating to the deaths and near-deaths from malaria among ADF personnel. As my article pointed out, the last malaria fatality among ADF personnel was in 1967 in Vietnam; however, in Timor Leste in 1999–2000, five ADF soldiers came close to death after contracting P. falciparum malaria. Their lives were saved by their prompt evacuation and hospitalisation in the intensive care unit of the Royal Darwin Hospital. These cases demonstrate that lethal malaria infections are not just a theoretical risk during modern military operations but remain a threat to the lives of all ADF personnel posted to malarious regions. In view of that, Dr Nevin and the AML might care to advise JMVH readers what measures they would recommend for protecting ADF personnel against malaria.

Yours sincerely,
Dr Ian Howie-Willis, OAM, PhD
Independent Professional Historian
Canberra, Australia