Conclusions and Recommendations
Medical concerns
5.1
The inquiry focused on three issues raised which will be addressed in
turn. First, the claims that the current symptoms experienced by individuals
are due to taking mefloquine and/or tafenoquine over 18 years ago. The
committee spoke with the individuals and groups making these claims and then
with the medical community in Australia, particularly those organisations
responsible for assessing these claims.
5.2
As in the executive summary, the committee again states that it is not
comprised of medical experts and so can make no medical findings or rulings on
this matter but it facilitated the case from each side to be presented. It is
clear to the committee that in the view of the medical professionals, the
weight of medical evidence does not support the claim that their current
symptoms are caused by antimalarial use 18 years ago. More specifically, in
summary, the committee was told that long term problems as a result of taking
mefloquine are rare and there is no compelling evidence that tafenoquine causes
long term effects.
5.3
It is important to note that although individuals presenting evidence to
the committee often did not clearly distinguish between them, mefloquine and
tafenoquine are different drugs that act differently in the body.
5.4
In relation to mefloquine, the committee notes that there has always
been recognition by Defence that mefloquine, like any drug, has side effects
and this has been taken into consideration in the development of health policy.
The committee accepts that Defence, when deploying ADF personnel to malarious
areas, takes it duty of care seriously[1]
and needs to provide the best protection for them for field conditions and to
have more than one option available in case the first line antimalarial,
doxycycline, is not tolerated or the deployment is to an area with antimalarial
resistance.
5.5
The medical evidence provided to the committee shows that the incidence
of long term or persistent neuropsychiatric adverse reactions to mefloquine is
very rare. The committee heard there have been an estimated 40 million doses of
mefloquine worldwide, with safety data on at least 1 million people in a recent
published Cochrane review. The committee was provided with no evidence that the
same symptoms reported by some veterans are manifesting in the Australian
population or across the world in the civilian population.[2]
The committee heard that there is no evidence of an emerging global public
health issue.
5.6
While sympathising with the veterans who spoke with the committee and
hoping for them to get the help they need, the medical experts have been very
clear with the committee that the medical evidence does not support their
contention that their current health conditions are caused by the drugs they
took over 18 years ago.
5.7
Mefloquine was an approved drug at the time of the trials, tafenoquine
was not. The committee notes that the newer drug tafenoquine has undergone
rigorous safety evaluation by the US FDA and the Australian TGA. TGA's Advisory
Committee on Medicines and the US FDA's Antimicrobial Drug Advisory Committee
(AMDAC) have all had input for both indications, prevention and radical cure, and
the findings are consistent. The processes of the US FDA and TGA included an
audit of the relevant Defence studies which would have affected registration if
anomalies or concerns about clinical practice had been found. On the contrary,
the committee was told that the auditor found that the level of oversight of
the studies was of a very high standard. The committee also notes that for the
independent regulators, commercial concerns of pharmaceutical companies are not
part of their considerations.
5.8
The committee is reassured that every effort has been made by the
systems and regulators in place to ensure the safety of patients who have
access to mefloquine and who will have access to tafenoquine. The committee was
also reassured by the efforts of the pharmaceutical companies to address the
concerns being raised by investigation and transparency of data. The committee
wishes to note that it received full cooperation during the inquiry by the
pharmaceutical companies who provided submissions, supplementary submissions to
address specific evidence and appeared at a hearing, with some witnesses
travelling from overseas to provide evidence in person.
5.9
The committee has confidence that Australia's independent medical bodies
have looked specifically at the issue of acquired brain injury (ABI) from the
use of mefloquine or tafenoquine. The committee was informed that the claim
that taking mefloquine and tafenoquine results in ABI is not backed by
definitive evidence. In August 2017, the Repatriation Medical Authority (RMA)
found there was insufficient sound medical evidence to support this claim. This
decision was reviewed by the Specialist Medication Review Council which in September
2018 supported the decision of the RMA.
5.10
The committee was reassured that, should any sound medical-scientific
evidence pertinent to this inquiry arise in the future, it would be identified
through existing channels and responded to by Defence and DVA. Existing
monitoring mechanisms include the regular reviews of the evidence undertaken by
the RMA and the work undertaken by Defence Joint Health Command (JHC).
5.11
It was suggested to the committee that it was hearing mostly from
malariologists.[3]
This is not the case as can be seen by the range of evidence detailed in
Chapter 2. The wide range of specialists contributing to accumulating and
analysing medical data was evident to the committee. The committee notes that
the US FDA engaged specialists including not only malariologists but
psychiatrists, epidemiologists, postmarketing surveillance professionals and
others. The TGA has toxicologists, pharmaceutical chemists, inspectors for the
manufacturing facilities as well as the ability to call on external advice from
an advisory committee of doctors, community representatives, epidemiologists
and statisticians. The committee notes the range of professionals who reviewed
the information in the RMA and SMRC with specialists drawn from pharmacology,
neurology, mental health, neuropsychology as well as medical academics and
epidemiological academics.
5.12
In conclusion, on this aspect, the committee respects the medical
findings of the various regulators and their experts as well as the vast amount
of evidence from international and domestic studies and clinical experience.
Also, this issue seems to be manifested in military populations where it
appears to the committee that trying to assign a single cause to veterans'
illnesses does not reflect the many potential contributors to their physical
and mental health at the time and in the many years since the medications were
taken.
5.13
The committee notes that the concerns of veterans have not been ignored
by pharmaceutical companies or regulators. Adverse events reported more
recently for tafenoquine were followed up, scrutinised and this work included
in the information provided to the US FDA and TGA. Dr Nevin presented to the US
FDA. The committee notes that he was the only person who submitted evidence
critical of the proposal to approve tafenoquine. The committee is reassured
that the medical concerns raised with the committee have been taken into
consideration by the independent regulators which have recently approved
tafenoquine and whose job it is to focus on safety and efficacy of medications.
5.14
However, the committee does not doubt that the symptoms being
experienced by individuals are real and regardless of the cause or causes,
these veterans are unwell and should receive the assistance to which they are
entitled. It has therefore been the focus of the committee to ensure that any
current and past ADF members receive appropriate treatment and the support they
need. The committee notes that this is not a different view to that stressed by
Defence and DVA, ie. that regardless of the cause of the symptoms, help is
available.
5.15
The committee understands that the individuals and families who spoke
with the committee are searching for answers to their poor health and
acknowledges the comfort and support felt by most veterans and family members
who are part of the group organised by the AQVFA. The committee is, however,
concerned that this support does not come at the expense of them reaching out
to receive available assistance because it does not come under the label they
would prefer it to have. The committee is also concerned that the efforts of
such advocates may unnecessarily cause public concern and negatively affect the
global effort to eradicate malaria.
5.16
The committee was concerned at the personal nature of some submissions
and evidence from advocates questioning the honesty and motives of witnesses
with whom they disagree. The committee accepts that officials and other
witnesses have provided evidence to the committee in their professional
capacities in good faith. In these cases the committee facilitated an exchange
of views and the individuals mentioned were given the opportunity to respond to
the submissions and evidence.
ADF participation in medical research
5.17
The second issue raised with the committee was the conduct of the
trials. The issue of ADF members participating in medical research is complex.
The committee is concerned that some members may not fully engage with the
information provided by researchers if they perceive participation in the
research to be a mandatory or routine part of their role. The committee also
believes that members are potentially vulnerable to feeling pressured to
participate by their superior officers due to the hierarchical culture of the
military.
5.18
However, the committee does not believe that all medical research with
members of the ADF should be prohibited, provided it does not disrupt the work
of the ADF and has been approved in accordance with the National Statement on
Ethical Conduct in Human Research (National Statement). This is because
research is essential for advancing medical care and force protection measures,
and the ADF has a duty of care to protect and maintain the health of its
personnel.
Informed consent during the trials
5.19
As noted above, the processes of the US FDA and TGA included an audit of
the trials involving tafenoquine, which Defence characterised as representing
'a thorough, independent validation of all aspects of the conduct of the
studies'.[4]
Moreover, allegations of misconduct in some of the trials involving the use of
mefloquine and tafenoquine have been investigated by the Inspector-General of
the Australian Defence Force (IGADF), a statutory role that is independent of
the ordinary chain of command. The IGADF found that the trials undertaken by
the Australian Malaria Institute from 2000 to 2002 in East Timor involving
mefloquine and tafenoquine 'were conducted ethically and lawfully' in
accordance with the guidelines issued by the National Health and Medical
Research Council (NHMRC) and the Therapeutic Goods Administration.[5]
It also concluded that members voluntarily consented to participate in the
trials involving mefloquine and tafenoquine, and were informed of the potential
side effects known at the time.
5.20
Some submitters have not accepted the findings of the audit and
investigation and have called for a Royal Commission. However, the committee has
not received evidence that undermines the existing independent findings, and so
does not support a further investigation. The committee was concerned to hear
that some ADF members who agreed to participate in the trials felt that they
were not provided sufficient information, or were pressured into participating.
The committee recognises that this perception is distressing for some veterans
and their families. Therefore, the committee makes some recommendations for
improving the consent process.
Improving the process of providing
informed consent
5.21
The committee believes that issues of informed consent should be
carefully considered when study protocols are developed by researchers, and
when the current Departments of Defence and Veterans’ Affairs Human Research
Ethics Committee (DDVA HREC) reviews and decides whether or not to approve the
research. This is in accordance with the NHMRC National Statement and the
recent recommendations made by the IGADF.
5.22
The committee notes that the DDVA HREC is comprised of a range of
members, including a veteran, lawyer, lay people, a pastoral care member, a
civilian clinical care provider and others with relevant experience in
research.[6]
The DDVA HREC terms of reference also establish that 'at least one third of the
members are to be external to Defence and DVA'.[7] The committee
views these requirements to sufficiently ensure a range of perspectives are
represented during the consideration of new study protocols.
5.23
The committee was pleased to note Air Vice-Marshal Smart's letter
requesting DDVA HREC also consider new methods of ensuring the military chain
of command does not influence the voluntary choice of members of the ADF to
participate or not in research.[8]
The committee encourages DDVA HREC, Defence and the Department of Veterans'
Affairs to implement measures to achieve this aim. It is supportive of
initiatives including providing a standard script to Command and standard
briefing materials to prospective participants, and engaging an external agency
observer to monitor, evaluate and report on the consent process.
5.24
Defence informed the committee that DDVA HREC already considers the
issue of informed consent in military populations each time it considers a
research proposal 'to ensure that there is no coercion, real or perceived, in
the recruitment of participants from the ADF'.[9] This
responsibility is implicitly contained in the DDVA HREC terms of reference as it
reviews research protocols in accordance with the National Statement, which
covers issues of informed consent.[10] However, the committee view
is that there is an opportunity to develop the DDVA HREC terms of reference to
explicitly note its responsibility to consider the vulnerability of prospective
participants to coercion.
Recommendation 1
5.25
The committee recommends that the terms of reference of the Departments
of Defence and Veterans' Affairs Human Research Ethics Committee be updated to
explicitly include consideration that prospective research participants may be
vulnerable to perceived coercion to participate.
5.26
Once DDVA HREC has approved a study protocol, the committee believes
that individual members should have access to independent advice regarding
their potential participation in medical research. The NHMRC National Statement
suggests:
In the consent process, researchers should wherever possible
invite potential participants to discuss their participation with someone who
is able to support them in making their decision. Where potential participants
are especially vulnerable or powerless, consideration should be given to the
appointment of a participant advocate.[11]
5.27
The committee did not hear evidence of participant advocates being
appointed elsewhere, however believes that this model may provide an
opportunity to improve the consent process for ADF members considering whether
to participate in research. The committee recommends that each prospective
participant should have access to a private conversation with an independent
participant advocate before providing their consent to participate. This person
should be informed of the study protocol and have knowledge of the medical
field, but should not be employed as part of the research team.
Recommendation 2
5.28
The committee recommends that all members of the Australian Defence
Force who are invited to participate in medical research have access to a
confidential conversation with an independent participant advocate prior to
consenting to participate.
Screening and post-trial
communication processes
5.29
The committee was concerned that a very small number of members
participated in a trial even though their previous experiences of mental
illness should have excluded them. The committee notes the development of the
Defence eHealth System, and supports the IGADF recommendation that future trial
investigators should be given access to the system to enable any relevant
medical history of contraindicators to be identified at the time of obtaining a
Defence member's consent to participate in a trial.[12]
5.30
The committee was also concerned to hear that some participants who
withdrew from the trial early may have missed out on some of the follow up
provided to other participants. However, the committee was reassured that these
members would have still received the healthcare provided to all ADF members,
including a medical examination at the end of deployment, two post deployment
psychological screenings and annual health assessments while with the ADF.[13]
5.31
The committee heard some veterans faced distressing delays while waiting
to receive information on their participation or otherwise in the trials. The
committee supports efforts to improve this process. It notes the Defence
eHealth System is likely to prevent future delays, as information on trial
participation can be incorporated into the ADF members' medical records once
the trial process has been concluded.
Assistance and support for veterans
Overarching need for assistance
5.32
While the committee acknowledges the actions taken by Defence and DVA to
address the concerns of veterans raised with the committee, the evidence to the
committee indicated that either more needs to be done to assist veterans or
done differently. Several witnesses who provided evidence were clearly in need
of immediate assistance.[14]
While there were some different views about the best and most appropriate ways
to provide assistance and support, there was unanimous agreement that these
veterans and their families need help. Therefore the focus of the committee was
to look for new and different approaches to facilitate better support for this
cohort and the wider veteran community.
5.33
The committee notes the commitments made and actions taken by the
government in this area in response to the recommendations in the committee's
report on veterans' mental health. However, the committee noted that despite
these efforts, this cohort of veterans, at which the actions were directed, were
mostly unaware of them. It was evident to the committee that additional support
is necessary to address the issues faced by these veterans.
Veterans' experiences with seeking
assistance
5.34
The clear message from Defence and DVA was that regardless of the cause
of their symptoms, assistance is available. While this may be true it was not
the experience for most individuals who spoke with the committee. The committee
explored with individuals their experiences of accessing assistance; whether
they had tried to access assistance, and if so, the details of that experience.
The committee also spoke to veterans who had not accessed assistance and
explored the reasons why not.
5.35
Some individuals appeared to be accessing helpful assistance but
unfortunately this was not a common experience for those who participated in
the inquiry. The committee heard of a number of practical barriers that are
inhibiting veterans accessing support, including cultural issues,
unavailability of information and challenges accessing and navigating the DVA
claims process as outlined below.
Barriers to assistance
ADF cultural issues
5.36
The committee heard from veterans who either did not wish to engage with
DVA as they had lost trust in the system or they found it difficult to ask for
assistance as the culture of the ADF means there are barriers to self-reporting
issues and vulnerability.
5.37
Acknowledging these cultural issues, it was suggested to the committee
by a veteran that there needs to be more assistance and support when a soldier
transitions to civilian life. To this end the committee notes the inquiry into
transition from the ADF being undertaken by the Joint Standing Committee on
Foreign Affairs, Defence and Trade which is examining support provided to
members of ADF as they transition from active service to civilian life. The
committee is not aware of the timeline for concluding the transition inquiry
but recognises the importance of the issues and that this is a critical time
for many veterans.
5.38
While the committee is concerned that some veterans do not wish to
engage with DVA, the committee encourages those veterans to seek assistance.
Although previous experience accessing assistance may not have been optimal,
there have been a number of actions taken to improve services in recent years.
5.39
The committee was also reassured that when a veteran is ready to seek
assistance, organisations such as the RSL and the Defence Force Welfare
Association as well as a community of advocates and DVA officials are ready to
help.
Provision of information
5.40
Some suggestions for assistance focused on addressing some of the
barriers reported by veterans to access information.
5.41
Veterans consistently told the committee that there is an ongoing need
for information about a range of issues: details about their participation on
the trials, information about the antimalarial medication they took and advice
about what support and assistance is available. The committee recognises that
both Defence and DVA have taken steps to make information available to
veterans, by providing information about their trial participation, publishing
information on websites and establishing a dedicated support team. It is
important that these actions continue and are built upon.
Dedicated support line
5.42
The dedicated mefloquine support line was a commitment by government as
detailed earlier in this report. The committee received a number of accounts
from witnesses which showed the support line has not been operating as
effectively as it could. The committee was pleased to note that DVA has
recognised this and taken action to make additional changes to ensure that
veterans calling this line receive appropriate assistance. Given the
consultation forums recently undertaken by DVA, there may be an increase in the
number of calls made to the dedicated support line. Therefore, it is important
that DVA ensures that staff working in that area receive ongoing training and
information about these matters and are ready to provide details about
available assistance.
DVA claims process
5.43
The committee recognises that the DVA claims process can be difficult to
navigate. Veterans reported that the process is particularly challenging when
dealing with complex health conditions that cannot be linked to a single
Statement of Principles. To this end the committee notes the evidence from the
RMA that with assistance from an advocate to navigate the system there is often
the ability to link some of their symptoms to service; however the committee
notes the extraordinary length of time this can take for some.
5.44
The committee was pleased to note that DVA is conducting further
investigation into the claims lodged relating to antimalarial medications since
September 2016. The committee urges DVA to expedite this process and continue
to offer these individuals either assistance from DVA or facilitate access to
an advocate.
Recommendation 3
5.45
The committee recommends that the Department of Veterans' Affairs
expedite their investigation on antimalarial claims lodged since September 2016
and continue to offer individuals assistance to lodge their claims and
facilitate access to an advocate if required.
Claims team
5.46
Evidence from DVA detailed the composition of the Complex Case Team,
noting that the seven delegates are supported by an EL1 Assistant Director, a
contracted medical advisor and two social workers. The committee notes that
delegates in this Complex Case Team also process claims relating to physical
and sexual abuse in the ADF and are rotated after approximately 12 months.
5.47
The committee recognises that the Complex Case Team are dealing with
challenging issues and that staff rotations are important to enable staff to
take a break. However, the regular rotation of staff may result in loss of
corporate memory. To ensure that all staff in the Complex Case Team
consistently have an understanding of the issues identified by veterans in this
inquiry, DVA needs to remain focused on providing ongoing training to staff.
5.48
In its report, The Constant Battle: Suicide by Veterans, the
committee recommended that DVA conduct a review of its training programs for
delegates and other staff dealing with veterans making claims for compensation
and rehabilitation. While the committee recognises that this recommendation was
accepted and progress against it has been reported as part of the estimates
process, the committee again emphasises the importance of DVA officers working
in the claims area undergoing ongoing training and support about issues facing
veterans. The feedback from veterans following the recently held consultation
forums may be instructive for the practices adopted by the Complex Case Team.
Recommendation 4
5.49
The committee recommends that the Department of Veterans' Affairs
continue to provide ongoing training, information and support for the officers
working in the Complex Case Team.
Ensuring access to additional support and assistance
5.50
Many of the identified barriers are familiar to the committee from its
previous inquiries into similar issues, including its inquiry into veteran
suicide. The committee has continued to monitor the implementation of the
recommendations of that report through the estimates process. While the
committee recognises that DVA is taking steps to streamline its systems and
processes in order to provide better support for veterans and their families,
it notes that results for veterans can take some time to flow through the
system.
5.51
The committee notes that underlying some of these practical barriers is
the stated need from some veterans and their families to have their symptoms
recognised as being primarily caused by mefloquine and tafenoquine, a view not
supported by the medical professionals (outlined in Chapter 2). As a committee
of non-medical experts, the committee can only respect the view of the medical
community. However, the committee notes the clear message from Defence and DVA
that regardless of the cause, assistance is available.
5.52
Building on the initiatives already in place or underway, the committee
has identified a number of areas for further improvement as outlined below. Due
to the fact that these issues are affecting the veteran community, the committee's
recommendations will necessarily be focused towards DVA.
Information for and consultation
with veterans and families
5.53
A clear concern identified to the committee was the need to provide more
information and support to families. If a veteran is unwell the burden of
seeking assistance often falls to family members which, the committee heard,
can sometimes mean seeking assistance from multiple agencies at the same time
as providing direct care for a veteran. As with its previous inquiries, family
members asked for support and information to be more readily available.
5.54
Family members identified that more tailored and coordinated support is
needed particularly during times of crisis, when family members are primarily
focused on addressing the immediate health needs of veterans and do not have
the time and ability to seek advice about various support options. The
committee heard that family members have received beneficial support from
ex-service organisations but these services have not been provided in a coordinated
manner. The committee sees the consultation forums being undertaken by DVA at
various locations as a way to increase family members' awareness of short and
long term assistance and how it can be accessed.
Consultation
5.55
It was clear to the committee that the previous commitment to an
outreach program was interpreted differently in the veteran community. Most
interpreted it as Defence or DVA contacting people individually who were involved
in the trials. Defence was clear to the committee that it did not view this
approach as beneficial as it does not wish to cause concern among veterans who
are well. Defence emphasised that they will continue to provide information to
trial participants upon request and provide support should there be concerns.
5.56
The committee understands the concerns raised by Defence about proactive
outreach, but also understands that this veteran community will continue to
call for what it considers to be an outreach program where soldiers involved in
the trials are contacted. Noting this stalemate in positions, the committee
supports the current round of consultation forums which is seeking to provide
information to veterans about available assistance at the same time as
receiving feedback from the veteran community.
DVA consultation
5.57
The recent consultation forums hosted by DVA in Adelaide, Melbourne and
Townsville, as well as other locations nationally, provide a further
opportunity for veterans and their families to access information and support
from DVA. DVA advised that attendees at the first forum in Adelaide reported
that it provided helpful information and was a good opportunity to openly
discuss their concerns.
5.58
Given that Defence is continuing to provide information to veterans
concerned about the use of antimalarials on its dedicated website, it would be
beneficial for Defence officials to attend the consultation forums to maintain
their knowledge of the issues raised by the veteran community and to update
their website accordingly.
5.59
The committee is pleased that DVA remains open to expanding their
consultation schedule and hosting additional events should there be sufficient
interest. DVA is also seeking formal feedback from participants about their
experience at the forum which will provide valuable insight about any changes that
could be made to future forums. Given the complexity of some of the issues
considered, it would be beneficial for consideration to be given to establish
mechanisms to follow up matters raised by attendees, such as running a series
of follow up events or a more individualised approach. As noted earlier,
seeking assistance at a time of crisis is particularly challenging for families
and the committee suggests that the consultation forums need to take account of
the best ways to assist families at this time.
5.60
The committee recognises that some veterans may be unable, unavailable
or currently unwilling to attend a consultation forum in the current schedule.
The committee is of the view that information should be made available in a
variety of ways to ensure that as many veterans as possible are able to access
the information.
Non-liability pathway
5.61
Evidence from DVA highlighted that some veterans are unaware that access
to mental health services is available under the non-liability pathway, with no
requirement to link the condition to their service. In light of this, it would
be beneficial for DVA to undertake an awareness raising campaign, targeted to
the veteran community, to increase veterans' understanding of the non-liability
pathway. This campaign could be developed in consultation with advocates and
ex-service organisations.
Recommendation 5
5.62
The committee recommends that the Department of Veterans' Affairs, in
addition to the existing program of consultation forums, ensure matters raised
by attendees and families are followed up. The forums should continue to be
promoted widely and in consultation with ex-service organisations and advocate
groups.
Recommendation 6
5.63
The committee recommends that the Department of Veterans' Affairs make
the material provided at the consultation sessions available online.
Recommendation 7
5.64
The committee recommends that the Department of Defence attend the
Department of Veterans' Affairs' consultation forums to maintain their
knowledge of the issues raised by the veteran community. This will assist
Defence to ensure their dedicated website is updated appropriately.
Recommendation 8
5.65
The committee recommends that the Department of Veterans' Affairs
undertake a targeted awareness raising campaign, in consultation with
ex-service organisations and veterans' advocates, to increase veterans'
awareness of the non-liability pathway.
Assistance from General
Practitioners
5.66
One of the key messages from Defence and DVA is that veterans who are
concerned about their health should contact their GP. The Royal Australian
College of General Practitioners (RACGP) and veterans also recognised the central
role of GPs.
5.67
Some veterans were concerned that their GP was not aware of mefloquine
and tafenoquine and therefore was unable to provide the required assistance.
Other witnesses described experiences when their GP had been helpful in terms
of referrals and making connections with specialist services. The provision and
regular review of information resources for GPs is important to ensuring that
GPs are able to provide appropriate assistance to veterans and their families.
Information resources for GPs
5.68
The committee notes that DVA and Defence developed information resources
for GPs about antimalarials and this material was distributed in 2016. The
committee also notes that an information briefing for GPs was held in
Townsville in 2016. The committee recognises that the actions taken to provide
information to GPs are positive however some evidence provided to the committee
suggested that veterans had experienced difficulties obtaining information from
their GP. It would be beneficial for the information resources previously
developed to be reviewed with particular advice for GPs to recognise the
complex conditions with which some veterans may present.
5.69
Furthermore, given the recent TGA approval of tafenoquine, it may be
beneficial for additional follow up information to be provided to GPs. This
could build on information that will be sent to doctors from the pharmaceutical
companies which will be producing tafenoquine.
5.70
The RACGP recognised that the provision of information about
antimalarials is particularly relevant around major bases as well as in
locations where there is a high volume of travel to and from malarial areas. In
this context, it would be advantageous for DVA and the RACGP to take this into
consideration when providing information.
5.71
The committee is pleased to note that a representative from the RACGP
attends the DVA Health Providers Partnership Forum to provide advice about
developing information resources for veterans. In addition, the committee is
aware that the RACGP includes DVA information and resources in its publications
distributed to the GP community. The continuation of this flow of information
is important. Furthermore, the terms of reference of the Health Providers
Partnership Forum indicate that the Forum can continue to provide a mechanism
to update resources and facilitate information sharing.
Recommendation 9
5.72
The committee recommends that the Department of Veterans' Affairs and
Department of Defence, in collaboration with the Royal Australian College of
General Practitioners and other health professionals, review and update the
clinical guidelines developed in 2016 to recognise the complex conditions with
which some veterans may present.
Recommendation 10
5.73
The committee recommends that the Department of Veterans' Affairs
consult with the Royal Australian College of General Practitioners to assess
whether General Practitioner briefings, like the one that occurred in
Townsville in 2016 would be beneficial in other areas, including around major
bases.
The need for multidisciplinary care
5.74
The other need which was evident to the committee is that these veterans
are dealing with complex and sometimes chronic health needs which require more
than a visit to a GP or one specialist to receive a diagnosis. In this context,
the committee supports the need for multidisciplinary care. The committee is
pleased to note that DVA has recognised that some individuals need tailored,
wrap around assistance and that this may need to include supports from a range
of specialists to address their complex needs.
Additional research
5.75
The committee is aware that Defence and DVA have jointly commissioned
the University of Queensland to undertake a research study looking at the
self-reported health of ADF personnel using antimalarials on deployment. This
research will use de-identified data from a number of the trials. DVA advised
that this new research will focus on the health outcomes of deployed veterans
who took antimalarial medications.
5.76
It is expected that this research study will be completed later in 2018.
The committee anticipates that the findings from this research may be
instructive for DVA in the context of developing services and support that
address the challenges reported by this cohort of the veteran community.
Recommendation 11
5.77
The committee recommends that the Department of Veterans' Affairs review
the University of Queensland research findings due in late 2018 with a view to
further inform the development of any new initiatives and the ongoing review of
existing programs.
Neurocognitive Health Program
5.78
As outlined in Chapter 2, veterans suffering from chronic and complex
conditions have attributed their symptoms to taking mefloquine or tafenoquine
some time ago. The committee heard from individuals that, as many of these
reported symptoms are similar to symptoms of PTSD, this has led to veterans
being misdiagnosed with PTSD, receiving treatment for PTSD which ultimately has
not been successful. While many witnesses including Dr Nevin could not name a
specific treatment that veterans attributing poor health to taking
antimalarials should be receiving, the committee heard that they are
particularly concerned about possible neurocognitive effects.
5.79
Recognising that this is an area which DVA does not have much expertise,
DVA has committed to the development of a program to deal with neurocognitive
issues, regardless of the cause. This new Neurocognitive Health Program will
be accessible to all veterans who have been assessed as requiring treatment for
neurocognitive issues.
5.80
The committee is pleased to note that Professor McFarlane and the AQVFA
are involved in the design of this program which will add to the range of assistance
available from DVA. The committee supports the development of this program,
recognising the value of developing treatment and services through a model of
co-design.
5.81
Given the potential positive impact of the program, the committee is of
the view that its development should be given a high priority. As a first step,
the committee encourages DVA to consider early rollout to a targeted population
as a pilot program. The pilot program could then be formally evaluated to inform
further development of the program prior to broader rollout.
Recommendation 12
5.82
The committee recommends that the Department of Veterans' Affairs
prioritise the development of the Neurocognitive Health Program. To enable
veterans to access this program as soon as possible, consideration should be
given to the rollout of a pilot program to a targeted population.
Recommendation 13
5.83
The committee recommends that the pilot program undertaken as part of
the Neurocognitive Health Program be formally evaluated and that the evaluation
report be made publicly available.
Collaborative working group
5.84
The committee recognises the importance of fostering cooperation and
collaboration between DVA and the veteran community and supports the
development of the Neurocognitive Health Program. As stated above, the
committee has recommended that a pilot program be considered which would
subsequently be evaluated. The post evaluation stage provides another
opportunity for DVA to further engage with the veteran community.
5.85
In this context, the committee suggests that a collaborative working
group be established to consider the outcomes of the pilot as well as how best
to roll out the program more broadly to the veteran community, should it be
supported. The establishment of this group could provide another means of
facilitating an ongoing dialogue between DVA and veterans. Given the concerns
raised by some veterans in the inquiry about the challenges they have
experienced when accessing assistance and support, the committee considers that
the collaborative working group model could provide a means of further
improving relationships and enhancing trust between veterans and the
organisations supporting them.
Recommendation 14
5.86
The committee recommends that, following the evaluation of the
Neurocognitive Health Program pilot, a collaborative working group be
established, including those who contributed to the development of the program,
veterans and advocates, medical professionals and the Department of Veterans'
Affairs. This group would consider the outcomes of the pilot and, if supported
by the evaluation, how best to roll out and promote the program to all veterans
it could assist.
Senator Alex Gallacher
Chair
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