Bupa’s $7000 health checks for mefloquine veterans

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A contract to support soldiers given mefloquine and tafenoquine has ended with a referral for alleged corruption.

The Department of Veterans Affairs has been referred to the National Anti-Corruption Commission over a contract to provide GP health checks to veterans experiencing neurotoxic sequelae from the antimalarials mefloquine and tafenoquine.

Health insurer and healthcare company Bupa was given the $2.1 million contract in 2019 to provide “comprehensive health assessments” to affected soldiers, in response to findings of a 2018 Senate inquiry into the use of quinolines in the ADF.

Only 109 assessments were provided.

The ex-soldier who made the NACC referral this month has told TMR he tried for a year to obtain an assessment, but could not get one and eventually gave up, and cited another ex-soldier he knew who was in a similar position.

A Bupa spokesperson told TMR that the number of veterans who took up the offer was “low” and had declined over the life of the contract, which ran until 30 June this year.

Veterans were entitled to a free health assessment “from a GP who has been selected on the grounds of their unique experience in providing medical care to serving and ex-serving personnel”, Bupa said.

“Veterans received a health support recommendations report at the end of the assessment, which forms the basis for clinical and diagnostic testing and appropriate pathways for ongoing treatment by the veterans’ regular GP … [P]articipation rates over the course of the program have been low, and have been declining over time.”

Bupa referred all further questions to the DVA.

A department spokesman said all current or former ADF members who had taken mefloquine or tafenoquine during their service, or even outside their service, were eligible. “Everyone who expressed an interest … was offered the opportunity to have an assessment. No one was denied access to a health assessment,” the spokesman said.

“There were 299 expressions of interest by veterans who were advised about the availability and process of scheduling an assessment if they wished. Of those 299, 175 made the next step in contacting Bupa and were offered an appointment. Of those 175, as at 30 June 2023, 109 attended for a health assessment.”

Based on the $2.1m total value of the contract, that comes to $19,266 per assessment. However, the DVA said the 109 health assessments came “at a total cost of $800,000” – or just $7339 each.

The department said any ongoing treatment “would be supported by Department of Veterans Affairs through established healthcare pathways available to veterans”.

“The low uptake of this initiative is a positive indication that many veterans in the community who were concerned about having taken anti-malarial medication have now accessed the assessments.”

Separate from the NACC referral and not cited in it, allegations of conflict of interest have been made over the awarding of the Bupa contract.

At this point, names begin to pop up that will be familiar if you’ve been following the coverage of PwC and Innowell, first reported by TMR and since by Nine newspapers and The Guardian.

Professor Jane Burns was chair of Open Arms (formerly the Vietnam Veterans’ Counselling Service), which advises the DVA on veterans’ needs, at the time when the contract was awarded to Bupa, while also employed by Bupa as a “mental health and wellbeing innovator”.

Professor Burns, who has a PhD in psychiatry from Adelaide University and an honorary professorship at Melbourne University’s School of Population and Global Health, told TMR she had led a CRC bid for Bupa during her seven years as Open Arms chair, but was not involved in contracts.

Professor Burns also, together with Professor Ian Hickie of Sydney University’s Brain and Mind Centre, set up the digital mental health company InnoWell as part of Project Synergy, a series of clinical mental health trials run by consultancy firm PwC with a $30m non-competitive grant from the federal government. These included work with veterans in partnership with Open Arms.

In October 2019 Bupa invested in the Brain and Mind Centre’s “Best Care, First Time” project – delivered through InnoWell – to investigate “how technology can support the co-ordination of highly personalised care across primary, secondary and hospital-level clinics as well as between private and public services”.

Another co-founder of InnoWell, and until recently its chair, was Kristin Stubbins, acting chief executive at PwC.

Since the media coverage of the $30m PwC grant, Health Minster Mark Butler has asked his department for a briefing.

Asked whether the contract was awarded under a competitive process, a DVA spokesman said: “Bupa was awarded the contract in 2019 through a Survey and Quote under the DVA Head agreement with Bupa. In accordance with Australian government procurement processes and policies, the final decision relating to the procurement and contract rested with the DVA delegate, an employee of DVA.”

The battle to be heard

Retired Army officer Stuart McCarthy has been voicing his concerns about quinolines exposure, and about the Bupa contract specifically, for years. 

Since the early 1990s about 5000 soldiers have been administered either mefloquine (Lariam) or tafenoquine (Kodatef), mostly as part of clinical trials, the bulk of them in East Timor and Papua New Guinea between 1999 and 2002. These antimalarials are a third-line alternative to doxycycline, which is not always tolerated and which requires a daily dose, and atovaquone/proguanil (Malarone).

Mefloquine, which is taken weekly, was developed in the 1960s and approved by the FDA in 1989. Neuropsychiatric adverse events began to be reported soon after it went to market. Since 2002 its package warnings list a range of side effects including vertigo, visual disturbances, psychotic manifestations, hallucinations, confusion, anxiety, depression and paranoia, some of which were “reported to continue long after mefloquine has been stopped”, as well as “rare cases of suicidal ideation and suicide”.

In 2013 the FDA added a black box warning saying: “Mefloquine may cause neuropsychiatric adverse reactions that can persist after mefloquine has been discontinued”, with some symptoms continuing months or years after cessation.

Tafenoquine was found in the 1970s and only approved for malaria prophylaxis by the FDA and TGA in 2018. Safety studies used by the FDA found similar rates of psychiatric adverse reactions as with mefloquine, and it is contraindicated in people with a history of psychotic disorders.

Like its predecessor primaquine, it is ineffective in people with CYP2D6 enzyme deficiency, which affects up to a fifth of some populations.

The ADF has said these drugs were administered with soldiers’ consent – but consent in a military context is a spurious notion, as Lieutenant General John Caligari, Commanding Officer of 1 RAR during the East Timor trials, told the 2018 inquiry: “I don’t think there is any such thing as informed consent in the military. We do things because we are ordered to do things; we don’t have the opportunity to say yes or no … Informed consent, as I understand it, for this activity in particular was more of an academic requirement than anything else.”

At the same inquiry, Mr McCarthy submitted on behalf of the Australian Quinoline Veterans and Families Association that the post-quinoline effects amounted to “acquired brain injury” and “chronic quinoline encephalopathy”; but the committee did not endorse these descriptions in its final report.

The symptoms, according to Mr McCarthy, are frequently attributed to PTSD and treated with SSRIs, which are ineffective and sometimes make symptoms worse. 

Mr McCarthy himself, who had a 28-year career in the ADF, was given both drugs, first in PNG and later in Africa. He believes rehabilitation for acquired brain injury is the only beneficial treatment.

In 2015 he proposed a comprehensive outreach program with specialist care for veterans, but this was rejected. He was invited in 2018, together with Associate Professor Jane Quinn of Charles Sturt University, to co-design a “neurocognitive health program” (NHP) for affected veterans.

He was on the NHP steering committee when the Bupa contract was publicly announced, and said none of the DVA committee members had heard of it.

“So it sounded to me right from the outset that this was a decision made at ministerial level as a political fix,” Mr McCarthy told TMR. “There certainly wasn’t any consultation with us on this program.”

He resigned from the committee in early 2020, citing a long list of flaws in leadership and breaches of probity and trust, including the Bupa contract and the involvement of Professor Burns, and the involvement of Brigadier Leonard Brennan, who Mr McCarthy said was directly involved in conducting the mefloquine and tafenoquine trials on ADF personnel.

He told TMR vulnerable veterans were distressed by the enrolment process “to the extent at least one of them experienced suicide ideation … Another made a formal complaint about the psychological abuse they were subjected to by a DVA employee during this process.”

In his 2020 submission to a Senate committee inquiry into proposed legislation on Defence and veteran suicide prevention (the bill lapsed at the last federal election), Mr McCarthy said veteran suicides were “the predictable outcome of toxic leadership and catastrophic failures by military and related institutions to uphold their own purported values”.

“I’ve long been concerned about a conflict of interest with this Bupa contract, so I’m pleased to hear someone has made a formal complaint to the National Anti-Corruption Commissioner,” Mr McCarthy told TMR. “Unfortunately the [current] Royal Commission into Defence and Veteran Suicide wasn’t established properly to deal with this kind of conflict of interest, despite my submissions on their terms of reference.

“The use of $2.1 million in public funds is bad enough, but what makes this case even worse is that it was part of an orchestrated effort to deny proper care for people who were injured during their service to this country.

“Blatant conflicts of interest such as these remain one of the biggest barriers to care for vulnerable veterans seeking help through various DVA-funded programs. Hopefully a NACC investigation will provide the catalyst for a dramatic improvement in the toxic culture among senior DVA and Open Arms officials.”

The DVA spokesman told TMR that any veterans still concerned about having taken the antimalarials “can still contact DVA’s 1800 MEFLOQUINE (1800 633 567) hotline, and access a range of other support services, including a general GP check-up using their Veteran Card, the Veterans’ Health Check and support for mental health through Non-Liability-Health Care”.

FRIDAY AM UPDATE: Calling the number above took TMR to a recorded welcome message on a loop, after which we were connected to DVA “Triage and Connect”. The operator told us that, now that the Bupa program had ended, veterans concerned about mefloquine should go to their usual GP and use their White Card. They could still call this number but only to receive this updated information.

However, veterans’ rebates have fallen behind the cost of care to the point where some practices have stopped accepting the cards.

For Mr McCarthy, one word – perhaps used carelessly – sums up the attitude of Defence and DVA officials when it comes to veterans’ health. It’s in a March 2019 email exchange, which he obtained through Freedom of Information, between a DVA assistant secretary and then ADF Surgeon General Air Vice Marshal Tracy Smart. The assistant secretary advises that the $2.1m “mefloquine Budget measure”, i.e. the Bupa contract, is to be announced simultaneously with the tabling of the government response to the 2018 Senate inquiry.

Air Vice Marshal Smart replies: “Thanks Veronica – appreciate the heads up. We sensed that the [Prime Minister’s Office] was looking for more ways to appease the concerns.”

“This was a $2.1m ‘appeasement’ exercise with no substantial health outcomes as far as I can ascertain,” Mr McCarthy told TMR.

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