FOI 345/19/20
Document 1
From:
s47E
To:
Ross, Victoria DR 1; Williams, Felicity DR; Kelaher, Cath DR
Subject:
Clinical Advisory Group: Anti-malarial co-design workshop [SEC=UNCLASSIFIED]
Date:
Wednesday, 11 December 2019 12:47:09 PM
Attachments:
image001.png
Dear All,
Thank you for your involvement up until this point with DVA’s efforts to address the issue of
veterans concerned with having taken the anti-malarial drugs tafenoquine and mefloquine.
Work on this issue has now progressed and DVA has commenced working with BUPA to develop
anti-malarial health assessments. As you will recall from the initial workshop in September where
the project design was initially discussed, BUPA will be convening a co-design workshop of
clinicians, namely a Clinical Advisory Group. The aim of the workshop will be to provide input and
review BUPA developed materials and processes for the conduct of a medical assessment that a
concerned veteran will present for. Once finalised, this workshop will complete an important
step towards the launch of the health assessment program in early 2020. A Veterans and
Families Stakeholder co-design workshop will also be conducted around the same time to
supplement the design and delivery of the health assessment process.
The co-design workshop has been proposed to take place at the DVA offices in Canberra in the
second half of January 2020. While these details are yet to be finalised, I wanted to touch base
with you to ascertain your availabilities over the January period. Thus far, we have identified
Thursday to be a preferable day with our Chief Health Officer and DVA Executive available to
attend a half-day workshop on either the 16th, 23rd or 30th of January.
I am seeking your interest in being part of this clinician co-design group and confirm whether we
can provide your name and contact email address as a potential participant. As per the
Statement of Work, BUPA will then be in contact with you on the finer details.
If you have any further questions or would like to discuss any of the issues raised here, please
feel free to contact me on the number below.
Cheers,
s47E
s47E
|  Assistant Director 
Mental and Social Health Programs Section
Client Coordination and Support Branch
Department of Veterans’ Affairs
Ph: s47E
| Email:s47E
@dva.gov.au
s47F
Location: Gnabra Building
Level 1, 21 Genge Street
Canberra ACT 2600
GPO Box 9998 Canberra ACT 2601 Australia
Page 1 of 92

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FOI 345/19/20
Document 2
From:
Smart, Tracy AVM 1
To:
OCJ HLTH; Schramm, Craig BRIG; shanks, dennis PROF; Ross, Victoria DR 1; Brennan, Leonard BRIG
Subject:
FW: MO advice re mefloquine announcement and govt response [DLM=Sensitive]
Date:
Sunday, 10 March 2019 6:31:24 PM
Attachments:
image002.png
070319 Minister TPs anti-malarial KP (002).docx
070319 VAXX Chester Release - Mefloquine.docx
Sensitive
Folks
My gut feeling is that this is a good thing and should finally mean the issue is closed for us…I
hope.
Cheers
Tracy
Tracy Smart
Air Vice-Marshal
Commander Joint Health/Surgeon General ADF
Joint Health Command
CP2-7-121
Department of Defence
CANBERRA ACT 2600
ph: 02 6266 3919
mob: s22
IMPORTANT: This email remains the property of the Department of Defence and is subject to the
jurisdiction of section 70 of the Crimes Act 1914. If you have received this email in error, you are
requested to contact the sender and delete the email.
From: Hancock, Veronica <xxxxxxxx.xxxxxxx@xxx.xxx.xx> 
Sent: Friday, 8 March 2019 7:00 PM
To: Smart, Tracy AVM 1 <xxxxx.xxxxxx@xxxxxxx.xxx.xx>
Cc s47E
dva.gov.au>;s47E
@dva.gov.au>s47E
s47E
@dva.gov.au>; s47E
@dva.gov.au>
Subject: MO advice re mefloquine announcement and govt response [DLM=Sensitive]
Hi again Tracy,
Following on from my email earlier this week, please find attached the proposed media release
and talking points which cover the tabling of the Government Response, the early
announcement of the Budget measure and the publication of the UQ research.
We are currently awaiting a letter from the PM which will include the necessary approval for an
early announcement and tabling of the Response. Minister Chester has expressed an intent to
table the Response and announce (via media release) the measure at the same time. The
President of the Senate must also sign off on the Government Response prior to it being tabled.
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FOI 345/19/20
At this stage, it looks like this is all likely to occur mid-next week.
Will keep you posted.
Regards, Veronica
Veronica Hancock
Assistant Secretary
Health Policy Branch
Veterans’ Services Design Division
Department of Veterans’ Affairs
t 02 6289 6712 m s22
 
e xxxxxxxx.xxxxxxx@xxx.xxx.xx
To support those who serve or have served in the defence of our nation
and commemorate their service and sacrifice.
The Department acknowledges the Traditional Owners of the land
throughout Australia and their continuing connection to country, sea and
community. We pay our respect to all Aboriginal and Torres Strait
Islander peoples, their cultures and to their elders past and present.
From: Smart, Tracy AVM 1 [mailto:xxxxx.xxxxxx@xxxxxxx.xxx.xx] 
Sent: Tuesday, 5 March 2019 10:25 AM
To: Hancock, Veronica <xxxxxxxx.xxxxxxx@xxx.xxx.xx>
Cc:s47E
@dva.gov.au>;s47E
@dva.gov.au>; Thomas,
Megan MS <xxxxx.xxxxxx@xxxxxxx.xxx.xx>; Oneill, Kim MRS <xxx.xxxxxx@xxxxxxx.xxx.xx>
Subject: RE: MO advice re mefloquine announcement and govt response [DLM=Sensitive]
Sensitive
Thanks Veronica – appreciate the heads up. We sensed that the MO was looking for more ways
to appease the concerns.
BTW we also got a media request yesterday re the Labor announcement but were still waiting on
DVA input. I have attached what was cleared from us – pretty vanilla but its really difficult for us
to respond to these requests when DVA has the lead and is the only area that the MO is really
talking about re the issue. In future we will try to push these back in to your space rather than
trying to answer in a vacuum. Hope this is ok.
Cheers
Tracy
Tracy Smart
Page 3 of 92

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FOI 345/19/20
Air Vice-Marshal
Commander Joint Health/Surgeon General ADF
Joint Health Command
CP2-7-121
Department of Defence
CANBERRA ACT 2600
ph: 02 6266 3919
mob: s22
IMPORTANT: This email remains the property of the Department of Defence and is subject to the
jurisdiction of section 70 of the Crimes Act 1914. If you have received this email in error, you are
requested to contact the sender and delete the email.
From: Hancock, Veronica <xxxxxxxx.xxxxxxx@xxx.xxx.xx> 
Sent: Monday, 4 March 2019 5:42 PM
To: Smart, Tracy AVM 1 <xxxxx.xxxxxx@xxxxxxx.xxx.xx>
Cc:s47E
@dva.gov.au>;s47E
@dva.gov.au>
Subject: MO advice re mefloquine announcement and govt response [DLM=Sensitive]
Hi Tracy,
For info.  Dylan called from the Minister’s office this afternoon to advise that following
discussions with Minister and PMO, Minister is intending to make an early announcement of the
mefloquine Budget measure, at the same time as tabling the Government response to the
Senate mefloquine inquiry. 
The Budget measure is a $2.1 million commitment “Response to Senate Inquiry into anti-
malarials mefloquine and tafenoquine” that will support veterans who are concerned about
having taken the anti-malarial drugs mefloquine or tafenoquine during their service.  This
initiative will deliver a national program of comprehensive health assessments for veterans,
providing a whole-of-person assessment which will allow for identification of potential service
related illness, disease or injury, and where appropriate referral for further specialist
assessment, treatment and support.  This measure will be implemented from 1 July 2019
through Open Arms.
We do not yet have confirmation as to when the announcement & tabling will take place
(although note that the Government response was due to be tabled today).  One possibility is
next week during a visit to Brisbane.
We are presently working on adding a para to the introduction section of the draft response to
announce the measure, and preparing a media release. 
We will provide you a copy of the revised response once FAS cleared.
Thanks, Veronica
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FOI 345/19/20
Veronica Hancock
Assistant Secretary
Health Policy Branch
Veterans’ Services Design Division
Department of Veterans’ Affairs
t 02 6289 6712 m s22
 
e xxxxxxxx.xxxxxxx@xxx.xxx.xx
To support those who serve or have served in the defence of our nation
and commemorate their service and sacrifice.
The Department acknowledges the Traditional Owners of the land
throughout Australia and their continuing connection to country, sea and
community. We pay our respect to all Aboriginal and Torres Strait
Islander peoples, their cultures and to their elders past and present.
IMPORTANT
1. Before opening any attachments, please check for viruses.
2. This e-mail (including any attachments) may contain confidential information
for the intended recipient. If you are not the intended recipient,
please contact the sender and delete all copies of this email.
3. Any views expressed in this e-mail are those of the sender and are not
a statement of Australian Government Policy unless otherwise stated.
4. Electronic addresses published in this email are not conspicuous publications and DVA
does not consent to the receipt of commercial electronic messages.
5. To unsubscribe from emails from the Department of Veterans' Affairs (DVA) please go
to
http://www.dva.gov.au/contact_us/Pages/feedback.aspx
, and advise which mailing list you would like to unsubscribe from. 
6. Finally, please do not remove this notice.
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FOI 345/19/20
Minister talking points 
Anti‐malarial funding and the Government’s response to Senate Inquiry into 
the use of Quinolone anti‐malarial drugs Mefloquine and Tafenoquine 
Prepared by:  
Cleared by:  
 Date:  
Anti‐malarial funding  
 The Government is committing $2.1 million to a new initiative to support
veterans who are concerned about having taken the anti‐malarial drugs
mefloquine or tafenoquine.
 This initiative will deliver a national program that will provide concerned
veterans with the option to receive a comprehensive health assessment to
identify service‐related illness, disease and injury.
 Where appropriate, the veteran will be referred for further specialist
assessment, treatment and support.
 This initiative responds to concerns heard from veterans during both the
recent Senate Inquiry and the Mefloquine and Tafenoquine Consultation
Forums coordinated across Australia last year.
 This initiative will be implemented from 1 July 2019.
 The Department of Veterans’ Affairs (DVA) provides help to veterans who
are concerned about having taken the anti‐malarial medications mefloquine
and tafenoquine.
 DVA has a designated phone line —1800 633 567 – for veterans with
enquiries, including available support, non‐liability health care and the
claims process.
 DVA can also pay for treatment for any mental health condition without the
need for the conditions to be accepted as related to service. This is known
as non‐liability health care, and it is available to anyone who has served a
single day in the full‐time ADF and some reservists.
 Open Arms – Veterans and Families Counselling provides free, confidential,
nationwide counselling and support for eligible current and former ADF
members and their families and can be contacted 24/7 on 1800 011 046.
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FOI 345/19/20
Government response to Senate Inquiry into the use of Quinoline anti‐malarial 
drugs Mefloquine and Tafenoquine in the ADF 
 The Government has presented to Parliament the Government response to
the Senate Inquiry into the use of Quinoline anti‐malarial drugs Mefloquine
and Tafenoquine in the Australian Defence Force (ADF).
 The Government largely supports the view of the Senate Inquiry Committee
and the recommendations.
 The Government response is available on the Senate Inquiry website
www.aph.gov.au/Parliamentary_Business/Committees/Senate/Foreign_Aff
airs_Defence_and_Trade/Mefloquine) and the DVA website
www.dva.gov.au/mefloquine.  
 The Senate Inquiry began in June last year, with both the Department of
Veterans’ Affairs and the Department of Defence having provided
submissions to the Inquiry, and appearing at the public hearings in
Canberra.
 The Government would like to thank the individuals and organisations who
participated in the Inquiry for their contribution to this important issue.
 The evidence provided to the Inquiry adds to the Government’s
understanding of how we can further serve and support veterans and their
families.
 The Government would like to acknowledge that for some it was a difficult
process to provide details about their concerns. Should any of these
individuals need support, or someone to talk to, Open Arms – Veterans and
Families Counselling provides 24/7 free, confidential, national‐wide
counselling.
University of Queensland research  
 The research was commissioned in 2017 by DVA and Defence in response to
concerns about the use of anti‐malarial medications during service.
 This is part of the Government’s ongoing efforts to understand the effects
of some of these medications used in the Australian Defence Force (ADF).
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FOI 345/19/20
 DVA and Defence will consider the report as part of further work to provide
support to veterans who are concerned about their use of anti‐malarial
medications during their service.
If asked 
What does this measure do?  
 This initiative will deliver a national program of comprehensive, whole‐
of‐person health assessments for veterans. This will allow for early
identification of service related illness, disease and injury. Veterans can
be referred for specialist assessment, treatment and support as
required.
What does this measure respond to?  
 This initiative responds to health related concerns heard from veterans
at both the recent Senate Inquiry and the Mefloquine and Tafenoquine
Consultation Forums which were held across Australia last year.
When will I be able to have my health assessment?  
 Health assessments will be available to veterans after July 2019.
How do I book a health assessment?  
 DVA is working on the implementation of this initiative.
 To register your interest in accessing a Health Assessment, please
contact 1800 MEFLOQUINE (1800 633 567) to provide your name and
contact details.
Once I have had my health assessment, what will happen next?  
 Where required, veterans will be referred for further specialist
assessment, treatment and support.
What were the Mefloquine and Tafenoquine Consultation Forums?  
 Between September and November 2018 DVA hosted seven Mefloquine
and Tafenoquine Consultation Forums.
 The forums were held in Adelaide, Sydney, Brisbane, Townsville, Perth,
Melbourne and Darwin.
 The purpose of the forums was to hear from current and former
members of the ADF who are concerned about having taken mefloquine
or tafenoquine, and outline the treatment, services and support
available.
 A summary of the key themes discussed by forum attendees and the
resources given to the attendees can be accessed via the DVA
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FOI 345/19/20
Mefloquine and Tafenoquine Information webpage 
(www.dva.gov.au/mefloquine).  
What about support for acquired brain injury or neurocognitive disorders? 
 If you would like further information about support available to veterans
who identify as having an acquired brain injury or neurocognitive
disorder, please call 1800 MEFLOQUINE (1800 633 567).
What support is currently available? 
 Information about support available to veterans who are concerned
about having taken mefloquine or tafenoquine during their service is
available at the Mefloquine and Tafenoquine Information webpage:
www.dva.gov.au/health‐and‐wellbeing/health‐services‐and‐
conditions/mefloquine‐and‐tafenoquine‐information
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FOI 345/19/20
The Hon Darren Chester MP 
Minister for Veterans’ Affairs 
Minister for Defence Personnel 
Minister Assisting the Prime Minister for the Centenary of ANZAC 
MEDIA RELEASE 
XX March 2019 
GOVERNMENT COMMITS $2.1 MILLION TO ANTI‐MALARIAL INITIATIVE 
FUNDING has today been announced for a new $2.1 million initiative to support veterans who are 
concerned about having taken the anti‐malarial drugs mefloquine or tafenoquine. 
Minister for Veterans’ Affairs Darren Chester said this initiative will be implemented from 1 July 
2019, and deliver a national program to concerned veterans with the option to receive a 
comprehensive health assessment to identify service‐related illness, disease and injury. 
This initiative responds to concerns heard from veterans during both the recent Senate Inquiry and 
the mefloquine and tafenoquine consultation forums coordinated across Australia last year.  
“The Government is pleased to present to Parliament its response to the Senate Inquiry into the use 
of Quinoline anti‐malarial drugs mefloquine and tafenoquine in the Australian Defence Force (ADF).” 
Mr Chester said.  
“We largely support the views of the Senate Inquiry Committee and its recommendations, and we 
acknowledge that some current and former ADF personnel have complex health concerns.” 
The evidence provided to the Inquiry adds to the Government’s understanding of how it can further 
serve and support veterans and their families. 
Mr Chester also thanked the individuals and organisations who participated in the Inquiry for their 
contribution to this important issue.   
“I would also like to acknowledge everyone who put forward their views on what is an issue this 
Government takes very seriously,” Mr Chester said. 
“For some it was a difficult process to provide details about their concerns.  Should any of these 
individuals need support, or someone to talk to, Open Arms — Veterans and Families Counselling 
provides 24/7 free, confidential, national‐wide counselling. 
“For those veterans who are who are concerned about having taken the anti‐malarial medications 
mefloquine and tafenoquine or are seeking information about support available, please contact the 
Department of Veterans’ Affairs (DVA).” 
Additionally, the report by the University of Queensland on the Self‐reported health of Australian 
Defence Force personnel after use of anti‐malarial drugs on deployment has also been released 
today. 
Open Arms – Veterans and Families Counselling, provides support for current and ex‐serving ADF personnel and their 
families. Free and confidential help is available 24/7. Phone 1800 011 046 (international: +61 1800 011 046 or +61 8 8241 
4546) or visit www.OpenArms.gov.au  
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FOI 345/19/20
“This is part of the Government’s ongoing efforts to understand the effects of some of these 
medications used in the Australian Defence Force (ADF),” Mr Chester said.  
A copy of the full Government response is available on the Senate Inquiry website. 
A copy of the University of Queensland on the Self‐reported health of Australian Defence Force 
personnel after use of anti‐malarial drugs on deployment is available on the Department of Veterans’ 
Affairs website.  
DVA can be contacted on the designated 1800 MEFLOQUINE (1800 633 567) phone line for support. 
ENDS 
MEDIA CONTACTS:  
Rachel Tharratt: 02 6277 7820 
DVA Media: 02 6289 6466 
Office of the Hon. Darren Chester, Canberra ACT. 
Open Arms – Veterans and Families Counselling, provides support for current and ex‐serving ADF personnel and their 
families. Free and confidential help is available 24/7. Phone 1800 011 046 (international: +61 1800 011 046 or +61 8 8241 
4546) or visit www.OpenArms.gov.au  
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FOI 345/19/20
Document 3
From:
 on behalf of CCS.MENTAL.SOCIAL.HEALTH
s47E
To:
Kelaher, Cath DR; Williams, Felicity DR; Ross, Victoria DR 1
Subject:
Invitation to participate in Anti-malarial Health Assessment Co-design Workshop (23 January 2020) [SEC=UNCLASSIFIED]
Date:
Friday, 20 December 2019 5:17:51 PM
Dear Cath, Vicki and Felicity,
I am emailing to invite you to participate in a clinical workshop next month to co-design a comprehensive health assessment
tool and clinical guidance for those veterans who are concerned with having taken anti-malarial medications Mefloquine or
Tafenoquine.
The workshop will be held on 23rd January 2020, 11am-2pm AEDT at DVA’s Canberra Office (21 Genge Street, Canberra City).
A working lunch will be provided, as will any interstate travel to the workshop.
As you know, a number of veterans are of the view that they are suffering an acquired brain injury due to taking anti-malarial
medications Mefloquine or Tafenoquine 20 years ago.  There was a Senate inquiry into this very issue in 2018 which found
there was no evidence to support this but noted that those who believed this have real symptoms (possibly related to many
other factors) and should be offered care.
https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Foreign_Affairs_Defence_and_Trade/Mefloquine/Report
In response, DVA is now working to implement the Australian Government’s initiative to deliver a national program that will
provide concerned veterans with the opportunity to receive a comprehensive health assessment to identify service-related
illness, disease and injury. In addition, Open Arms’ neuropsychological screening pilot in Townsville will commence from
February where a number of veterans who have taken Mefloquine live (and many thanks for your work in support of this in
particular).
DVA has engaged the services of an external provider – BUPA Australia - to develop and deliver the health assessments. The
health assessments will be conducted by a General Practitioner who has an understanding of the health concerns of those
who have taken Mefloquine or Tafenoquine, the complex conditions with which some veterans may present and the veteran
experience. Veterans will be referred for further specialist assessment, treatment and support as necessary.
A critical step in the program will be the development of the clinical health assessment tool and supporting materials and
guidance and as part of this we have asked that there be a co-design workshop. This will not only ensure the clinical efficacy of
the tools, but also ensure the assessment itself retains its clinical focus. As such, broader veteran/family stakeholders will be
consulted separately on other assessment related materials, such as patient consent forms and information, the
communications framework and advice on how this veteran cohort can best attain a positive experience from the assessment.
Please let us know if you are available to attend the clinicians workshop (RSVP to xxx.xxxxxx.xxxxxx.xxxxxx@xxx.xxx.xx by
10 January 2020 would be appreciated).
DVA has asked BUPA to make the travel arrangements for interstate participants. Please let us know if travel support is
required.
I look forward to hearing from you and working with you again in the new year.
For now, I wish you all the best this holiday season.
Kind Regards,
Leonie Nowland
Assistant Secretary
Client Coordination and Support
(02) 6289 6076 e xxxxxx.xxxxxxx@xxx.xxx.xx
To support those who serve or have served in the defence of our nation
and commemorate their service and sacrifice.
Page 12 of 92

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FOI 345/19/20
Document 4
From:
s47E
To:
Ross, Victoria DR 1
Cc:
s47E
Subject:
Participation in workshop on delivery of meflqouine health assessment [SEC=UNCLASSIFIED]
Date:
Friday, 16 August 2019 1:01:57 PM
Hi Vicki,
As discussed, we are working to engage Bupa to deliver and design the mefloquine and
tafenoquine health assessment budget measure through the new Defence health contract. As a
starting point we are organising a scoping workshop which help define how the assessments will
be delivered, the breadth of co-design activities and how we can utilise existing guidelines,
services etc. We would like to have Defence represented at this workshop. At this stage we are
looking to have the workshop in the week of 26 August, most likely Thursday 29 August, in
Canberra.
Bupa will provide a draft agenda for the workshop by early next week.
Could you please let us know who from Defence should attend the workshop?
Let me know if you have any further questions.
Thanks,
s4
7E
s47E
Assistant Director | Mental and Social Health Policy
Department of Veterans' Affairs
P:s47E
 E: s47E
@dva.gov.au | GPO Box 9998, CANBERRA 
ACT  2601
Page 13 of 92

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FOI 345/19/20
Document 5
From:
s47E
@dva.gov.au on behalf of MENTAL.SOCIAL.HEALTH.POLICY
To:
s47E
s47E
Tindall, Katherine CAPT - RAN; Ross, Victoria DR
1; Williams, Felicity DR; Kelaher, Cath DR; Lawson, Stephen CAPT - RAN 2; s47E
s47E
s47F
 s47E
s47E
Subject:
Planning Workshop - Health Assessments for veterans concerned about having taken mefloquine and
tafenoquine [SEC=UNCLASSIFIED]
Start:
Wednesday, 4 September 2019 12:00:00 PM
End:
Wednesday, 4 September 2019 5:00:00 PM
Location:
DVA Offices - Level 8 - Millen Room (Bridge Conference) - 21 Genge St Canberra
Attachments:
image001.png
Final Agenda - DVA Bupa Health Assessment Scoping Workshop.docx
Update 3/9 – Attached is the agenda for the workshop tomorrow. 
s47E
For Bupa and Defence attendees, please call on arrival and we will escort you to the meeting room
Thanks 
s47E
Good Morning 
Confirming the Planning Workshop will be held tomorrow from 12pm-5pm in the Millen Room, DVA Canberra Offices (21 Genge St Canberra).
Lunch will be provided. An agenda will follow later today. 
Kind Regards 
s47E
Good Afternoon 
This meeting invite is to replace the one cancelled bys47E  earlier today. 
This invitation is a placeholder for an initial co-design/planning workshop with the initiative delivery partner, Bupa, for the Health Assessment
for veterans concerned about having taken mefloquine and tafenoquine. 
The intent of the workshop is to commence the co-design and define the scope of the initiative. 
An agenda is being drafted. All papers will be shared with attendees ahead of the day.
It is anticipated that not all participants will be required for the entire duration of the workshop (12pm-5pm). 
More details about the times particular participants will be required during the workshop will be available soon. 
Thank you 
If you have any questions, please do not hesitate to free to reach out. 
Kind Regards 
s47E
 Policy Officer I Mental Health Policy 
Wellbeing Policy Branch I Veterans’ Services Design Division I Department of Veterans’ Affairs
s47E
p:
w: www.dva.gov.au <http://www.dva.gov.au/>  
The Department acknowledges the Traditional Owners of the land throughout Australia and their continuing connection to country, sea and
community. We pay our respect to all Aboriginal and Torres Strait Islander peoples, their cultures and to their elders past and present.
Page 14 of 92

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FOI 345/19/20
DVA anti-malarial scoping 
workshop 
 
 
Date 
Wednesday 4th September 2019  
Time 
12pm to 5pm 
Location 
Department of Veterans’ Affairs, Canberra 
Meeting 
DVA anti-malarial scoping workshop 
Attendees 
Bupa: s47F
Program coordinator / workshop facilitator  
DVA / ADF representatives 
 
Introductions & setting the scene – 30 minutes  
 
12:00PM 
Round of introductions 
Bupa – why are we here today? 
  Initial scoping workshop 
  Plan for initiation of health assessments 
  Phase II planning – design national program and network, codesign process 
  Operations 
  Today’s outcomes – Bupa will put together a detailed project plan and scope / proposal based on 
today’s decisions 
  Things not in scope for today (e.g. discussing in depth program documentation) 
DVA – provide brief program context 
  Brief history 
  Description of veteran experience and needs 
  Current context 
  Program objectives and desired outcomes 
 
 
Bupa Health Services Pty Ltd (Bupa) ABN 50 003 098 655                    Confidential 
1 
 
 
 
Page 15 of 92

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FOI 345/19/20
DVA anti-malarial scoping workshop 
 
Health assessment – 75 minutes    
 
 
12:30pm 
  Establish objectives and desired outcomes 
  Plan initial program roll out: WHAT specifics, WHERE location, WHO number of clinicians, 
clinician attributes, number of veterans, HOW patient flow  
  Communications, outreach and engagement plan (veteran and clinician) 
  Timelines, draft action plan 
  Evaluation metrics 
Decisions/Action Items 
Who 
Timeframe 
 
 
 
 
 
 
 
 
 
 
 
 
Break – 15 minutes 
 
 
 
 
 
 
         1:45PM 
Working lunch  
Comprehensive national program codesign – 90 minutes           2:00PM 
  Establish objectives of codesign phase 
  Decide on any items that should not be included in codesign (e.g. DVA non-negotiables) 
  Stakeholders – who should be involved in the codesign phase? Outreach plan. 
  Deliverables (e.g. clinical guidelines/work instructions, process maps, clinical pathways, etc.) 
  Timelines, including any workshops, draft action plan 
  Approval processes 
Decisions/Action Items 
Who 
Timeframe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bupa Health Services Pty Ltd (Bupa) ABN 50 003 098 655                    Confidential 
2 
 
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---

FOI 345/19/20
DVA anti-malarial scoping workshop 
 
Risk management – 45 minutes   
 
 
 
 
3:30PM 
  Discussion of project risks and management plan 
Decisions/Action Items 
Who 
Timeframe 
 
 
 
 
 
 
 
 
 
 
 
 
Rol  out of national network – 30 minutes 
 
 
 
4:15PM 
  Timelines 
  Early considerations 
Decisions/Action Items 
Who 
Timeframe 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wrap up & next steps – 15 minutes 
 
 
 
 
4:45PM 
  Consider workshop round 2 if needed 
  Decide on approval processes for deliverables stemming from today (proposal, scope of work) 
Decisions/Action Items 
Who 
Timeframe 
 
 
 
 
 
 
 
 
 
 
Bupa Health Services Pty Ltd (Bupa) ABN 50 003 098 655                    Confidential 
3 
 
Page 17 of 92

---

FOI 345/19/20
Document 6
From:
Ross, Victoria DR 1
To:
Kelaher, Cath DR; Tindall, Katherine CAPT - RAN; Lawson, Stephen CAPT - RAN 2; Williams, Felicity DR
Subject:
prep for DVA co-design workshop [SEC=UNCLASSIFIED]
Date:
Monday, 2 September 2019 10:21:00 AM
Attachments:
20190322 GP Clinical management guidelines - veterans with complex health issues.pdf
UK GWS assessment.pdf
AFP Managing unexplained symptoms in GP 2015.pdf
UNCLASSIFIED
Hi everyone,
I think we’re still meeting with DVA this Wednesday although it’s a bit confusing.
Attached is some background info, perhaps we could discuss our position on Tuesday so we’re all
on the same page.
From my perspective the issues are
·
It’s not all about the mefloquine. The veterans at whom this assessment is aimed are
those with complex symptomatology/conditions who aren’t accessing health care or feel
that they are not receiving the ‘right’ health care. The intent is to improve engagement
with the health care system and appropriate care to optimise their health and wellbeing.
It’s about acknowledging their concerns, assessing their symptoms and finding a way
forward. We are concerned that there is potential for the doctors doing the assessment
to accept and/or reinforce that mefloquine/tafenoquine are the cause of the veteran’s
poor health etc.
·
This health assessment appears to be in addition to the extant Veteran Health Check.
Does it need to be?
·
How does continuity of care factor in. If this assessment is done by a BUPA provider, will
they continue on as the veteran’s GP? The primary issue is that these veterans are not
engaged with or don’t trust the system. There is a risk that their care may become even
more fragmented.
Cheers,
Vicki
Dr Victoria Ross 
MBBS MPH FRACGP FAFPHM 
Senior Medical Advisor, Military Population Health
CP3-7-091 Department of Defence
PO Box 7912
CANBERRA BC ACT 2610
Tel (02) 62663936 
Fax (02) 62663933
E-mail: xxxxxxxx.xxxxx@xxxxxxx.xxx.xx
IMPORTANT: This email remains the property of the Department of Defence. Unauthorised
communication and dealing with the information in the email may be a serious criminal offence.
If you have received this email in error, you are requested to contact the sender and delete the
email immediately.
Page 18 of 92

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FOI 345/19/20
Clinical Guidelines for providing appropriate care to 
ADF members and veterans concerned about having 
been prescribed mefloquine or tafenoquine 
Version 3, March 2019 
PURPOSE
These clinical guidelines are primarily designed to assist clinicians manage patients 
who are concerned about having taken mefloquine or tafenoquine and specifically those 
that are suffering from neuropsychiatric symptoms which they attribute to historical
use of these antimalarials (often from the 1999-2002 period). They may also be useful 
in managing patients with neuropsychiatric symptoms that they attribute to other 
antimalarials and other medications more generally, or symptoms of unknown cause.
BACKGROUND
In recent years, there has been much publicity in the civilian media and concerns raised 
by some serving and ex-serving Defence members relating to the use of mefloquine
and tafenoquine for malaria chemoprophylaxis by the Australian Defence Force. The 
United Kingdom is experiencing similar concerns and the United States has experienced 
similar concerns in the past.
On 30 November 2015, Defence released a statement on the use of mefloquine in  the 
ADF that advised if “any ADF member, past or present is concerned that they might be 
suffering side-effects from the use of mefloquine Defence encourages them to raise 
their concerns with a medical practitioner so they may receive a  proper diagnosis and
treatment.”
http://news.defence.gov.au/2015/11/30/statement-on-the-use-of-mefloquine-in-
the-adf/
It is anticipated that Defence medical officers will encounter ADF members who are 
concerned that they may be suffering side-effects from historical use of mefloquine or 
tafenoquine. Similarly, civilian GPs may encounter ex-serving members with these 
concerns.
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FOI 345/19/20
Mefloquine side-effects
Mefloquine has been registered for malaria chemoprophylaxis in Australia since 1993, 
and has been prescribed to over 35 million people worldwide. The side-effect profile is 
well known. In chemoprophylaxis the safety profile of mefloquine is characterised by a 
predominance of neuropsychiatric adverse reactions. Most of the recent changes in 
product information relate to the duration that psychiatric or neurological side-effects 
may last. On occasions, these symptoms have been reported to continue long after 
mefloquine has been stopped.
https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/PICMI?OpenForm&t=PI&
q=Lariam&r=/
The neuropsychiatric side-effects of mefloquine have received the most attention and 
are best considered as psychiatric – disturbed sleep, anxiety, paranoia, depression, 
hallucinations and psychosis; and neurological – vertigo, loss of balance, tinnitus, 
sensorineural hearing loss and neuropathy.
Side-effects from mefloquine usually occur soon after commencing the medication. 
Side-effects usually resolve within days to weeks after ceasing the medication. Due to 
mefloquine’s long half-life (21 days on average) it is possible for symptom onset to be 
weeks after cessation. In rare cases, side-effects may persist for months or longer.
Mefloquine and Post-traumatic Stress Disorder (PTSD) or mild traumatic brain 
injury (mTBI)
There is no evidence that mefloquine causes or triggers PTSD or mTBI. In the acute 
situation, there is potential for acute mefloquine-related psychiatric symptoms to 
confound a PTSD or mTBI diagnosis. There is no evidence to suggest that a PTSD 
diagnosis made months or years after ceasing mefloquine can be attributed to past 
mefloquine use.
Mefloquine toxicity – CNS toxicity syndrome – mefloquine toxidrome
Dr Remington Nevin, an ex-US Army medical officer, has published a number of opinion 
articles proposing the adoption of diagnoses to describe long term or permanent 
neurological symptoms related to mefloquine use. None of the terms have been 
officially accepted and there are no accepted diagnostic criteria, diagnostic tests nor 
any treatment. Clinicians should understand that members may present seeking one 
of these diagnoses.
It is important to acknowledge that mefloquine has been associated with long term or 
permanent neurological symptoms which can be diagnosed.
Chemically acquired brain injury
Several veterans and people active in the media have suggested that the quinoline 
class of antimalarials can cause brain injury. In 2017 the Repatriation Medical Authority 
(RMA) conducted a review of the medical and scientific literature to investigate whether 
mefloquine, tafenoquine and primaquine can cause chemically acquired brain injury. 
The RMA found that there is insufficient sound medical-scientific evidence that 
exposure to these pharmaceuticals causes chronic brain injury.
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FOI 345/19/20
CYP2D6
CYP2D6 is one of the cytochrome P450 enzymes. It is necessary for the metabolism of 
primaquine to an active form against malaria. Its role in the metabolism of tafenoquine 
is less certain. It is not relevant to mefloquine metabolism. The gene that codes for 
this enzyme is highly polymorphic and individuals can be described as poor, 
intermediate or normal metabolisers. Several veterans and advocates have stated that 
people who are poor metabolisers can suffer from tafenoquine or mefloquine toxicity. 
There is no evidence linking this enzyme to side effects from these medications. The 
genetic mutation (for poor or intermediate metabolism) is not predictive of primaquine 
efficacy. Primaquine may still be effective in someone who has reduced enzyme 
metabolism. It is reasonable to test individuals who have had a confirmed vivax malaria
relapse despite having fully complied with a primaquine course (treatment failure).
This testing could be done to inform future malaria treatment options, if this is relevant
to their situation. There is no basis for pre-emptive or mass screening.
Tafenoquine
Tafenoquine is a relatively new anti-malarial medication which is chemically closely 
related to primaquine. As a quinine derivative, it falls into the same broad class of 
antimalarials as mefloquine however it acts quite differently in the body and its 
known side-effect profile more closely reflects those of primaquine (primarily gastro 
intestinal upset). It was registered in Australia in 2018 for both prophylaxis 
(Kodatef™) and radical cure (Kozenis™). It was trialled by the ADF between 1999 
and 2001 as an option for prophylaxis, eradication and treatment of malaria.
There is no evidence that tafenoquine causes serious neuropsychiatric effects, 
either acute or chronic. In patients receiving Kodatef™ in clinical trials, adverse 
psychiatric reactions included sleep disturbances (2.5%), depression/depressed 
mood (0.3%), and anxiety (0.2%). Long term use has been associated with an eye 
condition, vortex keratopathy (small deposits in the cornea), also seen with long 
term use of chloroquine. The condition does not affect vision and has no symptoms. 
It is benign and resolves completely after tafenoquine is stopped.
The prescribing information for Kodatef™ advises that it should not be used in 
people with a history of serious psychosis or current psychotic symptoms, delusions 
or hallucinations. This is a precaution as there is no data on the safety of 
tafenoquine in people with a history of psychiatric disorder as these individuals 
were excluded from clinical trials of tafenoquine for prophylaxis. Serious psychiatric 
disorders such as psychosis and depression have been associated with some 
quinoline anti-malarial agents.
Prescribing information and consumer medicine information for tafenoquine is 
available on the TGA website at www.tga.gov.au and searching the Australian 
Register of Therapeutic Goods (ARTG).
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FOI 345/19/20
CLINICAL APPROACH
Persons presenting with neurological or psychiatric symptoms with a history of previous 
mefloquine or tafenoquine use should be thoroughly assessed. It is important to accept 
that the member or veteran has concerns that their symptoms may be related to 
historical mefloquine or tafenoquine use and their concerns should not be summarily
dismissed.
Members presenting who are concerned because they have taken mefloquine or 
tafenoquine in the past but have no symptoms (the worried well) also need to have 
their concerns noted and addressed.
What can the general practitioner do?
1.
Document any symptoms as part of a comprehensive history. Note the date of 
symptom onset in relation to mefloquine or tafenoquine use and the nature of 
symptoms after ceasing the medication. A comprehensive history is very 
important, as there are many factors which could be relevant to the presenting 
symptoms. These include developmental and family history, social history, 
injury, deployment experiences and other life events. In the ADF, most
antimalarial use occurs in the context of deployment.
2.
Perform a thorough examination and document any abnormal neurological or 
other signs as well as relevant negatives. All patients should receive an 
audiogram and a Sharpened Romberg test.
3.
Assess the patient with readily available psychological screens, if relevant. For 
example, K-10, DASS-21, DAR or CAPS-5.
4.
Arrange further diagnostic investigations or specialist referral as appropriate.
5.
Those presenting with neurological symptoms will often require referral to one 
or more of the following to confirm a diagnosis, quantify symptoms and 
recommend treatment:
a.
Neurologist; and /or
b.
Neuropsychologist (including a request for a battery of tests to baseline 
neuropsychological function)
6.
Those presenting with psychiatric symptoms should be referred to a 
psychiatrist, preferably a psychiatrist with experience in military populations,
where available.
7.
Assess and document risk.
8.
Explore useful treatments. Treatment options will depend on the 
symptoms being experienced and whether a condition can be diagnosed.
a.
Where a clinical diagnosis (including a provisional diagnosis) is made, 
evidence based treatment for the condition should be provided.
b.
No specific treatment has been proposed for mefloquine related 
neuropsychiatric problems apart from ceasing the medication, which has 
already occurred.
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FOI 345/19/20
c.
Generally, pharmacotherapy or psychotherapy should be withheld until a
disorder is diagnosed, however treatment of specific symptoms causing 
significant distress should be considered even without a provisional or 
definitive diagnosis (e.g. prochlorperazine for dizziness).
9.
Document the claims in the medical record. Include details of deployment 
location, operation and dates; the antimalarial taken or believed to have been
taken and if relating to the 1998-2003 period whether they participated in an 
Army Malaria Institute trial. Be aware that some veterans will not accurately 
recall whether or not they participated in a trial. They can check if they were a 
trial participant by contacting xxx.xxxxxxx@xxxxxxx.xxx.xx.
10.
Advise the member/veteran that there is additional information on anti-
malarial use in the ADF available on the Joint Health Command external web 
site: www.defence.gov.au/Health/HealthPortal/Malaria/default.asp and the 
DVA website www.dva.gov.au/health-and-wellbeing/health-services-and-
conditions/mefloquine-and-tafenoquine-information.
In addition, clinicians may find this article from the September 2015 Australian 
Family Physician useful: Managing medically unexplained illness in general practice 
http://www.racgp.org.au/afp/2015/september/managing-medically-unexplained-
illness-in-general-practice/
Risk Assessment and Mental Health Management
Defence members who present to a Defence medical officer with mental health 
symptoms, psychological distress or increased risk should be assessed and
managed in accordance with Defence Health Manual Volume 2 Part 10 Chapter 2 –
Assessing and managing Defence members at Risk of Suicide, Self-Harm or Harm-to-
Others. Defence members who require mental health assessment and treatment are 
to be managed in accordance with Defence Health Manual Volume 2 Part 10 Chapter
1 - Coordinated care and management of Defence members receiving mental health 
services in garrison. The immediate assessment and management of risk, when 
identified, is the priority.
In the civilian sector, acute mental health presentations should be managed 
according to best practice and local arrangements.
DVA also provides non-liability health care for all mental health conditions and a wide 
variety of support services, including counselling through Open Arms. Non-liability 
health care means that the veteran doesn’t have to prove that their mental health 
condition was caused by their military service.
DVA now has a single free call contact number for all enquiries: 1800 555 254. The 
DVA website has more information (www.dva.gov.au).
Military Employment Classification and MEC Review Board
For those Defence members still in full time service or in the active Reserves, MEC 
considerations will depend on the health status, functional capacity and health support 
needs of the individual. If a member is not deployable, and the period of non-
deployability extends beyond 12 months from onset of illness, MECRB consideration is 
required.
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If the member has raised the possibility of mefloquine or tafenoquine being 
associated with their symptoms, this needs to be documented in the MEC Review.
In summary:
1. Be respectful and acknowledge the concerns
2. Treat when appropriate
3. Offer referral to appropriate specialists for testing/documentation of
function and exclusion of other causes
4. Document the member’s health record
5. Assess and manage risk
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GULF HEALTH: 
INFORMATION GUIDE FOR HEALTH 
PROFESSIONALS  
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CONTENTS 
 
 
 
Section 
Title Page 
 
1 
Introduction 1 
 
2 
Key Points 
3 
 
3 
Gulf Veterans’ Medical Assessment 
5 
Programme (GVMAP) 
 
4 
Gulf Veterans’ Illnesses Research.  
9 
 
5 Potential 
Exposures 
 
17 
 
Annex A 
MOD Publications on Gulf Veterans’ 
21 
Illnesses 
 
Annex B 
References 
23 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Section 1 
 
INTRODUCTION 
 
Twice over the last decade and a half, large numbers of UK military personnel 
have been called to active service in the Gulf region.  In health terms, this 
service presented considerable challenges, including those from: terrain; 
endemic infectious agents; climate; and the threat of chemical and biological 
warfare agents.  In addition there was unprecedented media interest and 
speculation in relation to all aspects of the campaign, including health issues,  
before, during and after the conflicts.  Already many participants, regular and 
reservists, have returned to civilian life and increasingly more will do so. 
 
This guide is produced by the Veterans’ Policy Unit (VPU) of the Ministry of Defence 
(MOD).  It is intended to provide health professionals, both service and civilian, with 
information that they may find useful in dealing with the health concerns of veterans 
from these operations in the Gulf. 
 
1990/1991 Gulf Conflict:  Around 53,000 UK Servicemen and women served in the 
1990/1991 Gulf Conflict.  At least two thirds have now left the Armed Forces and 
responsibility for their health care falls to the National Health Service, in particular to 
their GPs.  There are ex-Service Gulf veterans living in all parts of the UK, and many 
GPs will have veterans among their patients.  Since returning from the Gulf, some 
veterans have become ill.  In some cases this is due to disorders which are unrelated 
to service.  Others have recognised medical conditions such as Post Traumatic 
Stress Disorder (PTSD) where service links are accepted.  A third group reports the 
multi-system, multi-organ, non-specific, symptoms and illnesses which 
epidemiological evidence confirms are not specific to, but are more common in, those 
who served in the Gulf in 1990/1991.  
 
2003 and subsequent operations in the Gulf:  Over 80,000 UK Servicemen and 
women have served in operations in the Gulf since January 2003.  It is too soon to 
know whether any health issues will emerge following these operations but learning 
from experience of the 1990/1991 Gulf Conflict, the MOD has put in place a range of 
measures to monitor the health of returning personnel and investigate any concerns 
quickly. 
 
The Government and MOD considers its people its greatest resource and there is 
therefore considerable concern about the health and well-being of personnel both 
during and after service.  The Government is committed to addressing the complex 
and difficult issue of why some veterans have fallen ill since returning from the 
1990/1991 Gulf Conflict and has adopted three principles in its approach to the 
subject: 
  
•  First, that all Gulf veterans will have prompt access to medical advice. 
•  Second, there will be appropriate research into veterans' illnesses and factors 
which might have a bearing on these. 
•  Third, the MOD will make available to the public any information it possesses 
which is of potential relevance to this issue. 
  
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To oversee the Government's response to Gulf veterans' illnesses, in 1997 the MOD 
established a Gulf Veterans' Illnesses Unit.  The unit, which is now part of the 
Veterans Policy Unit, acts as a focal point for Gulf veterans who are ill or worried 
about their health and is responsible for conducting relevant reviews, providing 
support to research teams and answering public correspondence on this subject.  
 
Further information on Gulf veterans' illnesses, and copies of MOD publications on 
this subject, can be obtained by calling the VPU Gulf helpline on 0800 169 4495; by 
visiting the Gulf veterans’ illnesses website at www.gulfwar.mod.uk; or by writing to: 
 
VPU GVI 
7th Floor Zone H 
Ministry of Defence Main Building 
Whitehall 
London SW1A 2HB  
 
 
 
February 2005  
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Section 2 
 
KEY POINTS ABOUT GULF VETERANS’ ILLNESSES 
 
 
•  The MOD accepts that since returning from the 1990/1991 Gulf Conflict, some 
personnel have become ill.  The health of those who served in the Conflict remains 
a high priority.  
 
•  In some cases veterans’ illnesses are due to disorders which are unrelated to 
service. Others have injuries or recognised medical conditions such as PTSD, 
where service links are accepted.  A third group reports the multi-system, multi-
organ, non-specific, medically unexplained symptoms and illnesses which 
epidemiological evidence shows are not specific to, but are more common in, those 
who served in the Gulf in 1990/1991.  
 
•  The consensus of the medical and scientific community is that the ill health reported 
by some veterans of the 1990/1991 Gulf Conflict cannot be characterised as a 
discrete syndrome because similar symptoms are seen in non-Gulf veterans.  The 
difference is that in those who served in the 1990/1991 Gulf Conflict these 
symptoms are more common and more severe. 
 
•  This pattern of ill health is not unique to UK Gulf veterans, and is repeated amongst 
1990/1991 Gulf veterans from the other coalition countries.  This is regardless of the 
specific experiences and exposures of the personnel concerned, which were not the 
same for all participants.  Similar symptoms and illness are also reported by some 
who did not actually deploy. 
 
•  Only a minority, albeit an important minority, are ill.  We want to know why this is. 
 
•  Monitoring shows that there is no excess in overall mortality for veterans of the 
1990/1991 Gulf Conflict in comparison to a similar control group of personnel that 
did not deploy.   
 
•  Veterans of either the 1990/1991 Gulf Conflict or of operations in the Gulf since 
January 2003 can be referred by their GPs or Service Medical Officers to the Gulf 
Veterans’ Medical Assessment Programme (see section 3). 
 
•  The MOD has funded and continues to fund appropriate research into the ill health 
suffered by veterans of the 1990/1991 Gulf Conflict (see section 4).   
 
•  It is too soon to know whether any unusual health issues will emerge following the 
recent and continuing operations in the Gulf.  The MOD takes the health of its 
people very seriously and has put in place a range of measures to monitor the 
health of returning personnel and investigate any concerns quickly (see section 4). 
 
•  The MOD is committed to providing information to Parliament and to veterans on 
matters relevant to the issue of Gulf veterans' illnesses (see section 5).  
 
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•  Gulf veterans who are concerned about their health are invited to contact the MOD’s 
Veterans Policy Unit on Freephone 0800 169 4495 for advice. 
 
•  A considerable amount of information about the Ministry of Defence’s approach to 
Gulf veterans’ illnesses is available on our website at: 
 
For veterans of the 1990/1991 Gulf Conflict: www.gulfwar.mod.uk  
For veterans of operations in the Gulf since 2003: www.mod.uk/issues/optelic_health  
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Section 3 
 
THE GULF VETERANS' MEDICAL ASSESSMENT PROGRAMME (GVMAP) 
 
The GVMAP was established in July 1993 to examine UK Gulf veterans who were 
concerned that their health had been adversely affected by service in the 1990/1991 
Gulf Conflict.  The GVMAP is located at St Thomas' Hospital, London. 
   
On 7 May 2003, MOD Ministers announced in Parliament that the GVMAP’s remit 
would be extended to include those who had taken part in operations in Iraq since 
January 2003.  
 
Who is the GVMAP for? 
 
The GVMAP is open to all Servicemen and women, irrespective of whether they are still 
serving or not - as well as MOD civilians - who served in the Gulf at any time between 
August 1990 and July 1991, or who believe that their health has suffered as a direct 
result of the Gulf Conflict.  Individuals who worked for contractors providing direct 
support to UK operations during the Gulf Conflict may also be seen.  The programme is 
not intended to cover other UK citizens who may have been in the Gulf region at the 
time.  
 
The GVMAP is also open to those who were deployed to operations in the Gulf on or 
after 20 January 2003 (Operations TELIC and RESINATE). The facility is also available 
to attached voluntary aid society personnel, contractors working in direct support of UK 
operations in theatre and embedded journalists.  Contractors, some Voluntary Aid 
Society Personnel and embedded journalists will be asked to pay a fee to cover the 
cost of the assessment and tests carried out at the GVMAP.  
 
What is the purpose of the GVMAP? 
 
The GVMAP has two main purposes: 
 
•  First, to investigate patients' medical complaints and, so far as possible, to diagnose 
what they are suffering from and recommend appropriate management, or provide 
reassurance if no illness is found. 
 
•  Second, the GVMAP collates statistical information, which is available in an 
anonymised form as a resource for researchers who have obtained the appropriate 
ethical clearance. This has proved useful in helping to determine whether there are 
particular patterns of ill health associated with service in the Gulf.  (No information 
about named individuals will be given to third parties without express written 
consent).  A paper on the first 284 service and ex-service patients examined at the 
GVMAP was published in 19961, a paper on the first 1,000 service and ex-service 
patients was published in January 19992, a paper on the second 1,000 patients was 
published in June 20013.  Work analysing the third 1000 patients and an overview 
on all the first 3,000 patients was published in October 20024.  Analytical work 
continues. 
 
 
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Where is the GVMAP? 
 
The GVMAP is based at St Thomas’ Hospital in central London.  The location provides 
access to a wide range of facilities and enables interdepartmental referrals and 
laboratory or medical tests to take place without undue delay, and the Capital is well 
served by rail and air links to all parts of the country.  However, in order to improve our 
service to some Gulf veterans, who find travelling to London difficult or inconvenient, 
the GVMAP physician holds a clinic at Northallerton, North Yorkshire every two months 
for patients who might find that location more convenient. 
 
Rarely, special arrangements can be made for individual veterans who are unable to 
travel either to London or to Northallerton.  
 
Why should I refer my patient to the GVMAP? 
 
Doctors are encouraged to refer to the GVMAP any patients who are concerned that 
their health may have suffered as a result of their Gulf Service and who fulfil the criteria 
for being seen.  This will allow the patient to have a thorough assessment by a 
consultant physician with considerable knowledge of Gulf veterans’ illnesses issues and 
experience of dealing with Gulf veterans.  The GVMAP physician will then provide a 
report to the referring doctor including, as relevant, any diagnoses made and 
recommendations for treatment, or provide reassurance if no abnormalities are found.  
Satisfaction surveys indicate that the service provided by the Programme is well 
regarded by patients.  The GVMAP physician is happy to answer questions from health 
professionals and can be contacted on 020 7202 8322 or Freephone 0800 169 5401, or 
by email to xxx@xxxx.xxxxxxx.xxx.xx 
 
How do I refer my patient to the GVMAP? 
 
Veterans who are still serving in the Armed Forces can be referred to GVMAP by their 
Service Medical Officer.  Personnel who have left service and civilians who have 
concerns about their health and possible links to Gulf service should contact their GP to 
access the GVMAP. 
  
If the GP or Service Medical Officer thinks that referral to the GVMAP is appropriate, he 
or she should write to the Head of GVMAP at: The Baird Health Centre, Gassiot House, 
St Thomas’ Hospital, Lambeth Palace Road, London, SE1 7EH.  The referral letter 
should include details of past medical history, present health problems and any 
treatment that the patient is currently having, together with information (where 
applicable) on the branch of the Armed Forces in which the veteran served and the 
veterans’ former service number if known.   
 
Does the GVMAP see everyone referred? 
 
In the case of a very small number of patients referred, there is nothing to be gained 
from them being seen at the GVMAP – for example, because it is clear that their 
condition is being appropriately managed or they have been seen before and nothing 
new would be gained by a further visit.  The physician at the GVMAP therefore does not 
automatically see everyone referred.  When a decision is taken not to see a patient, the 
referring doctor is told why and given a brief update about Gulf health issues.  If the 
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physician at GVMAP decides not to see a veteran, this does not preclude him from 
seeing that veteran at a later date if circumstances change. 
 
What happens at the GVMAP? 
 
The GVMAP is currently staffed by a civilian consultant physician and supporting staff.  
Patients referred to the GVMAP are given a full interview and medical examination and 
a range of laboratory tests; investigations routinely undertaken for all patients include: 
urinalysis; haematological; biochemical; biological and serological tests; ultrasound 
scan of the abdomen and electrocardiography. These tests are carried out on the day of 
the appointment and take approximately four hours.  Additional investigations will be 
carried out if they are clinically indicated.  Referrals to other consultants/specialists may 
be required.  
 
What about psychological assessments?  
 
Amongst veterans of the 1990/1991 Gulf Conflict, there are some who suffer from 
psychological conditions.  Of over 3,000 patients who have been to GVMAP, about 20% 
were diagnosed as psychiatrically unwell with a range of symptoms and illnesses.  
Since 1999, the GVMAP has utilised, where appropriate, a country-wide network of 
psychiatric assessment centres with staff with specialist knowledge of the psychological 
injury of conflict and PTSD.  The GVMAP pays for this, including the patient’s travel 
costs.  As a result of such referrals, a study of outcomes has been carried out and, at 
the time of publication of this guide, is in press5. 
 
Is there a long waiting list? 
 
No.  Our aim is that all patients referred to the GVMAP will be sent an appointment 
letter within 5 days; and that as far as possible the date of the appointment will be within 
6 weeks of the patient's referral, provided that this is convenient for the patient.  If the 
patient cannot attend on the date shown, every effort will be made to rearrange the 
appointment as soon as possible. 
 
Funding arrangements? 
 
The examination and clinical tests will be provided free of charge except in the case of 
contractors, some voluntary aid personnel and embedded journalists who accompanied 
deployments since January 2003.  The MOD will also pay for further tests which the 
GVMAP physician believes are necessary to carry out the assessment. 
 
With the exceptions detailed above, the cost of the patient's travel to the GVMAP from 
within the UK will be met by MOD (normally we will provide rail warrants in advance).  
The MOD will also reimburse up to £10 for a snack or light lunch.  Where necessary (if 
the length of the journey precludes the possibility of a return trip within a single day) 
accommodation costs and the cost of breakfast and an evening meal at the hotel will 
also be met by MOD.   
 
Accommodation will be booked by MOD.  Veterans will not be able to claim 
reimbursement for accommodation they have booked themselves.  Any special 
requirements resulting from the veteran's medical condition (for example, for a carer to 
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accompany him/her) must be notified to the GVMAP in advance and supported by a 
note from the patient’s GP.   
 
What happens after my patient is seen? 
 
The GVMAP itself does not provide treatment. Its role is to assess patients and 
recommend treatment as appropriate.  Implementation and follow-up, via the Defence 
Medical Services (for serving personnel) and the NHS for those who have left service, 
will be for the individual’s own doctor. 
 
The GVMAP consultant will write to the referring doctor after the consultation with a 
copy of the assessment report with test results following within six weeks.  Patients who 
wish to see their report and who have signed a consent form are automatically sent a 
copy of the medical assessment report and test results at the same time as the results 
are sent to the referring doctor.  
 
We ask doctors to co-operate in taking forward treatment recommendations and in 
responding to any enquiries about a patient's progress.  GVMAP will send a standard 
follow up letter to all GPs who refer patients, asking for information on the patient's 
condition and subsequent treatment.  This is usually done 6 months after the GVMAP 
appointment. 
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Section 4 
 
GULF VETERANS’ ILLNESSES RESEARCH IN THE UNITED KINGDOM  
 
1990/1991 Gulf Veterans’ Illnesses Research Programme 
 
MOD's current 1990/1991 Gulf veterans’ illnesses research programme, with the 
exception of the Vaccines Interactions Research Programme which is described on 
page 13 of this guide, is being carried out independently of MOD.  The Vaccines 
Interactions Research Programme is being conducted partly at the Defence Scientific 
and Technology Laboratory at Porton Down.  To ensure that this research is conducted 
in an objective and scientifically sound manner, it is being overseen by an Independent 
Panel (consisting of scientists and doctors, two of whom were nominated as 
representatives of the Gulf veterans). 
 
Researchers are welcome to submit proposals for additional research to MOD at any 
time.  These will be passed either to the Medical Research Council (MRC) who provide 
independent advice on the merit of proposals and the direction Gulf veterans’ illnesses 
research should be taking, or, if appropriate, to the Independent Panel overseeing the 
vaccines interactions research, for independent scrutiny.  Recommendations of the 
MRC or Independent Panel are normally considered favourably by MOD.   
 
The MOD has funded or contributed to the funding of the following research studies: 
 
Morbidity and Mortality  
 
An epidemiological study by a team led by Professors Nicola Cherry and Gary 
Macfarlane at Manchester University aimed to determine whether Gulf veterans are 
experiencing greater ill-health than Service personnel who did not take part in the 
1990/1991 Gulf Conflict and to identify possible exposures and predisposing factors 
associated with any distinctive pattern of symptoms which may be found.  The randomly 
selected study group for this survey was composed of two groups of 4,800 Gulf 
veterans, plus a control group of 4,800 personnel who did not deploy to the Gulf.  The 
research team also investigated whether service in the Gulf is associated with 
increased mortality, by looking at all deaths that occurred in the 8 year period from 1 
April 1991 to 31 March 1999 in the total Gulf cohort of 53,462 and in a similar sized 
group, randomly selected from among those who did not deploy. 
 
The results of the morbidity study were published as two papers in the May 2001 edition 
of Occupational and Environmental Medicine6 7.  The research found that, although the 
overall severity of symptoms was not high, Gulf veterans reported a greater severity of 
symptoms than those who were not deployed to the Gulf.  There was no evidence of 
any illness unique to Gulf veterans and the various symptoms reported were ranked in 
generally the same order by both groups.  The researchers found no evidence of a 
“Gulf War Syndrome”.  The research also found weak associations between some 
reported exposures (handling pesticides, vaccinations and exposure to oil fire smoke) 
and particular types of ill health. 
 
The results of the mortality study were published in The Lancet on 1 July 20008.  The 
study found that the number of deaths and the causes of death in the comparison group 
who did not deploy to the Gulf were similar to those recorded amongst Gulf veterans. 
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There was however a small excess of deaths amongst Gulf veterans attributable to 
accidents, particularly road traffic accidents.  Since the publication of the study, the 
MOD has monitored the mortality of both the Gulf and control groups and has published 
updated statistics every six months.  The Defence Analytical Services Agency, who 
provide analytical and statistical services for the MOD, are responsible for this data and 
it can be viewed on their website: www.dasa.mod.uk/natstats/gulf/intro.html  
 
Reproductive Health 
 
A team led by Dr Patricia Doyle and Dr Noreen Maconochie at the London School of 
Hygiene and Tropical Medicine carried out a very large epidemiological study of the 
reproductive health of Gulf veterans and their partners, and the health of their children.  
Specific areas of interest were fertility, pregnancy outcomes and child health as well as 
information about specific occupational and environmental exposures.  A paper entitled 
“The study of reproductive outcome and the health of offspring of UK veterans of the 
Gulf war: methods and description of the study population” was published in BioMed 
Central on 10 January 20039.  The paper describes in detail the method used for the 
study and provides information about response rates. 
 
Papers reporting reproductive outcomes and male fertility were published in 2004.  In 
“Miscarriage, stillbirth and congenital malformation in veterans of the first Gulf war”10 the 
researchers reported that for male veterans of the 1990/1991 Gulf Conflict, they found 
no evidence for increased risk of stillbirth, chromosomal malformations, or congenital 
syndromes.  Some associations were reported between fathers' service and increased 
risk of miscarriage and other less well-defined malformations.   For female veterans, the 
number of stillbirths and malformations were too small to allow meaningful analysis and 
there was no effect on miscarriage.  In a paper published in the British Medical Journal 
Online First11 the researchers examined whether male Gulf veterans suffer increased 
risk of infertility.  The researchers found a small increased risk of reported infertility and 
that pregnancies fathered by Gulf veterans who did not report problems also took 
longer to conceive.  They could not however conclude that this association was caused 
by service in the Gulf. 
 
Although the study has primarily focussed on reproductive health, a member of the 
research team also published a paper in BioMed Central12  which looked at the general 
health reported by veterans.  The findings of this supported that of Cherry et al 
described above.  
 
Study of UK Gulf Veterans 
 
A further epidemiological study looking at whether service in the Gulf in 1990/1991 is 
associated with increased illness in UK veterans has been funded by the US 
Department of Defense and carried out by a team led by Professor Simon Wessely at 
the Institute of Psychiatry, King's College, London.  Although this study was carried out 
independently of MOD, the Department co-operated with the research team by 
providing essential data to the researchers.  This study involved 4,248 Gulf veterans 
and two control groups: one of 4,246 personnel who served during the Gulf Conflict but 
did not deploy there, and another of 4,250 personnel who have served in Bosnia.  The 
results from phase one of the study, which involved the completion of a health 
questionnaire, were published as two papers in The Lancet in January 199913 14. The 
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papers said that UK Gulf veterans reported symptoms of ill-health up to three times 
more frequently than the other groups, although the symptoms did not appear to be 
unique to this group, and the authors concluded that these findings did not support a 
unique Gulf illness.  The findings included a hypothesis that multiple immunisations are 
associated with later self-reported ill health in Gulf veterans.  A further paper published 
in May 200015 provided a more detailed analysis of that hypothesis.  The research did 
not find an association between ill health and the individual vaccines given in the 
1990/1991 programme.  Nor did it link ill health to a particular combination of vaccines.  
Multiple immunisations before deployment to the Gulf do not seem to be associated 
with self reported ill health, whereas multiple immunisations given during the 
deployment do seem to be associated with ill health.  The suggestion in the paper is 
that this different outcome is stress mediated.  However, this is no more than a 
hypothesis. 
 
Phase two of the study aimed to validate some of the findings of phase one by 
conducting clinical examinations and medical tests on a proportion of the study group in 
order to further define their conditions.  The results of this work have been published as 
several papers in peer reviewed scientific journals.  A paper on Antinuclear 
Autoantibodies (ANA) in Gulf War Related Illness and Chronic Fatigue Syndrome (CFS) 
patients was published in Clinical and Experimental Immunology in August 200216. The 
authors noted that the most common symptoms of Gulf veterans overlap with those of 
CFS patients.  The study tested the hypothesis that CFS and Gulf veterans’ illnesses 
were associated with a particular type of ANA, (autoantibodies to nuclear envelope 
antigens) which have been associated, albeit rarely, with autoimmune disorders.  The 
authors found no significant difference in the prevalence of ANA across the study 
groups and that none of the patients or veterans studied had ANA of the nuclear 
envelope type.  A paper entitled: “The Mental Health of United Kingdom Gulf War 
Veterans: A Two-Phase Cohort Study” was published in the British Medical Journal in 
September 200217.  The paper’s conclusion was that the majority of disabled Gulf 
veterans do not have a formal psychiatric disorder.  PTSD is not increased in Gulf 
veterans and psychiatric disorders do not fully explain self-reported ill health in Gulf 
veterans.   A paper on cognitive functioning and disturbances of mood in UK Gulf 
veterans was published in the November 2002 issue of Psychological Medicine18. The 
paper concluded that there was no evidence of major neuropsychological disturbance in 
Gulf veterans.  Test performance in unwell veterans was impaired compared with well 
Gulf veterans, but was generally within the normal range. 
 
A third phase of research consisting of a longitudinal study of the changing health of 
Gulf veterans over time, and a further analysis of the health of the Bosnia cohort 
examined in the earlier study, has been funded by MOD.  The work is complete and a 
number of papers19 20 21 have been published as a result.  They report that, at follow up: 
 
•  Gulf veterans continue to report poorer health than other military personnel, but the 
overall health gap has narrowed slightly; 
•  poorer health is associated with being older, having more severe symptoms at 
baseline, having psychological distress and believing that one is suffering from “Gulf 
War Syndrome”; 
•  reporting of hazards is not static, and is associated with current health perception.  
 
Neuromuscular Symptoms Study 
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MOD funded a clinical study which was carried out under Dr Michael Rose and Dr 
Mohammad Sharief at King’s College, London.  The study investigated the hypothesis 
that symptoms of fatigue, weakness, muscle pain and sensory disturbance which have 
been reported by some Gulf veterans might be due to disturbance of the nerve or 
muscle function.  It focused on those veterans who have, according to their response to 
the epidemiological study carried out at King’s under Professor Wessely, significant 
neuromuscular symptoms.  Two papers have been published.  The first, entitled 
“Neurophysiologic analysis of neuromuscular symptoms in UK Gulf war veterans”22 
reported that there was no objective evidence for a specific neuromuscular junctional 
disorder that could be linked to service in the 1990/1991 Gulf Conflict.  In the second, 
“Evaluation of Neuromuscular Symptoms in UK Gulf War Veterans.  A Controlled 
Study”23, the researchers report that there was no correlation between subjective 
complaints of weakness/fatigue and statistical and dynamic quantitative strength and 
fatigue measures, and that muscle biopsies did not find abnormalities in any group of 
veterans tested.  There was clinical evidence that symptomatic Gulf veterans did find an 
exercise bicycle test more effortful than other groups of veterans tested, reflecting some 
inefficiency in the muscle tissue.  However, the cause of the inefficiency is unclear.  
 
Systematic Literature Review 
 
MOD has funded, through the MRC, an independent systematic literature review of 
world-wide published research relating to Gulf veterans' illnesses.  The review was 
carried out by a team led by Professor Glyn Lewis.  The first paper entitled “Psychiatric 
disorder in veterans of the Persian Gulf War of 1991” was published in the British 
Journal of Psychiatry in May 200324.  The authors compared the prevalence of 
psychiatric disorder in Gulf veterans in 20 published papers which included data on 
psychiatric disorders to prevalence in the comparison groups used in those studies.  
They found an increased prevalence of Post Traumatic Stress Disorder and common 
mental disorders in Gulf veterans compared with the control groups.  Publication of 
similar systematic reviews on reproductive health, mortality and hospitalisations, multi-
symptom conditions and pain are awaited.
 
Cancer Study 
 
MOD has funded work led by the University of Manchester on the incidence of cancers 
in Gulf veterans as recorded on the NHS central registers for England and Wales and 
for Scotland.  The researchers concluded in their paper “Incidence of cancer among UK 
Gulf war veterans: cohort study”25 that there is no current excess risk of cancer overall 
nor of site specific cancers in veterans of the 1990/1999 Gulf Conflict.  Specific 
exposures during deployment do not appear to have resulted in a subsequent 
increased risk of cancer.  The long latent period for cancer however necessitates 
continued follow up. 
 
Paraoxanase work 
 
Findings on the levels of paraoxanase (PON1) (an enzyme that metabolises 
organophosphates) in Gulf veterans undertaken by a team at Manchester Royal 
Infirmary (MRI) were published in September 200026.  The MRI researchers found that 
a self-selected group of 152 ill Gulf veterans had paraoxonase activity levels 50% less 
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than those of healthy civilians in a control group.  MOD felt that the results were 
sufficiently important to warrant further study and made arrangements for MRI to 
analyse blood samples collected by King's during their Phase 2 clinical studies 
(described above) to see if the original MRI results would be replicated in a blinded 
study.  The MOD contributed towards the cost of the work.  In a paper published in the 
Journal of Occupational and Environmental Medicine in July 200327, the researchers 
report that they found that PON1 activity in Gulf veterans was lower than in the control 
groups used.  The study however found no statistically significant differences between 
PON1 activity in ill Gulf veterans and in healthy Gulf veterans. 
 
Study of the Social Construction of “Gulf War Syndrome” 
 
The MOD has part-funded, with the Economic and Social Research Council, a study by 
a PhD student in Medical Anthropology at the University of London into the Social 
Construction of “Gulf War Syndrome”.
 
The study is based on interviews with Service and ex-Service Personnel and their 
families about “Gulf War Syndrome”.  The first in a proposed series of papers was 
published in the August 2004 edition of Anthropology & Medicine28.  This paper 
discusses the way in which individual veterans may look to “Gulf War Syndrome” to 
make sense of life events and illness, and the part that dialogue with others can play in 
the veteran’s view of “Gulf War Syndrome”.  
 
Vaccines Interactions Research Programme 
 
MOD has also funded a programme of research at the Defence Science and 
Technology Laboratory (Dstl) Porton Down to investigate the possible adverse health 
effects of the combination of vaccines and tablets which were given to troops in the 
1990/1991 Gulf Conflict to protect them against biological and chemical warfare agents. 
 
The first phase of this investigation, involving guinea pigs, did not identify any 
remarkable findings with the combination of ten vaccines and pyridostigmine bromide 
(PB) (the active ingredient in Nerve Agent Pretreatment Sets tablets) examined, but 
helped to determine the appropriate vaccine doses for use in the subsequent phases. 
Results from the study were published in the Journal of Applied Toxicology on 21 
January 200129.
 
The next phase of this study was conducted in a small primate, the marmoset, using a 
complex experimental design.  A number of sensitive indices, including cognitive 
performance, electroencephalogram, sleep, endocrinology, biochemistry and immune 
responsiveness, were monitored for eighteen months following the co-administration of 
the ten vaccines and PB.  Preliminary results from the first 3 months of the study were 
presented by means of posters at two scientific conferences in April 2003.  These 
preliminary findings indicated no apparent adverse health consequences 3 months 
following the administration of vaccine and/or pyridostigmine bromide.  The main 
programme is complete and it is expected that final findings will begin to be submitted 
for publication in early 2005. 
 
Work has also been undertaken at the National Institute for Biological Standards and 
Control to validate a 1990 study which reported that the combination of anthrax and 
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pertussis vaccines produced an adverse response in one strain of mouse.  This study 
was undertaken in the light of a decision taken during the Gulf Conflict to offer 
immunisation against anthrax and to use pertussis vaccine as an adjuvant to enhance 
the immunisation effect.  The new study included a range of genetically diverse strains 
of mouse to examine whether genetic factors may have a role to play in such a complex 
interaction.  An outline of the findings of the first phase of this work was presented at 
the “Conference on Dangerous Pathogens” in September 2002.  The study is now 
complete and the full results were submitted for publication in 2004. 
 
Research on Organophosphate Pesticides 
 
In addition to MOD's Gulf veterans’ illnesses research programme, research funded 
jointly by the Department of Health, the Department for the Environment, Food and 
Rural Affairs and the Health and Safety Executive is studying the long-term health 
effects of low level exposure to organophosphate (OP) pesticides in the context of the 
health concerns of some farm workers.  This may help us to understand the possible 
effects of potential OP exposures during the Gulf Conflict, although in general the 
military and agriculture settings provide different usage and dose levels. 
 
MRC Review of Gulf Veterans’ Illnesses Research 
 
Following a request from MOD, the MRC undertook a review of Gulf veterans’ illnesses 
research.  The MRC’s report was published in May 2003 and is available on the MRC’s 
website at: www.mrc.ac.uk 
 
Key points of the report are; 
 
•  There is no unique “Gulf War Syndrome”.  
 
•  The same symptoms seen in Gulf veterans are also seen in personnel who did not 
deploy, but around twice as many Gulf as non-Gulf veterans (24% compared to 
10%) report having them, and suffer more severely.  
 
•  Thorough medical examinations and physical, psychological and psychiatric testing 
of ill veterans have detected no abnormalities.  There is no correlation between how 
badly people think their memory and concentration has been affected and how well 
they do in tests. 
 
•  Gulf veterans who report more severe symptoms are more likely to recall having had 
more inoculations and exposure to pesticides, but their perception of their health is 
known to influence recall. 
 
•  There is little evidence that vaccination was a cause of veterans’ illnesses.  No 
commonly accepted mechanism could account for immune system related 
symptoms more than 10 years on.    
 
•  Symptoms do not fit the expected pattern for damage to peripheral nerves of 
nerve/muscle junctions caused by exposure to organophosphates.  
 
The MOD has taken note of the Review’s conclusions and recommendations and is 
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working with the MRC to take these forward: 
 
•  The University of Manchester has been commissioned to carry out a short study 
looking at the relationship between mortality & reported exposures. 
 
•  In July 2004, the MRC issued a call for proposals for rehabilitative studies and 
related work.  The MOD hopes to commission work in early 2005. 
 
•  On neuro-imaging, the MRC has carried out a further review of the international 
literature and other available information, especially from the US, to decide the way 
forward. 
 
•  It is also anticipated that a workshop on paraoxonase studies will be held in early 
2005. 
 
Research and Monitoring of service personnel returning from Operations in the 
Gulf since 2003 
 
It is too soon to know whether any unusual health issues will emerge following 
operations in the Gulf since 2003.  The MOD has however put in place a range of 
measures to monitor the health of personnel returning from the Gulf and investigate any 
concerns quickly. 
 
Recognising the need for prompt action as a lesson learnt from the 1990/1991 Gulf 
Conflict, MOD commissioned a package of research into the health of veterans of the 
recent operations, which is being overseen by an independent Review Board.  The 
largest piece of research in this package is a study of the physical and psychological 
health of personnel, which is being conducted by the King’s Centre for Military Health 
Research under Professor Wessely.  Around 19,000 personnel will be assessed by 
questionnaire, including regulars, reserves, civilians and journalists, both deployed and 
non-deployed.  Questionnaires are being mailed out and base visits are underway.  
Initial findings should be available in late 2005. 
 
Qualitative research on personnel is underway as part of the work being done by King’s 
College, led by Professor Christopher Dandeker.  Around 250 personnel deploying in 
November 04 will be interviewed before, during (by postal questionnaire in theatre) and 
after deployment to examine the sociological issues.  Additional work will be undertaken 
looking at the effect on wives and families, with funding for this being provided by the 
Economic and Social Research Council.  A further non-MOD funded study on alcohol 
use in personnel has been funded by the Joseph Rowntree Foundation.  
 
The research package also includes a study of exposure to Depleted Uranium (DU) 
across the battlefield.  A sample of 700 personnel including clean-up personnel, medics 
and support staff from the main Health study will be asked to give urine samples, to 
assess the possible exposure to DU across the various theatre roles.  Sample collection 
began in the Autumn of 2004 and the sub-study is expected to report in 2005.  
Personnel are also eligible for biological monitoring for urinary DU.  More information on 
this can be found in section 5.  
 
A major difficulty with scientific study of the Gulf 1990/1991 cohort is the poor 
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contemporary records, with much based on individual recall which has been shown to 
vary with time.  For veterans of the recent operations, a project is underway with the 
MRC’s Institute of Environment and Health at Leicester University, to record a database 
of exposures and locations.  
 
When the initial results of these studies have been examined, further clinical studies 
may be commissioned on the advice of the Health Review Board.  This may include 
research into reproductive health where appropriate. 
 
The MOD also plans to monitor the mortality of veterans compared with a control group 
and publish figures every 6 months on the Defence Analytical Services Agency website. 
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Section 5 
 
POTENTIAL EXPOSURES 
 
Introduction 
 
In addition to the stresses associated with preparation for, and participation in, armed 
conflict, UK troops in the 1990/1991 Gulf Conflict may potentially have experienced a 
number of exposures which have been suggested by some as possible causes of 
illness among Gulf veterans.  Whilst there is currently no consensus among the 
scientific and medical communities on the aetiology of Gulf veterans' illnesses, the 
MOD is aware that veterans have health concerns about a number of possible 
exposures.   
 
The MOD is committed to providing information to Parliament and to the public on 
matters of potential relevance to the issue of Gulf veterans' illnesses and a series of 
reports have been published, listed at Annex A to this document.  The research 
programme following operations in the Gulf in 2003 includes work on exposures. 
 
The current state of knowledge relating to the potential exposures that may have 
taken place is as follows: 
 
Medical countermeasures/other vaccinations 
 
In the 1990/1991 Gulf Conflict, British troops were offered vaccination against 
anthrax and plague, as protection against the possible use of these agents for 
biological warfare purposes by Iraq.  Pertussis vaccine was also given as an adjuvant 
to the anthrax vaccine.  In addition, where troops did not have a current 
immunisation, they were likely to have received routine vaccinations against yellow 
fever, tetanus, typhoid, poliomyelitis and cholera at about the same time.  Particular 
categories of Service personnel e.g. health staffs will have received Hepatitis B 
vaccine.  There is evidence that some troops also received meningitis vaccine; 
additionally, Hepatitis A immunoglobulin may have been given to some individuals.  
MOD is aware of one individual who was vaccinated against smallpox by private 
arrangement and another who was vaccinated against Japanese Equine Encephalitis 
for a possible deployment to the Far East. 
 
British troops were given Nerve Agent Pretreatment Sets (NAPS), consisting of 
tablets containing 30mg pyridostigmine bromide.  One tablet was to be taken orally 
every eight hours.  Pyridostigmine reversibly blocks the enzyme acetylcholinesterase 
to which many nerve agents irreversibly bind.  Many individuals would have taken 
anti-malarial prophylactics, namely Paludrine (proguanil hydrochloride) and 
chloroquine, for a short period, although the available evidence suggests that most 
individuals would have stopped taking them shortly after arriving in the Gulf.  Further 
information on the origin and implementation of the medical countermeasures 
programme is contained in MOD publications C & I at Annex A. 
   
Personal medical records were generally not taken to the Gulf, and were therefore 
unavailable for the recording of vaccination details.  In many cases, this means that 
the vaccination records of Gulf veterans are incomplete.  A paper has been produced 
which gives details of the Service medical documentation system, how it is designed 
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to operate in the three services and explains why a number of problems arose with 
medical record keeping during the 1990/1991 Gulf Conflict.  The paper also explains 
how Gulf veterans or their representatives can gain access to their medical records, 
why there may be delays in gaining access, and from where assistance may be 
obtained.  (See publication M at Annex A). 
 
Service personnel, including those deployed to the Gulf in 2003, are currently offered 
a range of immunisations to protect against disease as appropriate. These include 
standard service immunisations, immunisations for deployment to areas with specific 
health hazards, immunisations to help protect personnel against the effects of 
biological weapons, and immunisations for personnel in specific occupational or “at 
risk” groups.  The anthrax vaccine is offered to UK personnel.  Poliomyelitis, 
tuberculosis, meningococcal meningitis, typhoid, tetanus, diphtheria, hepatitis A, 
yellow fever, rabies, hepatitis B, rubella and smallpox are also offered as appropriate.  
As in the 1990/1991 Gulf Conflict, UK service personnel were given NAPS tablets.  
All immunisations are offered in accordance with General Medical Council guidelines 
on consent. 
 
Chemical and biological warfare (CBW) agents 
 
There is no confirmed evidence of the offensive use of CBW agents by Iraq during 
the 1990/1991 Gulf Conflict.  A number of chemical agent alarms did occur, but were 
followed up at the time and were not substantiated.  However, MOD has reviewed 
incidents where CBW exposure is alleged to have occurred, and the results of such 
reviews are reported in MOD Publications D, E, H, J - L and O at Annex A. 
 
Further information about how Chemical Warfare Defence was organised in the UK 
during the Gulf Conflict is given in MOD publication G at Annex A.  
 
Oil well fire pollution 
 
No evidence has emerged to suggest that pollution caused by oil well fires in Kuwait 
during the 1990/1991 Gulf Conflict could be responsible for ill-health among Gulf 
veterans.  Pollutant levels from the fires appear to have been relatively low.  The 
health of individuals working in the proximity of oil well fires in the Gulf was closely 
monitored and a number of reports were produced detailing the findings of this 
monitoring.  The US Presidential Advisory Committee on Gulf War Veterans' 
Illnesses reached similar conclusions in a report published in December 1996.  A 
report published in the United States by the RAND corporation30 reported the results 
of a review of the health effects of the oil well fires. It concluded that the cumulative 
doses of relevant pollutants would fall below doses known to cause adverse health 
effects.  It also concluded that there are no data to suggest that the symptoms of 
some veterans of the 1990/91 Gulf Conflict are associated with oil fire exposure. 
 
Organophosphate (OP) pesticides 
 
An investigation into the use of OP pesticides by UK forces during the 1990/1991 
Gulf Conflict was carried out in 1996, and is reported in MOD Publication A (see 
Annex A).    This found that Fenitrothion (C9H12NO5PS) - based pesticide was used 
routinely for residual insecticide spraying in the Gulf during late 1990 and early 1991.  
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There was also extensive use of two insecticides based on Azamethiphos 
(C9H10ClN2O5PS) as fly bait.  Malathion (C10H19O6PS2)-based dusting powder was 
used to treat some hundreds of Iraqi prisoners of war (for lice).  There was also 
evidence of local purchase of unidentified residual insecticides.  One of the latter 
pesticides, which may have been based on Diazinon (C12H21N2O3PS), was used for a 
limited period by some environmental, and possibly unit hygiene, personnel although 
the total quantity involved was probably small.       
 
Pesticides would have been used by Service personnel who had been trained in the 
safe use of these products.  When considering possible exposures to pesticides 
during the Gulf Conflict it is important to distinguish between spraying surfaces with a 
residual insecticide and space, or swing, fogging using direct contact insecticide with 
a knockdown effect in a thermal fog to clear areas out of doors or whole buildings.  
OP pesticides are used for the former, but not the latter purpose.  
 
Depleted uranium (DU) 
 
There have been a number of claims about the health effects of DU, many of which 
are exaggerated or groundless.  During the 1990/1991 Gulf Conflict, a 120mm DU-
based round was used in the UK's Challenger 1 tanks.  MOD's assessment is that 
UK tanks fired fewer than 100 rounds against Iraqi military forces during hostilities, 
although additional rounds were fired during earlier work-up training in Saudi Arabia.  
MOD is not aware of any UK personnel who sustained shrapnel injuries from DU-
based ammunition in the 1990/1991 Gulf Conflict.  There is no evidence to suggest 
that the illnesses being experienced by some UK Gulf veterans are linked to 
exposure to DU.  Further information on DU is available on the MOD website: 
www.mod.uk/issues/depleted_uranium/index.htm. 
 
Following a consultation exercise, and recognising that veterans of the 1990/1991 
Gulf Conflict and Balkans are concerned about their possible exposures to DU in 
theatre, MOD has funded the development of a retrospective test for DU in urine, 
which is being implemented by the independent DU Oversight Board (DUOB).  A pilot 
exercise commenced in March 2004 and the main testing programme was launched 
in September 2004.  Progress of the programme can be viewed on the DUOB 
website at: www.duob.org.uk.  Those interested in the test receive factsheets on DU 
and the test with their application form.  Results of the tests with general advice on 
interpretation will be issued to participants by appropriate health professionals and a 
copy sent to the participant’s GP, where consent is given.  A telephone helpline 
(01527 532198) is available for those requiring further advice on the implications of 
their test result. 
   
British Forces deployed to the Gulf in 2003 had DU munitions available as part of 
their armoury, and used them as necessary.  1.9 tonnes of DU were expended by 
British Challenger tanks.  Since January 2003, all regular and reservist Service 
personnel and MOD civilians who are deployed to a theatre of war where DU is used 
are entitled to receive a urine test for DU if they have any concerns.  The small 
numbers who may have received relatively high exposures are positively encouraged 
to do so.  Contractors' personnel, aid workers and embedded journalists will also be 
able to receive the test.  To provide a baseline for comparison, we have 
commissioned the Institute of Occupational Medicine in Edinburgh to carry out a 
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study to establish normal values in a military population who did not deploy. 
 
How do I request a urinary DU test for my patient?  
 
If your patient served in the 1990/91 Gulf conflict, they may apply directly and 
without referral for the DUOB developed retrospective test.  Details including an 
application form are available on the DUOB website:  www.duob.org.uk.  
Alternatively, they can write for an application form to: 
 
DUOB Secretariat 
Floor 7, Zone H 
Main Building 
Whitehall 
London  SW1A 2HB  
 
If your patient served in the 2003 Iraq conflict (Op TELIC), you can request a 
urinary uranium test from the Defence Radiological Protection Service (DRPS).  The 
point of contact at DRPS, to whom requests for urine sampling are to be directed, is 
given below. Request forms, containers and instructions on the collection of urine 
samples will be issued by DRPS as required.  Results of tests carried out will be 
returned with appropriate comment.  Where results are considered to require 
specialist interpretation, additional comment on the medical aspects will be included 
from the Institute of Naval Medicine’s Radiation Medicine specialist.  
 
For urine sample bottles and information 
For advice on results (GPs or 
on testing 
Occupational Health only) 
 
 
DRPS Dosimetry Section 
Duty Radiation Medicine Specialist 
Institute of Naval Medicine 
Institute of Naval Medicine 
GOSPORT 
GOSPORT 
Hampshire 
Hampshire 
PO12 2DL 
PO12 2DL 
 
 
Mil: 9380 Ext 68162 or 68267 
Mil: 9380 68026 
Tel: 02392 768162 or 768267 
Tel: 02392 768026 
Fax: Ext 68150 
Fax: 02392 504823 
 
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ANNEX A 
 
MOD PUBLICATIONS ON GULF VETERANS' ILLNESSES 
 
A. 
Organophosphate Pesticide Investigation Team (OPPIT): Substantive 
Report.  6 December 1996.  Investigates the circumstances in which 
organophosphate (OP) pesticides were used during the 1990/1991 Gulf Conflict. 
 
B. 
Gulf Veterans' Illnesses: A New Beginning.  14 July 1997.  Set out the how 
MOD intended to address the Gulf veterans’ illnesses issues and underpins our 
approach today. 
 
C. 
Background to the use of Medical Countermeasures to protect British 
Forces against biological and chemical warfare agents during the Gulf Conflict 
(Operation GRANBY).  28 October 1997.  Explains the basis on which various 
medical countermeasures, principally vaccines and nerve agent pre-treatment tablets, 
were used to protect British troops during the 1990/1991 Gulf Conflict. 
 
D. 
Kuwaiti Girls' School Case Narrative. 19 March 1998.  Joint UK/US review of 
what has become known as the “Sabahiyah” incident, in which a large tank of liquid, 
initially thought to contain Iraqi mustard agent, was found in Kuwait after the end of the 
1990/1991 Gulf Conflict.   
 
E. 
Dead animals during the Gulf Conflict: A review of the circumstances in 
which UK forces reported the presence of groups of dead animals in theatre 
during Operation GRANBY in 1990/91.  6 April 1998. 
 
F. 
Testing for the presence of depleted uranium in UK veterans of the Gulf 
conflict, the current position.  19 March 1999. 
 
G. 
British Chemical Warfare Defence During the Gulf Conflict.  December 
1999.  A background paper detailing how Chemical Warfare Defence was organised in 
the UK at the time of the 1990/1991 Gulf Conflict. 
 
H. 
Review of Events Concerning 32 Field Hospital and the Release of Nerve 
Agent Arising from US Demolition of Iraqi Munitions at the Khamisiyah Depot in 
March 1991.  December 1999.  A review of the possible effects on UK units, in 
particular 32 Field Hospital, of possible exposure to very low levels of nerve agent 
which may have been released as a result of US demolition activity at the Khamisiyah 
depot in Iraq.  See also publication O. 
 
I. 
Implementation of the Immunisation Programme against Biological 
Warfare Agents for UK Forces during the Gulf Conflict 1990/91.  20 January 2000.  
A detailed overview of the UK’s anti-biological warfare immunisation during the 
1990/1991 Gulf Conflict. 
 
J. 
A Review of the Suggested Exposure of UK Forces to Chemical Warfare 
Agents in Al Jubayl on 19 January 1991.  20 January 2000, a review of events in Al 
Jubayl on 19 January 1991 during the Gulf Conflict, where veterans have suggested 
that they were exposed to chemical warfare agents. 
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K. 
A Review of the Activities of the 1 Field Laboratory Unit and Suggested 
Biological Warfare Agent Detections during Operation GRANBY.  18 May 2000. A 
review of events during the Gulf Conflict where veterans have suggested that they 
were exposed to biological warfare agents.  
 
L. 
A Review of UK Chemical Warfare Agent Alerts during the 1990/1991 Gulf 
Conflict. 20 July 2000.  A review of UK chemical warfare agent alerts from August 
1990 to March 1991. 
 
M. 
Medical Records in the Gulf.  October 2001.  An explanation of the relevant 
parts of the Service medical documentation system which describes how it operated in 
the Gulf Conflict, how veterans may obtain copies of their records, and why there may 
be difficulty in accessing records. 
 
N. 
The 1990/1991 Gulf Conflict: Health and Personnel Related Lessons 
Identified.  4 November 2004.  This paper focuses on the health and personnel 
related issues resulting from the 1990/1991 Gulf Conflict, with the aim of learning from 
the problems identified.  The paper identifies what the Ministry of Defence has already 
done to improve procedures and assesses how these have been applied to the current 
Iraq deployment (Operation TELIC).  It also indicates where improvements are still 
required. 
 
O. 
Review of Modelling of the Demolitions at Khamisiyah in March 1991 and 
Implications for UK Personnel.  27 January 2005.  The only known release of nerve 
agent during the 1990/91 Gulf conflict was following the demolition of Iraqi rockets at 
Khamisiyah in March 1991. A substantial amount of work has been done in the US to 
model this incident, with the latest results published in 2002.  This paper details the 
MOD’s assessment of the US model. 
 
 
Copies of all the documents listed above and further information on Gulf veterans' 
illnesses can be obtained by calling the VPU Gulf helpline on 0800 169 4495; fax 020 
7218 1482, or by writing to VPU, 7th Floor Zone H, Ministry of Defence, Main Building, 
Whitehall, London SW1A 2HB. They are also available at: www.gulfwar.mod.uk
 
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ANNEX B 
 
REFERENCES 
                                                           
 
1  W J Coker. A Review of Gulf War Illness. Journal of the Royal Naval Medical Service 1996; 82: 141-146 
 
2  Coker WJ, Bhatt BM, Blatchley NF, and Graham JT. Clinical Findings for the first 1000 Gulf War veterans 
in the Ministry of Defence's medical assessment programme. BMJ 318:290-4, 1999. 
 
3  Lee HA, Gabriel R, Bale AJ, Bolton P, Blatchley NF. Clinical Findings of the second 1000 UK Gulf War 
Veterans who attended the Ministry of Defence’s Medical Assessment Programme.  J R Army Med Corps 
2001; 147: 153-160. 
 
4  Lee HA, Gabriel R, Bolton JPG, Bale AJ, Jackson M. Health Status and clinical diagnosis of 3000 UK Gulf 
War Veterans.  J R Soc Med 2002; 95: 491-497. 
 
5  Lee HA, Gabriel R, Bale AJ. Clinical outcomes of Gulf Veterans’ Medical Assessment Programme 
(GVMAP) referrals for Gulf veterans with post traumatic stress disorder to specialised centres. In Press. 
 
6  Cherry N, Creed F, Silman A, Dunn G, Baxter D, Smedley J, Taylor S, Macfarlane GJ. Health and 
exposures of United Kingdom Gulf war veterans. Part 1: The pattern and extent of ill health.  Occupational 
and Environmental Medicine May 2001, Vol 58, No 5, p291-298. 
 
7  Cherry N, Creed F, Silman A, Dunn G, Baxter D, Smedley J, Taylor S, Macfarlane GJ. Health and 
exposures of United Kingdom Gulf war veterans.  Part 2. The relation of health to exposure. Occupational 
and Environmental Medicine May 2001, Vol 58, p299-306. 
 
8  Macfarlane G J , Thomas E, Cherry N. Mortality among UK Gulf  War veterans, Lancet; 356: 17 – 21 
2000. 
 
9  Maconochie N, Doyle P, Davies G, Lewis S, Pelerin M, Prior S, Sampson P. The study of reproductive 
outcome and the health of offspring of UK veterans of the Gulf war: methods and description of the study 
population.  BMC Public Health 2003,3:4. 
 
 
10  Doyle P, Maconochie N, Davies G, Maconochie I, Pelerin M, Prior S, Lewis S.   Miscarriage, stillbirth and 
congenital malformation in the offspring of veterans of the first Gulf war.  International Journal of 
Epidemiology 2004; 33: 74-86. 
 
11  Maconochie N, Doyle P, Carson C.  Infertility among male UK veterans of the 1990-1 Gulf war: 
reproductive cohort study. BMJ, doi: 10.1136/bmj.38163.620972.AE (published 14 July 2004) 
 
12  Simmons R, Maconochie N, Doyle P.  Self-reported ill health in male UK Gulf War veterans: a 
retrospective cohort study. BMC Public Health 2004, 4:27 doi: 10.1186/1471-2458-4-27 
 
13  Unwin C, Blatchley N, Coker W, Ferry S, Hotopf M, Hull L, Ismail K, Palmer I, David A, and Wessely S. 
Health of UK servicemen who served in the Persian Gulf War. Lancet 353:169-78, 1999. 
 
14  Ismail K, Everitt B, Blatchley N, Hull L, Unwin C, David A, and Wessley S. Is there a Gulf War syndrome? 
Lancet 353:179-82, 1999. 
 
15  Hotopf M, David A, Hull L, Ismail K, Unwin C, Wessely S. Role of vaccinations as risk factor for ill health 
in veterans of the Gulf war: cross sectional study. BMJ,320: 1363-1367, 2000. 
 
16  Skowera A, Stewart E, Davis E T, Cleare AJ, Unwin C, Hull L, Ismail K,  Hossain G, Wessely S C, 
Peakman M. Antinuclear autoantibodies (ANA) in Gulf War-related illness and chronic fatigue syndrome 
(CFS) patients. Clinical and Experimental immunology, volume 129, issue 2, August 2002. 
 
17  Ismail K, Kent K, Brugha T, Hotopf M, Hull L, Seed P, Palmer I, Reid S, Unwin C, David A S, Wessely S. 
The mental health of UK Gulf war veterans: phase 2 of a two phase cohort study. BJJ 2002;325:576. 
23 
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18  David AS, Farrin L, Hull L, Unwin C, Wessely S, Wykes T. Cognitive functioning and disturbance of mood 
in UK veterans of the Persian Gulf War: a comparative study. Psychological Medicine 2002 32:1327-1370. 
 
19  Hotopf M, Anthony DS, Hull L, Nikalaou V, Unwin C, Wessely S.  Gulf war illness – better, worse or just 
the same? A cohort study.  BMJ 13 December 2003, Vol 327, p1370 
 
20 Hotopf M, David A, Hull L, Nikalaou V, Unwin C, Wessely S.  Risk factors for continued illness among Gulf 
War veterans: a cohort study.  Psychological Medicine 2004:  34: 1-8 
 
21  Wessely S, Unwin C, Hotopf M, Hull L, Ismail K, Nikalaou V, David A.  Stability of recall of military 
hazards over time.  Evidence from the Persian Gulf War of 1991.  British Journal of Psychiatry 2003, 183, 
314-322. 
  
22  Sharief M , Priddin J, Dalamont R S, Unwin  C, Rose MR, David A, Wessely S. Neurophysiologic analysis 
of neuromuscular symptoms in UK Gulf War veterans. Neurology volume 59, Number 10, November 26, 
2002. 
 
23 Rose MR, Sharief M , Priddin J, Nikolaou V, Hull L, Unwin  C, Ajmal-Ali R, Sherwood R, Spellman A, 
David A, Wessely S.  Evaluation of neuromuscular symptoms in UK Gulf War veterans. Neurology volume 
63, Number 9, November 9, 2004. 
 
24  Stimpson NJ, Thomas HV, Weightman AL, Dunstan F, Lewis G, Psychiatric disorder in veterans of the 
Persian Gulf War of 1991 systematic review. British Journal of psychiatry 2003, 182,391-403. 
 
25  Macfarlane G, Biggs A-M, Maconochie N, Hotopf M, Doyle P, Lunt M.  Incidence of cancer among UK 
Gulf war veterans: cohort study.  BMJ 13 December 2003, Vol 327, p1373. 
 
26  Mackness B, Durrington PN, Mackness MI. Low paraoxanase in Persian Gulf War Veterans self reporting 
Gulf War Syndrome.  Biochem Biophys Res Commun 2000 Sep 24; 276(2): 729-.33. 
 
27  Hotopf M, Mackness MI, Nikolaou V, Collier D, Curtis C, David A, Durrington P, Hull L, Ismail K, Peakman 
M, Unwin C, Wessely S, Mackness B. Paraoxonase in Persian Gulf War Veterans.  Journal of Occupational 
and Environmental Medicine 2003: 45(7):668-675. 
 
28  Kilshaw S.  Friendly Fire  The construction of Gulf War Syndrome narratives.  Anthropolgy & Medicine Vol 
11, No.2 August 2004, pp. 149-160. 
   
29  Griffiths GD, Hornby RJ, Stevens DJ, Scott LAM, Upshall DG. Biological Consequences of Multiple 
Vaccine and Pyridostigmine Pretreatment in the Guinea Pig. J. Appl. Toxicol, 21, 59-68 (2001). 
 
30 Spektor D.M., A Review of the Scientific Literature as it pertains to Gulf Veterans Illnesses, Volume 6, Oil 
Well Fires, RAND 1998. 
24 
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FOCUS
Managing medically unexplained 
illness in general practice
Louise Stone
atients with medically unexplained symptoms commonly 
Background
present to general practice,1,2 and their symptoms can 
P
Patients with medically unexplained symptoms commonly 
be severe and disabling.3,4 The challenge for the general 
present to general practice and experience significant disability. 
practitioner (GP) involves managing individual symptoms, but 
Many have a history of trauma, which complicates the 
also crafting a framework for the chronic care of patients with 
therapeutic relationship between doctor and patient. Because 
significant ongoing illness.5,6 For many patients, this includes 
diagnosis is an expected outcome of a medical interaction, 
management of comorbid depression and anxiety,2,7,8 and 
doctors and patients can feel frustrated and lost without one.
ongoing psychosocial stress.9
This article provides an approach to the management of 
Objectives
patients with medically unexplained symptoms. Three ways 
This article provides practical management strategies that 
these patients may present are outlined, and some of the 
general practitioners (GPs) can use when patients present with 
strategies that may be utilised to alleviate their suffering are 
medically unexplained symptoms. 
discussed. The article does not address the care of patients 
who are malingering, patients with individual syndromes (eg 
Discussion
irritable bowel syndrome) or patients with hypochondriasis. 
Three types of common presentations are discussed. Enigmatic 
Why is diagnosis so important? The 
illnesses occur when the doctor and patient believe that a 
importance of validation and explanation
biomedical disease is likely, but a diagnosis is not forthcoming. 
Diagnosis is not just a tool to guide management. It is an 
Contested illnesses occur when a patient is committed to a 
expected part of a medical interaction. To be left without 
diagnosis the doctor does not accept. Chaotic illnesses occur 
when symptoms are over-determined; there are many possible 
a diagnosis is to be left without a story, with no way to 
diagnoses, but none fully explain the complex web of distress 
make sense of distressing symptoms,10,11 or explain the 
the patient experiences. Common strategies for managing 
disability to friends, family and workplace colleagues.12,13 
medically unexplained symptoms are discussed, and specific 
No diagnosis means no prognosis, so patients live with 
approaches to each presentation are outlined.
perpetual uncertainty.14–16 Diagnosis also ‘authorises’ suffering, 
establishing illness as legitimate and socially acceptable.17 It is 
difficult to access health and disability services or peer support 
without a diagnosis.18
For the doctor, a lack of diagnosis means a lack of guidelines 
and evidence-based treatments. Doctors often describe 
a sense of helplessness in the face of undiagnosable 
suffering.17,19 Therefore, doctors and patients can share feelings 
of anxiety, anger and frustration.20,21
Patients may have no diagnosis that fully explains 
their illness experience, but there are often fragments of 
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explanation that contribute to our understanding of their 
Box 1. Common approaches to managing medically 
symptoms.17,22 Different explanatory fragments can reflect 
unexplained symptoms
different perspectives, and may include biomedical, psychiatric 
Validation
and psychosocial elements.23 The challenge for the GP lies 
•  Acknowledge that the symptoms are real and distressing
in weaving these fragments together and crafting a shared 
•  Acknowledge that medicine has limits and the uncertainty is 
understanding of the problem that the patient and doctor can 
frustrating
work with and accept because this leads to better clinical 
Explanation
outcomes.22 For the GP, this means creating an explanation 
•  Consider and record physical, psychiatric and psychosocial 
that will ‘do for now’, while accepting that a more satisfactory 
diagnoses and symptoms 
diagnosis may emerge over time. This issue is explored further 
•  Craft explanations that include the body and the mind 
in the case presented at the end of this paper. This can be a 
•  Always consider the role of past or current trauma, psychosocial 
stress and personal vulnerabilities
difficult and frustrating task for all concerned.22,24
Coordination of care and advocacy
The role of psychiatric and psychosocial 
•  Coordinate care to avoid duplication of investigations and 
precipitants: ‘Are you saying this is all in 
exacerbation of iatrogenic harm
my head, doctor?’
Symptom management
One of the most difficult dilemmas in the management of 
•  Offer symptom relief and practical support to address disability (eg 
home help, workplace assessment)
medically unexplained symptoms involves understanding 
•  Encourage physical therapies (eg massage, physiotherapy, 
the role of psychiatric illness and psychosocial stress. In 
hydrotherapy)
contemporary culture, these illnesses are often seen as less 
•  Manage comorbidities as effectively as possible
real and legitimate than physical illness; they are ‘all in the 
Broadening the agenda beyond physical symptom management
head’.17 Unfortunately, accepting a psychiatric label also means 
•  Encourage psychological care to address the impact of illness and 
accepting a deep and unpleasant social stigma.5 It is not 
underlying issues that may exacerbate symptoms 
surprising that patients resist the idea of being diagnosed with 
•  Address healthy lifestyle goals
a psychiatric illness. Nevertheless, comorbidity of medically 
Harm minimisation
unexplained symptoms and psychiatric illness is high.2,7,8 This 
•  Check for new diagnoses when the illnesses changes significantly 
is not to say that all medically unexplained symptoms have a 
(eg the emergence of a new symptom) or during a yearly health 
psychiatric cause, or that psychiatric treatment can cure physical 
check 
symptoms, but concurrent management can be very helpful.25
Empathy
It is important to help patients understand that the mind and 
•  Manage the therapeutic relationship carefully and seek support if it 
body are interconnected in complex ways, and that holistic care 
becomes unhelpful
is often essential to improve health. The technique of shifting 
the focus away from just physical symptoms and biomedical 
diagnoses, to a more holistic understanding of illness is known 
diseases,27 and many people present early, when symptoms 
as reattribution: a useful technique in primary care.26
are difficult to detect or characterise. We are often in a position 
to see a patient with significant illness that we are unable to 
Types of medically unexplained illness
diagnose. We are also unable to ‘exclude disease’. Almost any 
There are three distinct types of medically unexplained 
symptom can herald a prodrome of autoimmune disease or an 
symptoms, which present differently and require different 
early carcinoma that is undetectable. Patients often find this 
management approaches. While these categories can overlap, it 
uncertainty difficult to understand28 and commonly request ‘a 
is helpful to consider them individually because they profoundly 
blood test to check for everything’. 
affect the way the consultation occurs. However, there are also 
The challenge for GPs lies in balancing the iatrogenic risk of 
common strategies for managing all medically unexplained 
investigation with the therapeutic risk of missing something 
illness (Box 1).
important. Statistically, increasing the number of investigations 
increases the risk of false positives and a cascade of further 
Elusive illness: Where a significant biomedical 
investigation and treatment that are unnecessary and potentially 
diagnosis seems to be ‘just around the corner’
harmful.29 By investigating, we also entrench the idea that there 
In elusive illnesses, symptoms seem to suggest there is a 
is something seriously wrong.17 Patients can develop a career of 
diagnosis, but it cannot be determined at this time. These 
medical investigation and treatment.30
consultations are characterised by frustration, and fear 
Strategies for managing elusive illnesses are listed in Box 2. 
of ‘missing something’. General practice is immersed in 
Essentially, the goal is harm minimisation and supportive care. 
uncertainty. At least 5% of patients in general practice have rare 
Harm minimisation includes regular monitoring for changes 
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in symptoms, or the emergence of possible diagnoses, while 
diagnosis on the internet.33 These patients often present with a 
preventing unhelpful cycles of referrals and re-referrals.31
list of requests for investigations, referrals and treatments, and 
may have well-developed strategies to obtain these. 
Contested illnesses: When every consultation 
Strategies for managing contested illnesses are outlined 
becomes a battleground
in Box 3. The goal is to maintain the therapeutic relationship 
Contested illnesses occur when a patient is committed to 
between doctor and patient, and develop trust, while holding 
a particular diagnosis, but the doctor does not agree. These 
clear boundaries. This includes ensuring the patient receives 
consultations are characterised by conflict,22 and can become a 
good general practice care – it is easy to focus on Lyme 
battleground,17 described as a ‘duet of escalating antagonism’.32 
disease and miss essential hypertension or generalised anxiety 
Patients arrive with a diagnosis they wish to have ‘authorised’ 
disorder. Contested illnesses are managed best when doctors 
– an ‘illness you have to fight to get’.18 Common contemporary 
and patients are able to define some common ground. It is 
examples include Lyme disease and multiple chemical sensitivity. 
important to clarify areas of agreement and disagreement.22 
Contested illnesses are more common now that diagnosis 
has become more democratic. Easy access to online 
information and support networks have made it easy for people 
Box 3. Specific approaches to the management of 
with medically unexplained symptoms to find their preferred 
contested illnesses
Validation
•  Acknowledge what you can accept (eg that the symptoms are real 
Box 2. Specific approaches to the management of elusive 
and distressing, that medicine has its limits)
illnesses
•  Acknowledge what you cannot agree on (eg that as a GP, you have 
no evidence for a particular treatment, that you cannot find sufficient 
Validation
evidence to justify a particular diagnosis)
•  Acknowledge that rare and early diseases can be difficult to 
•  Acknowledge that the patient is doing the best they can to manage 
diagnose and may take time
their illness
•  Acknowledge that many tests will exclude diseases but will not 
Harm minimisation
diagnose it
•  Acknowledge that at this time, the medical community has not 
•  Acknowledge that many patients have diseases within a discipline, 
accumulated sufficient evidence to justify the diagnosis, investigation 
but are without a diagnosis (eg cancer of unknown primary)
or treatment the patient is proposing. This may mean that proposed 
Harm minimisation
investigations or treatments are unhelpful or unsafe
•  Revisit diagnosis regularly. Over time, there will be multiple pieces 
•  Where possible, acknowledge the limitations of self-report and 
of information from multiple sources. It may be helpful to have 
anecdote, and encourage the patient to think critically of treatments 
a medical student or registrar take a full, formal history and 
that have no objective evidence. This may involving searching the 
examination, and present the case
literature to find evidence on behalf of your patient, particularly when 
•  Monitor mental health. The despair associated with severe, medically 
they are considering risky or expensive treatments
unexplained illness is significant, pervasive and risky
•  Encourage patients to consider the potential for harm, particularly 
Therapeutic relationship
with complementary medicines in those with comorbidities. Health 
professional and consumer information can be found on websites 
•  Acknowledge your own frustration and reiterate your commitment to 
such as the National Center for Complementary and Integrative 
care for the patient and their family 
Health40 or the National Prescribing Service (NPS MedicineWise)41 
•  Focus on coordinating care to relieve the patient of as much of the 
•  Continue to encourage ‘normal’ general practice care, including 
burden of managing their disability as possible. It may require some 
preventive screening, management of comorbidities and lifestyle 
advocacy as agencies may not accept disability without diagnosis
advice
Clinical reasoning
Therapeutic relationship
•  Pattern recognition is more accurate when patterns are retrieved 
•  Be prepared to offer support ‘within the limits of my discipline’. Do 
the same way they are laid down. Describe the case using medical 
not be reluctant to let patients know when they are exploring options 
language when writing referrals or notes (eg acute, severe, burning 
outside your range of expertise
chest pain not associated with exertion or inhalation). If the problem 
is represented in the notes in the same way it is stored in your 
•  Recognise when the consultation is degenerating into unhelpful 
memory, the diagnosis is more likely to be triggered and recalled.38,39
conflict and find a way to break the cycle. Some therapeutic 
relationships may become unworkable and need to be terminated. 
•  ‘A clever head trumps a clever test’: In the absence of a clear 
Others may require discussion with colleagues
diagnostic hypothesis, consider referral before expensive or 
potentially harmful investigations
Clinical reasoning
•  Patterns exist in different forms in different disciplines. Rare 
•  It may be helpful to think of the illness as a type: ‘I do not know that 
genetic diseases may be recognised by dentists, dermatologists, 
this is Lyme disease, but it is certainly behaving like an infectious 
physiotherapists or general paediatricians on the basis of patterns 
disease’. This will help you design appropriate support strategies 
familiar to them in their own discipline. Therefore, referral to a 
(encouraging general health, managing fatigue) and referring 
multidisciplinary team can be critical
appropriately in case a different infectious disease is being missed
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We should also advocate for our patients and, where possible, 
These consultations are characterised by despair and 
protect them from harm. This includes informing them of 
hopelessness in the doctor and patient. 
the risks of expensive and potentially harmful interventions, 
Patients with chaotic illness have troubles that are ‘too complex 
particularly from specialised clinics overseas that are not subject 
in both medical and social terms for fixing’.14 Consultations can 
to Australian regulations. 
feel like a whirlpool; it is easy to become caught in a spiral of 
suffering with no solutions available. Many of these patients are 
Chaotic illnesses: Where problems ‘go way down 
victims of childhood trauma,34–36 and have complex social needs. 
to the bottomless depths’
Trauma complicates the therapeutic relationship. These patients 
Chaotic illnesses have symptoms that are ‘over-explained’; there 
often find it difficult to trust, and have difficulty establishing and 
are many problems and managing one exposes another.  
maintaining positive interpersonal relationships.36 It is therefore 
not surprising that the consultation dynamics can be challenging. 
Strategies for managing chaotic consultations include ensuring 
there are regular opportunities to conduct an overview of clinical 
Box 4. Specific approaches to the management of chaotic 
illnesses
care, documenting all the agencies and health professionals 
involved in treatment, and ensuring that important preventive 
Validation
activities are performed. A yearly health assessment can help 
•  Acknowledge that life is overwhelming and often lonely
avoid focusing on the cascade of presenting symptoms alone. It 
•  Acknowledge that the patient has survived a difficult life
•  Ask about, recognise and empathise with childhood trauma issues, 
is important to record, for each consultation, issues in ongoing 
and encourage patients to seek support
care (eg following up results, or monitoring treatment) and 
•  Explain how childhood trauma can ‘upregulate’ the nervous system, 
presenting symptoms requiring attention before negotiating what 
and change the structure and function of the brain so that many 
can be attempted in a single consultation. Setting a clear agenda 
physical symptoms, including pain, are worsened in adult life.42,43 
minimises the risk of drowning in symptoms without managing 
Explain clearly and explicitly that this means the pain is ‘in the body’ 
as well as ‘in the head’
the illness effectively. Other strategies for managing chaotic 
•  Explain that you understand there are no simple solutions, but offer 
illness are listed in Box 4.
what you can
Case 
Harm minimisation
– Explanatory ‘fragments’ that may 
•  Do not forget preventive care strategies
help address the diagnostic dilemma of 
•  Attend to physical and psychological issues separately so that 
fatigue
neither are likely to be overlooked. Sometimes, splitting care with 
another GP can be helpful. This is particularly the case where you 
Mia, a university student aged 19 years, presents with 
are discussing sexual trauma and need to perform an intimate 
fatigue. She lives away from home in a shared house. Her 
examination like a Pap smear
accommodation is unstable and she has spent some time 
•  Be prepared to acknowledge when a consultation did not go well, 
in refuges when her housing has ‘fallen through’. Mia has 
and reiterate your commitment to continue to do the best you can
a boyfriend who is verbally abusive, and admits he can 
•  Protect your patient as much as you can from health professionals 
become physically violent after alcohol consumption and 
who are dismissive or judgemental. Choose ‘generalist specialists’ 
like geriatricians or general physicians where possible to minimise the 
drug use. Mia has a background of childhood trauma due to 
number of therapeutic relationships that need to be managed
sexual and physical abuse from her stepfather. She describes 
herself as lacking confidence and says she ‘attracts one loser 
Therapeutic relationship
•  Find a point of empathy: Many of these patients are frustrating and 
after another’. This has become obvious at work, where she 
difficult to help. Understanding their trauma history can help you 
describes bullying and harassment from her boss. Her medical 
manage intractable issues that are difficult to address, and manage 
history includes glandular fever 5 years ago, irritable bowel 
your own feelings of helplessness
syndrome and migraine. She smokes, binge drinks on the 
•  Accept that regular, scheduled visits can reduce crisis consultations 
weekends and has a poor diet. 
•  Try to keep as few doctors as possible involved in care: It is easy for 
Case discussion
management to become confused
The following diagnoses are all possible in this case and all 
•  Spread the load with a small team: Involve other health professionals 
(including the practice nurse) and agencies as appropriate. 
provide potentially helpful directions for care. Note that no one 
•  Seek your own support if the therapeutic relationship becomes 
diagnosis explains the whole picture, and it is difficult to prove 
troubled 
which diagnosis (if any) accounts for the fatigue. Treatment will 
Clinical reasoning
require a framework incorporating fragments that are relevant 
•  Make a clear list of current symptoms, ongoing issues and 
to the patient and helpful to the doctor. The outcome depends 
unresolved problems. Revisit this list if a new symptom occurs to see 
on the way such an explanation can help guide treatment and 
whether a new disease is emerging
prioritise treatment approaches.
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Potential biomedical diagnoses
4.  de Waal MW, Arnold IA, Eekhof JA, van Hemert AM. Somatoform disorders 
in general practice prevalence, functional impairment and comorbidity with 
• Postviral fatigue
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•  Iron deficiency anaemia secondary to poor nutrition
5.  Sadler JZ. Diagnosis/antidiagnosis. In: Radden J, editor. The philosophy of 
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•  Murtagh’s ‘serious disorders not to be missed’ and common 
6.  Stone L. Being a botanist and a gardener: using diagnostic frameworks in 
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7.  Smith BJ, McGorm KJ, Weller D, Burton C, Sharpe M. The identification 
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Potential psychiatric diagnoses
8.  Löwe B, Spitzer RL, Williams JB, Mussell M, Schellberg D, Kroenke K. 
Depression, anxiety and somatization in primary care: Syndrome overlap 
• Depression
and functional impairment. Gen Hosp Psychiatry 2008;30:191–99.
• Anxiety disorder
9.  Hanel G, Henningsen P, Herzog W, et al. Depression, anxiety, and 
somatoform disorders: Vague or distinct categories in primary care? Results 
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from a large cross-sectional study. Journal Psychosom Res 2009;67:189–97.
10. Nettleton S, O’Malley L, Watt I, Duffey P. Enigmatic illness: Narratives of 
Possible psychosocial formulation
patients who live with medically unexplained symptoms. Soc Theory Health 
Mia is a survivor of childhood trauma but has continued to 
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11.  Kirmayer LJ, Groleau D, Looper KJ, Dao MD. Explaining medically 
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13. Mik-Meyer N, Obling AR. The negotiation of the sick role: General 
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explanation, and maximising general health. Harm minimisation 
19. Stone L. Blame, shame and hopelessness: Medically unexplained 
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Author
Rijswijk E, Lucassen P. Explanatory models of medically unexplained 
symptoms: a qualitative analysis of the literature. Ment Health Fam Med 
Louise Stone MBBS, BA, MPH, MQHR, PhD, FRACGP, FACRRM, Clinical Senior 
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Lecturer, Australian National University - Academic Unit of General Practice, The 
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Canberra Hospital, ACT. xx.xxxxxx.xxxxx@xxxxx.xxx
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Competing interests: None.
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3.  Koch H, van Bokhoven MA, ter Riet G, van der Weijden T, Dinant GJ, 
29. Hatcher S, Arroll B. Assessment and management of medically unexplained 
Bindels PJ. Demographic characteristics and quality of life of patients with 
symptoms. BMJ 2008;336:1124–28.
unexplained complaints: A descriptive study in general practice. Qual Life Res 
30. Page LA, Wessely S. Medically unexplained symptoms: Exacerbating 
2007;16:1483–89.
factors in the doctor–patient encounter. J R Soc Med 2003;96:223–27.
628 REPRINTED FROM AFP VOL.44, NO.9, SEPTEMBER 2015
© The Royal Australian College of General practitioners 2015
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MEDICALLY UNEXPLAINED ILLNESS  FOCUS
31.  Balint M. The Doctor His Patient and the Illness. New York: International 
42. Wegman HL, Stetler C. A meta-analytic review of the effects of childhood 
Universities Press, 1959.
abuse on medical outcomes in adulthood. Psychosomatic Medicine 
32. Kleinman A. The illness narratives: Suffering, healing, and the human 
2009;71:805–12.
condition. New York: Basic Books, 1988.
43. Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The impact of adverse 
33. Fair B. Morgellons: Contested illness, diagnostic compromise and 
childhood experiences on health problems: Evidence from four birth cohorts 
dating back to 1900. Prev Med 2003;37:268–77
medicalisation. Sociol Health Illness 2010;32:597–612.
34. Fiddler M, Jackson J, Kapur N, Wells A, Creed F. Childhood adversity and 
frequent medical consultations. Gen Hosp Psychiatry 2004;26:367–77.
35. Arnold R, Rogers D, Cook D. Medical problems of adults who were sexually 
abused in childhood. BMJ 1990;300:705–08.
36. Waldinger RJ, Schulz MS, Barsky AJ, Ahern DK. Mapping the Road 
From Childhood Trauma to Adult Somatization: The Role of Attachment. 
Psychosom Med 2006;68:129–35.
37.  Murtagh J. Fatigue – a general diagnostic approach. Aust Fam Physician 
2003;32:873.
38. Stone L. Reasoning for registrars: an overview for supervisors and medical 
educators. Aust Fam Physician 2008;37:650.
39. Elstein AS, Schwarz A. Clinical problem solving and diagnostic decision 
making: Selective review of the cognitive literature. BMJ 2002;324:729–32.
40. National Center for Complementary and Integrative Health. Webpage. 
Bethesda: NCCIH, 2015. Available at https://nccih.nih.gov [Accessed 28 April 
2015].
41.  NPS MedicineWise. Using complementary medicines. Sydney: National 
Prescribing Service Ltd, 2015. Available at www.nps.org.au/topics/how-to-
be-medicinewise/using-complementary-medicines [Accessed 28 April 2015].
© The Royal Australian College of General practitioners 2015
REPRINTED FROM AFP VOL.44, NO.9, SEPTEMBER 2015 629
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FOI 345/19/20
Document 7
From:
Morton, David MR 3
To:
Hancock, Veronica
Cc:
s47E
OCJ HLTH; s47E
 Ross, Victoria DR 1
Subject:
Re: Mefloquine Health Assessment Budget measure - Legislative Instrument [SEC=UNCLASSIFIED]
Date:
Tuesday, 2 July 2019 2:53:40 PM
Attachments:
image002.png
Veronica, what if you just do not refer to current serving in the Explanatory statement.
Sent from my iPad
On 2 Jul 2019, at 1:58 pm, Hancock, Veronica <xxxxxxxx.xxxxxxx@xxx.xxx.xx> wrote:
Hi David,
The intent is not to specifically include current serving, but rather not to exclude
any particular category of concerned persons.  If we specifically exclude current
serving, this will potentially provoke further concerns.  We do not want to be in the
situation where an allegation could be made that we are forcing people to quit
before they can have a health assessment. As discussed, we could handle this via
processes once a person has come forward, noting the service provider will be
Bupa.  For info, of the 15 who have currently come forward, as far as we can tell
none are currently serving.
Happy to discuss.
Thanks, Veronica
<image001.jpg>
Veronica Hancock
Assistant Secretary
Wellbeing Policy Branch
Veterans’ Services Design Division
Department of Veterans’ Affairs
t 02 6289 6712 m s22
 
e xxxxxxxx.xxxxxxx@xxx.xxx.xx
<image003.jpg>
To support those who serve or have served in the defence of our nation
and commemorate their service and sacrifice.
<image002.png>The Department acknowledges the Traditional Owners
of the land throughout Australia and their continuing connection to
country, sea and community. We pay our respect to all Aboriginal and
Torres Strait Islander peoples, their cultures and to their elders past and
present.
From: Morton, David MR 3 <xxxxx.xxxxxxx@xxxxxxx.xxx.xx> 
Page 57 of 92

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FOI 345/19/20
Sent: Tuesday, 2 July 2019 11:59 AM
To:s47E
@dva.gov.au>
Cc: OCJ HLTH <xxxxxxx@xxxxxxx.xxx.xx>; Hancock, Veronica
<xxxxxxxx.xxxxxxx@xxx.xxx.xx>; s47E
dva.gov.au>;
s47E
dva.gov.au>; s47E
s47E
dva.gov.au>; Ross, Victoria DR 1
<xxxxxxxx.xxxxx@xxxxxxx.xxx.xx>
Subject: RE: Mefloquine Health Assessment Budget measure - Legislative
Instrument [SEC=UNCLASSIFIED]
UNCLASSIFIED
His47E
We appreciate the consideration of current serving members in relation to the
eligibility provision of the instrument being drafted.  However, The JHC advice on
this matter is that reference to current serving members in the eligibility provisions
is not necessary as such assessment are available to serving ADF members through
the defence health system.  If appropriate may choose to access the package of
assessment that DVA are putting in place but we would purchase that through our
existing arrangements.
Regards
David
P: +61 2 6266 3897  M:. s22
 E: xxxxx.xxxxxxx@xxxxxxx.xxx.xx
EA: Ms Georgina Gill P:0262663986  E: xxxxxxxx.xxxx@xxxxxxx.xxx.xx
IMPORTANT: This email remains the property of the Department of Defence and is
subject to the jurisdiction of section 70 of the Crimes Act 1914. If you have received
this email in error, you are requested to contact the sender and delete the email.
From:s47E
dva.gov.au> 
Sent: Tuesday, 2 July 2019 10:40 AM
To: Morton, David MR 3 <xxxxx.xxxxxxx@xxxxxxx.xxx.xx>
Cc: OCJ HLTH <xxxxxxx@xxxxxxx.xxx.xx>; Hancock, Veronica
<xxxxxxxx.xxxxxxx@xxx.xxx.xx>; s47E
@dva.gov.au>;
s47E
dva.gov.au>; s47E
s47E
@dva.gov.au>
Subject: Mefloquine Health Assessment Budget measure - Legislative Instrument
[SEC=UNCLASSIFIED]
Good morning David and team,
As you would be aware, we are currently working to implement the Mefloquine
health Assessment budget measure. This includes the development of a legislative
instrument to establish eligibility for these assessments. The draft legislative
Page 58 of 92

---

FOI 345/19/20
instrument and explanatory statement are attached for your oversight and
comment.
Unfortunately, we are working to a very tight timeframe as we are seeking
agreement to this legislative instrument from the Repatriation Commission on 11
July. If you have any comments on this instrument could you please send them
trhough by COB today?
Apologies for the timeframe.
Kind regards,
s4
7E
s47E
Assistant Director | Mental and Social Health Policy
Department of Veterans' Affairs
P: s47E
 | E:s47E
@dva.gov.au | GPO Box 9998,
CANBERRA  ACT  2601
Page 59 of 92

---

FOI 345/19/20
Document 8
From:
Hancock, Veronica
To:
Morton, David MR 3; Ross, Victoria DR 1
Cc:
OCJ HLTH; s47E
Subject:
RE: Mefloquine Health Assessment Budget measure - Legislative Instrument [SEC=UNCLASSIFIED]
Date:
Thursday, 4 July 2019 9:46:03 AM
Attachments:
image001.png
Hi David and Vicki, apologies, I did not get to this in time to incorporate these suggested changes
to the wording – although we did manage to cover off your earlier point David, and have
replaced the references in the ES to current and former serving with references to eligible
persons.
We will send you through the final versions of the instrument and ES.
Kind regards, Veronica
Veronica Hancock
Assistant Secretary
Wellbeing Policy Branch
Veterans’ Services Design Division
Department of Veterans’ Affairs
t 02 6289 6712 m s22
 
e xxxxxxxx.xxxxxxx@xxx.xxx.xx
To support those who serve or have served in the defence of our nation and
commemorate their service and sacrifice.
The Department acknowledges the Traditional Owners of the land throughout
Australia and their continuing connection to country, sea and community. We pay
our respect to all Aboriginal and Torres Strait Islander peoples, their cultures and to
their elders past and present.
From: Morton, David MR 3 <xxxxx.xxxxxxx@xxxxxxx.xxx.xx> 
Sent: Tuesday, 2 July 2019 4:47 PM
To: Ross, Victoria DR 1 <xxxxxxxx.xxxxx@xxxxxxx.xxx.xx>; Hancock, Veronica
<xxxxxxxx.xxxxxxx@xxx.xxx.xx>
Cc: OCJ HLTH <xxxxxxx@xxxxxxx.xxx.xx>
Subject: RE: Mefloquine Health Assessment Budget measure - Legislative Instrument
[SEC=UNCLASSIFIED]
UNCLASSIFIED
Veronica, I realise it is late in the day but Vicki Ross had some further observations  and
suggested changes to wording .  Please see her email below.
Regards
Page 60 of 92

---

FOI 345/19/20
David
P: +61 2 6266 3897  M:. s22
 E: xxxxx.xxxxxxx@xxxxxxx.xxx.xx
EA: Ms Georgina Gill P:0262663986  E: xxxxxxxx.xxxx@xxxxxxx.xxx.xx
IMPORTANT: This email remains the property of the Department of Defence and is subject to the
jurisdiction of section 70 of the Crimes Act 1914. If you have received this email in error, you are
requested to contact the sender and delete the email.
From: Ross, Victoria DR 1 <xxxxxxxx.xxxxx@xxxxxxx.xxx.xx> 
Sent: Tuesday, 2 July 2019 2:58 PM
To: Morton, David MR 3 <xxxxx.xxxxxxx@xxxxxxx.xxx.xx>
Cc: OCJ HLTH <xxxxxxx@xxxxxxx.xxx.xx>
Subject: RE: Mefloquine Health Assessment Budget measure - Legislative Instrument
[SEC=UNCLASSIFIED]
UNCLASSIFIED
Thanks David,
My only concerns are to do with  the explanatory note
Under purpose, third para says
As acknowledged in the Committee’s report, many of the individuals who have taken these
medications are unwell and have complex health needs.
            This statement is erroneous, we don’t know how many people who have taken
these meds in the past are unwell etc, so to say ‘many’ is misleading, it also implies that
they are unwell because they took the meds. It would be preferable if it said something
like
There are a number of veterans who are unwell and have complex health needs who are
concerned about their past use of mefloquine and/or tafenoquine.
Also, under Overview, it says
There has been ongoing public concern in sections of the ADF community about the use of
the anti-malarial medications mefloquine and tafenoquine in the ADF, in particular relating
to the anti-malarial trials conducted by the ADF.
Most of the concern has actually been in the veteran community, not the ADF community, so
this statement should reflect that.
Regards
Vicki
IMPORTANT: This email remains the property of the Department of Defence and is subject to the
Page 61 of 92

---

FOI 345/19/20
jurisdiction of section 70 of the Crimes Act 1914. If you have received this email in error, you are
requested to contact the sender and delete the email.
From: Morton, David MR 3 <xxxxx.xxxxxxx@xxxxxxx.xxx.xx> 
Sent: Tuesday, 2 July 2019 11:38 AM
To: Ross, Victoria DR 1 <xxxxxxxx.xxxxx@xxxxxxx.xxx.xx>
Cc: OCJ HLTH <xxxxxxx@xxxxxxx.xxx.xx>
Subject: FW: Mefloquine Health Assessment Budget measure - Legislative Instrument
[SEC=UNCLASSIFIED]
UNCLASSIFIED
Vicki, I have reviewed this but would welcome your review.  DVA want to include current serving
ADF members as part fo eligibility.  I can’t see a problem here can you.  We need to respond to
DVA by COB today and I will need to run it by CJHLTH.
Regards
David
P: +61 2 6266 3897  M:. s22
 E: xxxxx.xxxxxxx@xxxxxxx.xxx.xx
EA: Ms Georgina Gill P:0262663986  E: xxxxxxxx.xxxx@xxxxxxx.xxx.xx
IMPORTANT: This email remains the property of the Department of Defence and is subject to the
jurisdiction of section 70 of the Crimes Act 1914. If you have received this email in error, you are
requested to contact the sender and delete the email.
From:s47E
@dva.gov.au> 
Sent: Tuesday, 2 July 2019 10:40 AM
To: Morton, David MR 3 <xxxxx.xxxxxxx@xxxxxxx.xxx.xx>
Cc: OCJ HLTH <xxxxxxx@xxxxxxx.xxx.xx>; Hancock, Veronica <xxxxxxxx.xxxxxxx@xxx.xxx.xx>;
s47E
@dva.gov.au>; s47E
@dva.gov.au>; s47E
s47E
@dva.gov.au>
Subject: Mefloquine Health Assessment Budget measure - Legislative Instrument
[SEC=UNCLASSIFIED]
Good morning David and team,
As you would be aware, we are currently working to implement the Mefloquine health
Assessment budget measure. This includes the development of a legislative instrument to
establish eligibility for these assessments. The draft legislative instrument and explanatory
statement are attached for your oversight and comment.
Unfortunately, we are working to a very tight timeframe as we are seeking agreement to this
legislative instrument from the Repatriation Commission on 11 July. If you have any comments
on this instrument could you please send them trhough by COB today?
Page 62 of 92

---

FOI 345/19/20
Apologies for the timeframe.
Kind regards,
s4
7E
s47E
Assistant Director | Mental and Social Health Policy
Department of Veterans' Affairs
s47E
| E: s47E
@dva.gov.au | GPO Box 9998, CANBERRA 
ACT  2601
Page 63 of 92

---

FOI 345/19/20
Document 9
From:
Ross, Victoria DR 1
To:
s47E
Cc:
Williams, Felicity DR; Mooney, Helen DR 1; Kelaher, Cath DR
Subject:
RE: Mefloquine Health Assessments - potential attendees for co-design process [SEC=UNCLASSIFIED]
Date:
Wednesday, 11 September 2019 11:21:00 AM
UNCLASSIFIED
Hi Annie,
From DVA I think we had also suggested s47E
. If he can’t attend then Dr Cath Kelaher
from JHC could.
From our end please include Dr Felicity Williams and Dr Helen Mooney
As far as local GPs go we suggest
one or more of the GPs from Holt Medical Practice s47F
s47F
s47F
 Jerrabombera Medical Centre s47F
Also s47F
 in Brisbane s47F
.
Timing of the workshop will be important as GPs work fee for service, absence from their
practice means no income for that period and having to juggle patient bookings etc.
Regards,
Vicki
IMPORTANT: This email remains the property of the Department of Defence. Unauthorised
communication and dealing with the information in the email may be a serious criminal offence.
If you have received this email in error, you are requested to contact the sender and delete the
email immediately.
From: s47E
@dva.gov.au> 
Sent: Tuesday, 10 September 2019 3:34 PM
To: Ross, Victoria DR 1 <xxxxxxxx.xxxxx@xxxxxxx.xxx.xx>
Subject: Mefloquine Health Assessments - potential attendees for co-design process
[SEC=UNCLASSIFIED]
Good Afternoon Vicki
Thank you for attending the workshop last Wednesday.  The input of yourself, Felicity and Cath
helped to guide the design of the health assessments and was much appreciated. 
At the workshop, we agreed to provide Bupa with a list of contacts who could be included as part
of the co-design process.  Below are some potential names, would you have any additional
suggestions?
Clinical
Name
Role
Dr Gordon Wing
Military GP s47F
s47F
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---

FOI 345/19/20
s47F
s47F
Dr Francisco Paco Munoz
Military GPs47F
s47F
Dr Jenny Firman
Chief Health Officer, DVA
Dr Victoria Ross
Senior Medical Advisor, Military
Population Health
Department of Defence
RACGP representatives
ACRRM representatives
Lived Experience
Name
Role
Stuart McCarthy
Lived Experience Military /
Mefloquine
s47F
Lived experience family
s47F
Lived Experience Family
If you could respond by COB tomorrow that would be appreciated.
Kind Regards
s47E
s47E
 Policy Officer I Mental Health Policy
Wellbeing Policy Branch I Veterans’ Services Design Division I Department of Veterans’ Affairs
p s47E
w: www.dva.gov.au
Page 65 of 92

---

FOI 345/19/20
Document 10
From:
Ross, Victoria DR 1
To:
MENTAL.SOCIAL.HEALTH.POLICY; s47E
Tindall, Katherine CAPT - RAN; Williams, Felicity DR; Kelaher, Cath DR; Lawson, Stephen CAPT - RAN
s47E
2; s47E
s47F
 s47E
Subject:
RE: Planning Workshop - Health Assessments for veterans concerned about having taken mefloquine and tafenoquine [SEC=UNCLASSIFIED]
Date:
Tuesday, 3 September 2019 1:48:00 PM
Attachments:
image001.png
AFP Managing unexplained symptoms in GP 2015.pdf
20190322 GP Clinical management guidelines - veterans with complex health issues.pdf
UNCLASSIFIED
Thank you s47E
I wonder if we could have a few minutes pencilled in to the agenda please to give some background and context from the
Defence perspective?
Also, I’ve attached a couple of relevant documents, just in case you haven’t already seen them,
And the Senate Inquiry report
https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Foreign_Affairs_Defence_and_Trade/Mefloquine/Report
Regards,
Vicki
IMPORTANT: This email remains the property of the Department of Defence. Unauthorised communication and dealing with
the information in the email may be a serious criminal offence. If you have received this email in error, you are requested to
contact the sender and delete the email immediately.
-----Original Appointment-----
From: s47E
dva.gov.au  s47E
dva.gov.au> On Behalf Of MENTAL.SOCIAL.HEALTH.POLICY
Sent: Tuesday, 3 September 2019 12:18 PM
To: s47E
s47E
 Tindall, Katherine CAPT - RAN; Ross, Victoria DR 1; Williams, Felicity DR; Kelaher, Cath
DR; Lawson, Stephen CAPT - RAN 2; s47E
s47F
s47F
 s47E
Subject: Planning Workshop - Health Assessments for veterans concerned about having taken mefloquine and tafenoquine
[SEC=UNCLASSIFIED]
When: Wednesday, 4 September 2019 12:00 PM-5:00 PM (UTC+10:00) Canberra, Melbourne, Sydney.
Where: DVA Offices - Level 8 - Millen Room (Bridge Conference) - 21 Genge St Canberra
Update 3/9 – Attached is the agenda for the workshop tomorrow.
For Bupa and Defence attendees, please call on arrival and we will escort you to the meeting room s47E
Thanks
s47E
Good Morning
Confirming the Planning Workshop will be held tomorrow from 12pm-5pm in the Millen Room, DVA Canberra Offices (21
Genge St Canberra).
Lunch will be provided. An agenda will follow later today.
Kind Regards
s47E
Good Afternoon
This meeting invite is to replace the one cancelled by Jane Le earlier today.
This invitation is a placeholder for an initial co-design/planning workshop with the initiative delivery partner, Bupa, for the
Page 66 of 92

---

FOI 345/19/20
Health Assessment for veterans concerned about having taken mefloquine and tafenoquine.
The intent of the workshop is to commence the co-design and define the scope of the initiative.
An agenda is being drafted. All papers will be shared with attendees ahead of the day.
It is anticipated that not all participants will be required for the entire duration of the workshop (12pm-5pm).
More details about the times particular participants will be required during the workshop will be available soon.
Thank you
If you have any questions, please do not hesitate to free to reach out.
Kind Regards
s47E
s47E
I Policy Officer I Mental Health Policy
Wellbeing Policy Branch I Veterans’ Services Design Division I Department of Veterans’ Affairs
p: s47E
w: www.dva.gov.au
The Department acknowledges the Traditional Owners of the land throughout Australia and their continuing connection to country,
sea and community. We pay our respect to all Aboriginal and Torres Strait Islander peoples, their cultures and to their elders past and present.
Page 67 of 92

---

FOI 345/19/20
Document 11
From:
Oneill, Kim MRS on behalf of OCJ HLTH
To:
Ross, Victoria DR 1
Cc:
Morton, David MR 3; Clarke, Jay GPCAPT 2
Subject:
URGENT REVIEW: Mefloquine Health Assessment Budget measure - Legislative Instrument
[SEC=UNCLASSIFIED]
Date:
Tuesday, 2 July 2019 11:14:25 AM
Attachments:
020719 - explanatary statement.docx
020719 Instrument.docx
Importance:
High
UNCLASSIFIED
Hey Vicki,
Can you have a look at this one prior to David reviewing it please, noting they have requested a
response/comments back by COB today.
Thanks
Kind Regards
Kim O’Neill
Executive Officer Coordination, Joint Health Command
CP2-7-33 Campbell Park Offices, PO Box 7911, Canberra BC ACT 2610
Phone: (02) 6127 0187 Mobile s47F
IMPORTANT: This email remains the property of the Department of Defence and is subject to the
jurisdiction of section 70 of the Crimes Act 1914. If you have received this email in error, you are
requested to contact the sender and delete the email.
From: s47E
@dva.gov.au> 
Sent: Tuesday, 2 July 2019 10:40 AM
To: Morton, David MR 3 <xxxxx.xxxxxxx@xxxxxxx.xxx.xx>
Cc: OCJ HLTH <xxxxxxx@xxxxxxx.xxx.xx>; Hancock, Veronica <xxxxxxxx.xxxxxxx@xxx.xxx.xx>;
s47E
@dva.gov.au>; s47E
@dva.gov.au>; s47E
s47E
@dva.gov.au>
Subject: Mefloquine Health Assessment Budget measure - Legislative Instrument
[SEC=UNCLASSIFIED]
Good morning David and team,
As you would be aware, we are currently working to implement the Mefloquine health
Assessment budget measure. This includes the development of a legislative instrument to
establish eligibility for these assessments. The draft legislative instrument and explanatory
statement are attached for your oversight and comment.
Unfortunately, we are working to a very tight timeframe as we are seeking agreement to this
legislative instrument from the Repatriation Commission on 11 July. If you have any comments
on this instrument could you please send them trhough by COB today?
Page 80 of 92

---

FOI 345/19/20
Apologies for the timeframe.
Kind regards,
s47E
Assistant Director | Mental and Social Health Policy
Department of Veterans' Affairs
P: s47E
 | E: s47E
@dva.gov.au | GPO Box 9998, CANBERRA 
ACT  2601
Page 81 of 92

---

FOI 345/19/20
EXPLANATORY STATEMENT 
Veterans’ Entitlements (Anti-Malarial Medications Health Assessment) 
Determination 2019  
(Instrument 2019 No. R36) 
EMPOWERING PROVISIONS 
Paragraphs 88A(1)(a) and (d) of the Veterans’ Entitlements Act 1986 (VEA). 
PURPOSE 
The attached instrument (Instrument 2019 No. R36) implements the Government’s 2019-20 
Budget measure to provide assistance to former and current members of the Australian 
Defence Force (ADF) who were prescribed mefloquine or tafenoquine, both of which are 
prescribed anti-malarial medications, during their service with the ADF. The Government is 
committing $2.1 million to this measure which will deliver a national program of 
comprehensive health assessments for eligible former and current ADF members. 
This Budget initiative responds to the Foreign Affairs, Defence and Trade References 
Committee’s Report, The use of the Quinoline anti-malarial drugs Mefloquine and 
Tafenoquine in the Australian Defence Force. The Committee’s Report and Government 
Response can be accessed at the Australian Parliament House website:  
https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Foreign_Affairs_Defen
ce_and_Trade/Mefloquine. 
As acknowledged in the Committee’s report, many of the individuals who have taken these 
medications are unwell and have complex health needs. The health assessments will provide 
eligible former and current ADF members with an opportunity to discuss their concerns with 
a general practitioner with an understanding of health issues related to mefloquine or 
tafenoquine, the complex conditions with which some former and current ADF members may 
present and the ADF experience. This will allow for identification of service related illness, 
disease and injury. Where appropriate, the former or current ADF member will be referred 
for further specialist assessment, treatment and support, including potential referral to the 
Open Arms – Veterans and Families Counselling Neurocognitive Health Pilot.  
The attached instrument is made under section 88A of the VEA. The instrument specifies the 
class of person who is eligible for specified treatment under Part V of the VEA. To be 
eligible, a person must: 
 have rendered at least one day of continuous full-time service since 1 January 1989
(the year which mefloquine was first prescribed to members of the ADF) ; and
 have taken mefloquine or tafenoquine during their service or believe on reasonable
grounds that they have taken mefloquine or tafenoquine during their service.
whether or not the person has ceased to be a member of the ADF.  
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FOI 345/19/20
This means the instrument applies to both former and current members of the ADF who meet 
the above eligibility criteria.  
The specified treatment consists of one comprehensive health assessment by an authorised 
general practitioner. An authorised general practitioner is a general practitioner engaged by 
an organisation that has entered into a contract with the Commonwealth or the Repatriation 
Commission, or both, to provide health assessments for the purposes of this instrument. Only 
an authorised general practitioner can provide a health assessment under this instrument. The 
term ‘general practitioner’ has its ordinary meaning. A general practitioner refers to someone 
who is trained in a wide range of medicine and medical procedures, but excludes medical 
specialists who have undergone speciality training in a specific field of medicine after 
completing the same training as a general practitioner.  
An external service provider will be contracted to deliver the national program of health 
assessments. A former or current ADF member seeking to access a health assessment will only 
need to contact the contracted service provider to schedule the assessment (rather than needing 
to contact or seek approval from DVA first). The service provider will be required to ensure the 
former or current ADF member meets eligibility criteria. Access to these health checks is in 
addition to any existing entitlements eligible former and current ADF members have to health 
assessments.  
This instrument commences on the day after it is registered on the Federal Register of 
Legislation.  
CONSULTATION 
Section 17 of the Legislation Act 2003 requires the rule-maker to be satisfied that any 
consultation that is considered appropriate and reasonably practicable to undertake, has been 
undertaken.  
External consultation has been undertaken with the Department of Defence. DVA hosted 
Mefloquine and Tafenoquine Consultation Forums across Australia in late 2018. Consultation 
within DVA has been undertaken with the Wellbeing Policy Branch.  
Further consultation was not considered necessary as the proposal is beneficial in nature in 
terms of its impact on clients and does not have regulatory impacts on businesses, community 
organisations or individuals. In these circumstances it is considered that the requirements of 
section 17 of the Legislation Act 2003 have been met. 
RETROSPECTIVITY 
None. 
DOCUMENTS INCORPORATED BY REFERENCE 
None. 
REGULATORY IMPACT 
Nil.  
2 
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FOI 345/19/20
HUMAN RIGHTS STATEMENT 
Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.   
Human rights implications 
The attached legislative instrument engages and promotes the Right to Health. The Right to 
Health  is  contained  in  article  12(1)  of  the  International  Covenant  on  Economic  Social  and 
Cultural Rights. The Right to Health is the right to the enjoyment of the highest attainable 
standard of physical and mental health. The UN Committee on Economic Social and Cultural 
Rights has stated that health is a fundamental human right indispensable for the exercise of 
other human rights. Every human being is entitled to the enjoyment of the highest attainable 
standard of health conducive to living a life in dignity. 
Overview 
There has been ongoing public concern in sections of the ADF community about the use of 
the anti-malarial medications mefloquine and tafenoquine in the ADF, in particular relating to 
the anti-malarial trials conducted by the ADF. Although there is limited medical scientific 
evidence underpinning the causal effect of taking mefloquine and tafenoquine, the 
Government acknowledges that there is a cohort of former and current ADF members in need 
of additional assistance and seeks to provide them with appropriate treatment and support. 
The measure will allow any former or current ADF member who has concerns about having 
taken the anti-malarial medications mefloquine or tafenoquine during service to access a 
comprehensive health check by an authorised general practitioner.   
Conclusion 
The attached instrument promotes the Right to Health by enabling eligible former and current 
ADF members to access treatment by way of a comprehensive health assessment by an 
authorised general practitioner.   
Accordingly, the attached instrument is considered to be “human rights compatible” 
Repatriation Commission 
Rule-Maker 
FURTHER EXPLANATION OF PROVISIONS 
See: Attachment A 
3 
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FOI 345/19/20
Attachment A 
FURTHER EXPLANATION OF PROVISIONS   
Section 1 
This section provides the name of the instrument is the Veterans’ Entitlements (Anti-Malarial 
Medications Health Assessment) Determination 2019. 
Section 2 
This section provides the instrument is to commence on the day after it is registered on the 
Federal Register of Legislation.  
Section 3 
This section sets out the primary legislation that authorises the making of the instrument, 
namely paragraphs 88A(1)(a) and (d) of the VEA. 
Section 4 
This section is a purpose provision. The purpose of this instrument is to enable persons within 
a class specified in section 6 to receive treatment consisting of one health assessment by a 
general practitioner.  
The note to this section informs the reader that a person’s health assessment by a general 
practitioner is in addition to any other health assessment available to the person as a client of 
the Department of Veterans’ Affairs. 
Section 5 
This is the interpretation section.  
The term ‘Australian Defence Force’ has the same meaning as in the Defence Act 1903.  
The term ‘authorised general practitioner’ is defined as a general practitioner engaged by an 
organisation that has entered into a contract with the Commonwealth or the Repatriation 
Commission, or both, to provide health assessments for the purposes of this instrument.  
The note to section 5 provides that ‘continuous full-time service’ is defined in section 5C(1) 
of the VEA.  
Section 6 
Paragraph 88A(1)(a) of the VEA empowers the Repatriation Commission to make a written 
determination stating “that a veteran included in a specified class is eligible to be provided 
with treatment of a specified kind”. 
Paragraph 88A(1)(d) of the VEA empowers the Repatriation Commission to make a written 
determination stating “that a person who is not covered by paragraph (a), (b) or (c) and who 
is in a specified class is eligible to be provided with treatment of a specified kind”. 
4 
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FOI 345/19/20
Using these powers, section 6 specifies the class of person who will be eligible for the 
treatment specified in section 7 of the instrument. 
The class of person specified in section 6 is a person who: 
 has taken, or reasonably believes that he or she has taken, mefloquine or tafenoquine
as part of his or her service in the Australian Defence Force; and
 has rendered at least one day of continuous full-time service on or after
1 January 1989;
whether or not they have ceased to be a member of the Australian Defence Force. 
The Note to section 6 provides that mefloquine and tafenoquine are prescribed anti-malarial 
medications. 
Section 7 
Section 7 sets out the kind of treatment under Part V of the VEA that a person who is in the 
specified class in section 6 is eligible to be provided with. The treatment is one health 
assessment by an authorised general practitioner. Only an authorised general practitioner can 
provide a health assessment under this instrument.  
The note to section 7 confirms that the Treatment Principles under section 90 of the VEA, the 
Repatriation Private Patient Principles under section 90A of the VEA and the Repatriation 
Pharmaceutical Benefits Scheme under section 91 of the VEA apply to any treatment 
provided, if they are relevant to the treatment. 
Section 8 
This section provides that the instrument is revoked on 30 June 2023. 
5 
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FOI 345/19/20
Repatriation Commission 
Veterans’ Entitlements (Anti-Malarial Medications 
Health Assessment) Determination 2019 
Instrument 2019 No. R36 
The Repatriation Commission, under paragraphs 88A (1)(a) and (d) of the Veterans’ 
Entitlements Act 1986, makes the following instrument. 
Dated this
of
2019 
The Seal of the
               ) 
Repatriation Commission
      ) 
was affixed hereto in the
          ) 
presence of:
) 
) 
………… 
……………………… 
ELIZABETH COSSON 
CRAIG ORME 
AM CSC 
DSC AM CSC 
PRESIDENT 
DEPUTY PRESIDENT 
………………… 
DONALD SPINKS 
AM 
COMMISSIONER 
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FOI 345/19/20
1 Name  
This instrument is the Veterans’ Entitlements (Anti-Malarial Medications Health 
Assessment) Determination 2019. 
2 Commencement 
This instrument commences on the day after it is registered on the Federal Register 
of Legislation.  
3 Authority 
This instrument is made under paragraphs 88A (1)(a) and (d) of the Veterans’ 
Entitlements Act 1986. 
4 Purpose 
The purpose of this instrument is to enable persons within a class specified in 
section 6 to receive treatment consisting of one health assessment by a general 
practitioner.  
Note: A person’s health assessment under this instrument is in addition to any other health 
assessment available to the person as a client of the Department of Veterans’ Affairs. 
5 Definitions 
In this instrument: 
Act means the Veterans’ Entitlements Act 1986. 
Australian Defence Force has the same meaning as in the Defence Act 1903. 
authorised general practitioner means a general practitioner engaged by an 
organisation that has entered into a contract with the Commonwealth or the 
Repatriation Commission, or both, to provide health assessments for the purposes 
of this instrument. 
Note: The term ‘continuous full-time service’ is defined in section 5C(1) of the Act. 
6 Specified class 
For paragraphs 88A(1)(a) and (d) of the Act, the specified class is a person who: 
(a) has taken, or reasonably believes that he or she has taken, mefloquine or
tafenoquine as part of his or her service in the Australian Defence Force; and
(b) has rendered at least one day of continuous full-time service on or after
1 January 1989;
whether or not the person has ceased to be a member of the Australian Defence 
Force. 
Note: Mefloquine and tafenoquine are prescribed anti-malarial medications. 
2 
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FOI 345/19/20
7 Specified kind of treatment 
A person who is a member of the specified class in section 6 is eligible to be 
provided with treatment under Part V of the Act consisting of one health 
assessment by an authorised general practitioner. 
Note: The Treatment Principles under section 90 of the Act, the Repatriation Private Patient 
Principles under section 90A of the Act and the Repatriation Pharmaceutical Benefits Scheme under 
section 91 of the Act apply to any treatment provided. 
8  Revocation 
This instrument is revoked on 30 June 2023. 
3 
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FOI 345/19/20
Document 12
From:
Ross, Victoria DR 1
To:
s47E
@dva.gov.au)
Cc:
Tindall, Katherine CAPT - RAN; Lawson, Stephen CAPT - RAN 2; Williams, Felicity DR; Kelaher, Cath DR
Subject:
Veterans health assessment planning workshop 4 Sep [SEC=UNCLASSIFIED]
Date:
Friday, 30 August 2019 12:45:00 PM
UNCLASSIFIED
Hi s47E
Just touching base before the workshop next week, you’re on the invitation list so hoping you’ll
be there.
From our perspective there are several issues that we need to be cognisant of.
·
It’s not all about the mefloquine. The veterans at whom this assessment is aimed are
those with complex symptomatology/conditions who aren’t accessing health care or feel
that they are not receiving the ‘right’ health care. The intent is to improve engagement
with the health care system and appropriate care to optimise their health and wellbeing.
It’s about acknowledging their concerns, assessing their symptoms and finding a way
forward. We are concerned that there is potential for the doctors doing the assessment
to accept and/or reinforce that mefloquine/tafenoquine are the cause of the veteran’s
poor health etc.
·
This health assessment appears to be in addition to the extant Veteran Health Check.
Does it need to be?
·
How does continuity of care factor in. If this assessment is done by a BUPA provider, will
they continue on as the veteran’s GP? The primary issue is that these veterans are not
engaged with or don’t trust the system. There is a risk that their care may become even
more fragmented.
Looking forward to the workshop, no doubt all these, and other, issues will be explored then.
Regards,
Vicki
Dr Victoria Ross 
MBBS MPH FRACGP FAFPHM 
Senior Medical Advisor, Military Population Health
CP3-7-091 Department of Defence
PO Box 7912
CANBERRA BC ACT 2610
Tel (02) 62663936 
Fax (02) 62663933
E-mail: xxxxxxxx.xxxxx@xxxxxxx.xxx.xx
IMPORTANT: This email remains the property of the Department of Defence. Unauthorised
communication and dealing with the information in the email may be a serious criminal offence.
If you have received this email in error, you are requested to contact the sender and delete the
email immediately.
Page 90 of 92

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UNCLASSIFIED 
FOI 345/19/20
Document 13
NOTING BRIEF FOR CJC 
DEPARTMENTAL RESPONSE TO MR STUART MCCARTHY 
– TAFENOQUINE STUDIES AND USE
Branch: Joint Health Command 
Reference: MC19-001019 
Due Date: 02 May 19 
For Information: N/A 
   Routine 
Purpose 
1.
The purpose of this brief is to seek your clearance and signature on a
response to Mr Stuart McCarthy’s correspondence of 25 March 2019 to the Minister
for Defence Personnel, the Hon Darren Chester MP, about the antimalarial
medication tafenoquine (Enclosure 1). The Minister has asked for the Department of
Defence to respond to Mr McCarthy.
Recommendations 
2.
That you:
a.
Sign the draft response letter to Mr Stuart McCarthy at Enclosure 2.
Key Issues 
3.
On 25 March 2019, Mr McCarthy emailed the office of the Minister for
Defence Personnel, the Hon Darren Chester MP, about his concerns regarding
tafenoquine (Enclosure 1).
4.
A draft response to Mr McCarthy is at Enclosure 2 for your consideration
and signature.
5.
The Therapeutic Goods Administration (TGA) approved the importation
and use of tafenoquine for the ADF antimalarial studies in the early 2000’s.  The
TGA visited the ADF Malaria and Infectious Diseases Institute with the United
States Food and Drug Administration to review the study paperwork and processes
as part of the two organisation’s registration and approval processes.
a.
Signed / Please Discuss
TL Smart 
WG McDonald 
Air-Vice Marshal 
AIRMSHL 
CJHLTH 
CJC 
   Apr 19 
   Apr 19 
Contact Officer: Mr David Morton 
Tel: 02 6266 3897 
Clearance Officer: Mr David Morton 
Tel: 02 6266 3897 
UNCLASSIFIED 
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UNCLASSIFIED 
FOI 345/19/20
2 
6.
The TGA thoroughly assessed the applications from 60 Degrees
Pharmaceuticals and Biocelect to register tafenoquine in Australia.  The TGA
approved tafenoquine for registration in Australia on 13 September 2018 under the
brand names Kodatef® for malaria prophylaxis and Kozenis® for radical cure
(malaria treatment). JHC has revised the Defence malaria policy to include
tafenoquine as an option for antimalarial prophylaxis.
7.
On 15 March 2019, the Minister for Defence Personnel announced a new
$2.1 million initiative to support veterans who are concerned about their use of
mefloquine and tafenoquine. The initiative will deliver a national program that will
provide veterans with the option to receive a comprehensive health assessment to
identify service-related illness, disease and injury. Where appropriate, the veteran
will be referred for further specialist assessment, treatment and support.
8.
The initiative responds to concerns raised by veterans during the 2018
Senate inquiry, as well as during the mefloquine and tafenoquine consultation forums
conducted by the Department of Veterans’ Affairs across Australia last year.
9.
The initiative will be implemented from 1 July 2019. Veterans seeking to
register their interest in accessing a health assessment should contact 1800
MEFLOQUINE (1800 633 567), the Department of Veterans’ Affairs’ designated
phone line for concerned veterans.
Background 
10.
Nil.
Way ahead 
11.
Nil.
Conclusion 
12.
Tafenoquine is now a registered medicine in Australia and is available for
use in Defence and the wider Australian community. Defence has revised its health
policy regarding the prevention and management of malaria to include tafenoquine.
This is still in the formal policy review process and will be considered by the
Defence Health Policy Steering Group shortly for endorsement and progression to
Surgeon General ADF for approval to publish.
Consultation 
13.
Nil.
Enclosures: 
1.
Enclosure 1: Correspondence from Mr Stuart McCarthy, dated 25 March 2019.
2.
Enclosure 2: Draft response letter to Mr McCarthy.
UNCLASSIFIED 
Page 92 of 92

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Document Outline

• Binder1
  • Clinical Advisory Group_ Anti-malarial co-design workshop [SEC=UNCLASSIFIED]
  • FW_ MO advice re mefloquine announcement and govt response [DLM=Sensitive]
  • Invitation to participate in Anti-malarial Health Assessment Co-design Workshop (23 January 2020) [SEC=UNCLASSIFIED]
  • Participation in workshop on delivery of meflqouine health assessment [SEC=UNCLASSIFIED]
  • Planning Workshop - Health Assessments for veterans concerned about having taken mefloquine and tafenoquine [SEC=UNCLASSIFIED]
• Binder2
  • prep for DVA co-design workshop [SEC=UNCLASSIFIED]
    • UK GWS assessment.pdf
      • GULF HEALTH:
      • INFORMATION GUIDE FOR HEALTH PROFESSIONALS
      • Veterans who are still serving in the Armed Forces can be re
      • If the GP or Service Medical Officer thinks that referral to
        • What about psychological assessments?
  • Re_ Mefloquine Health Assessment Budget measure - Legislative Instrument [SEC=UNCLASSIFIED] 02 Jul 19
  • RE_ Mefloquine Health Assessment Budget measure - Legislative Instrument [SEC=UNCLASSIFIED]
  • RE_ Mefloquine Health Assessments - potential attendees for co-design process [SEC=UNCLASSIFIED]
  • RE_ Planning Workshop - Health Assessments for veterans concerned about having taken mefloquine and tafenoquine [SEC=UNCLASSIFIED]
  • URGENT REVIEW_ Mefloquine Health Assessment Budget measure - Legislative Instrument [SEC=UNCLASSIFIED]
  • Veterans health assessment planning workshop 4 Sep [SEC=UNCLASSIFIED]
• Untitled

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