New Book: Antimalaria Drugs Part of Secret Program to Torture Detainees at Guantanamo

It isn't often that a book that sets out a case that drugs were used to disorient and disable Guantanamo detainees for interrogation makes the front pages, or gets the news coverage one new book did. What's even more remarkable is that the revelations in that book are just the tip of the iceberg, as new evidence shows the drug use was even greater and more varied than previously reported.

Earlier this year, Simon and Shuster published to great acclaim former Guantanamo guard Joe Hickman's book, Murder at Camp Delta: A Staff Sergeant's Pursuit of the Truth About Guantanamo Bay. The book described Hickman's investigation of the 2006 purported suicides by three Guantanamo inmates, deaths the Guantanamo commander, Rear Adm. Harry B. Harris Jr., called at the time, "asymmetrical warfare waged against us."

But rather than a planned terrorist event of exquisitely-timed suicidal protest -- an implausible tale in the high-security Guantanamo setting to begin with -- Hickman, whose story was first told in an award-winning Harper's magazine article in 2010, discovered the deaths were likely linked to a secret, most likely CIA, black site on the Guantanamo base. As a tower guard, the night of the "suicides" he had witnessed three detainees secretly taken out of camp earlier that evening and driven in the direction of the black site.

Later, he was witness when the warden at the Guantanamo prison facility, Army Colonel Michael Bumgarner, told prison personnel that despite the fact it was known in the camp that the prisoners had died with rags stuffed down their throats, they were to say nothing to the press when the story was released the detainees supposedly had hanged themselves. A year after the Harper's article, Almerindo Ojeda, a researcher at University of California, Davis, made a strong case that the three detainees had been killed by a torture technique known as "dryboarding."

Hickman knew the official story did not hold together, and while he tried to put the nightmare of Guantanamo out of his mind, when a year later another detainee died of supposed suicide, Hickman knew he could not let the story rest. He began a private investigation into what occurred, later linking up with researchers led by attorney Mark Denbeaux at Seton Hall University Law School's Center for Policy and Research. Together, they released a number of reports deconstructing and refuting the official story.

The most recent Seton Hall report, published last year, included claims Hickman would make in Murder at Camp Delta, including charges that the Naval Criminal Investigative Service (NCIS) had suppressed evidence from their report, removed witness statements, failed to interview other crucial witnesses, and in general had produced, at best, a shoddy work. At worst, it was circumstantial evidence of a major government cover-up.

But one of the strangest links in the tale of government crimes concerned the use of a drug meant to prevent or help cure malaria. As Hickman was looking over a deceased detainee's medical record, he discovered that the detainee had been give a large dose of mefloquine upon admission to Guantanamo. (Mefloquine is often known by its former brand name, Lariam.) He later found that mefloquine had been administered to all the Guantanamo detainees on medical intake. But what was mefloquine?

Why mefloquine?

Mefloquine administration was standard operating procedure upon admission. The official story, first reported to Jason Leopold and me and published at Truthout, was that Cuban officials told Guantanamo camp officials that they were worried that detainees would bring malaria to the otherwise malaria-free Cuban isle. Perhaps never in the annals of U.S. history were Department of Defense officials so sensitive to Cuban fears and needs.

According to Navy nurse, and then chief surgeon for Guantanamo's Task Force 160, Capt. Albert Shimkus, at the behest of the Cubans he gathered experts, and a determination was made that mefloquine would be the primary drug used to control possible malaria. But when queried more closely on the issue, including the fact Cuba had no malaria, Shimkus admitted he and others had been told there were "certain issues we were advised not to talk about.”

But to date, Shimkus's story, which supposedly included consultation with the Centers for Disease Control (CDC), the Navy Environmental Health Center (NEHC) and the Armed Forces Medical Intelligence Center at Fort Detrick, Maryland, has not panned out, as FOIA requests for documents from the above agencies have all received a response of "no responsive documents."

Even more, as another article I wrote in 2011 with Leopold explained, foreign workers brought in to build Camp Delta itself were drawn heavily from malarial-endemic parts of the globe, including India and the Philippines, but DoD showed no interest in ensuring these workers did not carry malaria.

What DoD did was administer 1250mg of mefloquine in divided doses in the first 12 hours. Hickman is correct that this is five times the usual prophylactic weekly dose of the drug. But it is not, as Hickman portrays it in the book, a "massive overdose" of the drug. It is the amount administered when you are seeking to eliminate a certain stage of the malaria parasite from the bloodstream. It is a "treatment dose."

But that does not change the fact, which Hickman discovered, that there was no reason to administer such a large dose, and that large doses of the drug -- even the lower 250 mg level prophylactic dose -- carried intolerable neurological and psychological side effects.

Indeed, by 2013, DoD had requested that all service personnel, including special forces, forego use of the drug because of rare but documented neurological toxicity. That same year, the prestigious Institute on Medicine as a Profession called for an investigation on the use of mefloquine at Guantanamo.

An Army doctor-researcher, Remington Nevin, later confirmed in a 2012 published report in the medical journal Tropical Medicine and International Health that DoD's "presumptive treatment" of possible mefloquine in the detainees was both unprecedented and "inappropriate." He added that his "analysis suggests the troubling possibility that the use of mefloquine at Guantanamo may have been motivated in part by knowledge of the drug’s adverse effects...."

Hickman would conclude that the mefloquine was used at the highest known dosage precisely because of its propensity to cause side effects, including dizziness, nightmares, nausea, and suicidal feelings.

"... [T]he entire purpose of Gitmo," Hickman wrote, "was to practice new interrogation techniques on detainees, regardless of any information they may or may not have possessed. From this research, it became clear that not only was mefloquine administered as part of this program, the deaths of the three detainees likely occurred under the shadowy operations of something called a special access program (SAP)— and it had to be kept secret at all costs."

Presence of Mefloquine Examined in Autopsies

But there was more to the drug story than even Hickman knew. According to autopsy records for one of the three 2006 "suicides," Yemeni prisoner Ali Abdullah Ahmed, and the May 2007 death that had galvanized Hickman's investigation, the purported suicide of Abdul Rahman Al Amri, both had autopsy reports that specifically called for toxicology results on the presence of possible mefloquine in their bodies. See here and here.

But this made no sense. Why would Armed Forces epidemiology workers look for mefloquine in some of the deceased detainees and not others? Why would they look for mefloquine at all, as it was supposedly only administered as a malaria precaution upon entrance to the facility? Both Ahmed and Al Amri had been at Guantanamo four years or more when they died. Neither of their medical records such as we have extant point to the presumed presence or fear of infection by malaria.

The evidence points to use of the drug for other than malaria prophylaxis or treatment, in other words, exactly for the use that Hickman and Nevin and the Seton Hall researchers feared. The drug was being used to torture people.

Other drugs used: Chloroquine

But there was even more.

Al Amri, like the three 2006 detainees, was discovered with his hands bound. But unlike the 2006 victims, Al Amri had his hands tied behind his back.

As for Yasir al Zahrani, Mari Al-Utaybi, and Ahmed, the three 2006 "suicides," all had been tested for the presence of yet another antimalaria drug, chloroquine. (Of the three, only Ahmed was tested for presence of mefloquine.)

Chloroquine has long been used in the prophylaxis and cures of certain forms of malaria. Over the years mosquitos in various parts of the world have become immune to chloroquine. Nevertheless, it remains a drug in common usage, though it has its own problematic side effect profile. While not as neurotoxic as mefloquine, chloroquine can cause a large range of side effects, including dizziness, blurred vision and "extrapyramidal disorders (eg, dystonia, dyskinesia, tongue protrusion, torticollis)."

Chronic or long-term use of the drug can cause even worse side effects, including muscle weakness. There are a host of other "rare" side effects.

While other drugs involved in the toxicology tests on the three detainees, including for the presence of "cannabinoids" and cocaine, could be chalked up to the use of a standard protocol, there's no reason to assume that chloroquine, a drug used almost exclusively for malaria, should have been on the standard drug testing test panel. Indeed, the fact that mefloquine was included for testing on one of the three detainees demonstrates that the drug test could be manipulated selectively.

Was chloroquine also used as a drug of disorientation and abuse on detainees? We don't know for sure. In his book, Hickman pointed to a 1977 Senate investigation that disclosed past CIA research on the class of drugs from which mefloquine was derived. (Hickman wrongly attributes the entire investigation to use of that class of drugs, but it was a much larger investigation than that.)

Hickman's nod in that direction got me looking a few years ago, and I discovered that not only had the CIA investigated that class of drugs, but they used at least one of these drugs, a cousin of mefloquine called Cinchonine, as an "incapacitating drug" in its MKULTRA program. The revelations were part of the famous 1975 Church investigations in the U.S. Senate.

Not only were there indications that the antimalaria drugs mefloquine and chloroquine were used to chemically degrade the physical and mental condition of prisoners, but now there was a CIA precedent!

Other drugs used: Scopolamine

If the malaria drugs were used to incapacitate and disable, I asked myself, were there any other drugs used for the same purpose? We knew from a DoD Inspector General report that antidepressant and antipsychotic drugs were administered to detainees before interrogations (though DoD maintains not supposedly to affect the interrogation), even forcibly to restrain prisoners. But was there anything else like the antimalaria drugs?

Yes, there was. I discovered that the Standard Operating Protocol for nurses dated October 2003 refers to the presence of a scopolamine patch behind the ear on incoming detainees, themselves flown via extraordinary rendition to Guantanamo. (We now know some of those renditions were funneled via DoD's European command out of Germany.)

Scopolamine has a long history as a supposed "truth drug." While it is sometimes prescribed to prevent air sickness -- and that's the official reason DoD used the drug on detainees -- it is also known to cause a number of disorienting side effects. In fact, as far back as 1956, the military advised using meclizine instead of scopolamine to deal with motion sickness in pilots because of the latter's "distressing side effects."

The side effects, according to a CIA document that detailed use of the drug for possible interrogation, include "hallucinations, disturbed perception, somnolence, and physiological phenomena such as headache, rapid heart, and blurred vision."

Scopolamine has long-lasting effects. We can see now that prisoners arrived in Guantanamo frightened and disoriented. They had often been hooded. All were retrained. Many must have been suffering side effects from the scopolamine. Upon arrival they were given mefloquine, another long-lasting drug with possible horrific side effects. And these are only the drugs we know about. None of these drugs were either first-rank drugs, and in the case of mefloquine and chloroquine, there was no known reason to presumptively give the drug upon arrival. And even if there were, there was even less reason to administer the drug again years after a prisoner's initial medical intake at the island prison.

We owe a huge debt of gratitude to Joe Hickman for digging out much of this information, and having the courage to publish it and talk publicly about it. But as Hickman writes at the end of his book, "I wrote this account to provoke further research and informed debate, so that hopefully we may do a better job with our detention program."

I think that detention program is an abomination. It was and likely remains an experimental program in interrogation and torture. It should be closed down, and a full independent investigation with subpoena powers undertaken to finally bring the criminals who implemented the torture to justice.

While Hickman's book has gotten great coverage in the press, no one has really picked up the author's challenge to further the research the book began. This review is offered as a challenge itself to extend the investigative reporting on Guantanamo and the U.S. torture detention program in general.

The recent publication of the Senate Intelligence Committee's report on the CIA torture program was a limited hangout, and questions about the origin of the program, or how exactly it was approved and implemented still remain unknown. The Senate will not release the vast bulk of their own study for public consumption. Indeed, they will not even explain inconsistencies in their own account, such as the presence of SSCI staff members at the CIA's Dark Prison black site in Afghanistan in late 2003.

The truth is that only a public outcry will bring significant attention to move the torture story beyond the partial boundaries set by human rights organization attorneys, vote-sensitive politicians, and career-fearing journalists. Hickman has shown that the examination of drugs in the U.S. torture program can be mainstream. Who will pick up the baton now?

Cross-posted at FDL/The Dissenter

IMAP/OSF Report Calls for Investigation of Drug Given to All Guantanamo Detainees

Breaking a three-year silence by the medical and human rights community, a panel of doctors, attorneys, human rights professionals, university professors and ethics experts have called for an investigation into the use of mefloquine on detainees at Guantanamo Naval Prison. The prison camp had instituted in very early 2002 an unprecedented policy of administering full-treatment doses of mefloquine to all incoming detainees at Guantanamo.

Mefloquine is an anti-malaria drug that has been very controversial over the years. It has been linked to severe neurological and psychiatric side effects, including depression, suicide, hallucinations, seizures, neurotoxicity as well as adverse and sometimes long-lasting central nervous system problems. The drug was also sold for years under the brand name Lariam in the United States, but Swiss manufacturer Hoffmann–La Roche ceased marketing it in here in August 2009.

The rationale for the Department of Defense policy on mefloquine at Guantanamo -- ostensibly to counter a supposed threat of malaria brought in by the newly arriving detainees -- underwent a withering analysis in a series of articles I wrote with Jason Leopold (see here, here, and here). At the same time, there was a strongly critical  2010 report by Seton Hall University School of Law’s Center for Policy and Research. This was followed by an article by Dr. Remington Nevin in the October 2012 edition of the medical journal, Tropical Medicine and International Health, entitled "Mass administration of the antimalarial drug meflouqine to Guantanamo detainees: a critical analysis" (PDF).

Nevin, a former Army doctor, concluded "there was no plausible public health indication for the use of mefloquine at Guantanamo," and suggested "the troubling possibility that the use of mefloquine at Guantanamo may have been motivated in part by knowledge of the drug’s adverse effects...."

The call to investigate mefloquine was made in the context of the report's strong recommendation that President Obama "order a comprehensive investigation of U.S. practices in connection with the detention of suspected terrorists... [including] inquiry into the circumstances, roles, and conduct of health professionals in designing, participating in, and enabling torture or cruel, inhuman, or degrading treatment of detainees in interrogation and confinement settings and why there were few if any known reports by health professionals."

The report, Ethics Abandoned: Medical Professionalism and Detainee Abuse in the “War on Terror, was released last week by its sponsors, the Institute on Medicine as a Profession (IMAP) and the Open Society Foundations (OSF) [link to PDF of full report]. IMAP is a major player in the medical ethics field and is funded by a number of foundations, including the Open Society Institute, the Josiah Macy Jr. Foundation, Kaiser Foundation Health Plan, Inc., the Selz Foundation, and the The Pew Charitable Trusts. IMAP also plays a central role in funding Columbia University's Center on Medicine as a Profession at Columbia University's College of Physicians and Surgeons.

The bulk of the report described how the CIA and the Department of Defense, with the connivance of the Department of Justice and health professional organizations like the American Psychological Association, changed the rules and procedures surrounding the use of health care professionals in interrogations and national security detention centers such that doctors and psychologists were enlisted in the design, participation and enabling of torture and cruel, inhumane and degrading treatment of prisoners.

In an article on November 5 at The Dissenter, Kevin Gosztola looked at the ways doctors and other health professionals participated in unethical forced-feedings of hunger strikers. In a previous look at the report, I noted its call for a new executive order banning certain interrogation techniques currently used in the Army's field manual on interrogation, which has been falsely sold to the public as "nonabusive."

The Role of Captain Shimkus

While labeling as "highly questionable" and "unexplained" the use of mefloquine at Guantanamo, the IMAP/OSF report did not investigate its use at length because, strangely enough, its task force panel included the former commanding officer at the Guantanamo Naval Hospital and chief surgeon (until summer 2003), Captain Albert Shimkus. Shimkus was the Guantanamo official who signed off on the mefloquine protocol to begin with.

IMAP/OSF report writers realized the dilemma they were in. Here's what they wrote about it:

Questions have arisen about the unexplained administration of an antimalaria drug with neuropsychiatric side effects to detainees at Guantánamo, including whether there were intelligence or security reasons rather than medical reasons for doing so. As the conduct of a member of the task Force has been questioned on this subject, the task Force does not address the matter here, but urges that the circumstances of the use of mefloquine, including the reasons for choosing it, be addressed as part of the full investigation of medical practices we recommend. [p. 48]

Asked to comment on Shimkus's inclusion on the IMAP/OSF panel, and on the report's recommendation on mefloquine, Dr. Nevin replied via email:

"While the recommendations of the Task Force to investigate the highly questionable use of mefloquine among Guantanamo detainees is welcome and long overdue, the Task Force has missed an opportunity to further explore this issue independently owing to the remarkable fact that one of the Task Force’s own members, CAPT (Retired) Albert Shimkus, former commander of the Guantanamo detainee hospital, was critically involved in the formulation and administration of detainee mefloquine policy.

For years CAPT Shimkus has consistently defended the practice by denying any misuse of the drug, including in a report published this year by the Constitution Project. Given the seriousness of allegations of misuse of mefloquine and the reluctance of CAPT Shimkus to acknowledge his role in having facilitated its questionable use, the Task Force should have recused CAPT Shimkus of involvement in their work so that the remaining panel members may have independently investigated this practice themselves, free of overt conflicts of interest. The loss of this opportunity will only further delay obtaining answers to the question of why mefloquine was used, and lessens the value of this report relative to its full potential."

Dr. Nevin's citation of The Constitution Project (TCP) report on detainee abuse is worth expanding upon, because Captain Shimkus was interviewed at length by TCP report investigators. Here's how the mefloquine issue was handled in their report, issued earlier this year:

Among Shimkus’ continuing critics are some who have suggested he aided interrogators by approving and initiating a regime of prescribing anti-malaria medication for all the detainees, at dosages far higher than those normally used for prevention rather than treatment of malaria. The drug, mefloquine, had side effects that could include paranoia, hallucinations, and depression, theoretically making recipients more vulnerable to interrogation. But Shimkus denied that this was the purpose of the anti-malarial medication, and the allegations that it was prescribed to assist in interrogation are speculative. Shimkus said he agreed with the medical decisions of others, including senior military medical officers, to conduct the medication program, and had consulted with officials at the Centers for Disease Control. He said that no one involved in the interrogation regime had any role in the decision or discussed the matter with him.

According to press reports from February 2002, malaria was far more prevalent in Afghanistan than in Cuba, where it was largely eradicated, and Cuban doctors had raised the issue of malaria prevention in meetings with Shimkus. In 2011, a Pentagon spokesperson told Stars and Stripes that the high doses of medication were appropriate because “[t]he potential of reintroducing the disease to an area that had previously been malaria-free represented a true public health concern. Allowing the disease to spread would have been a public health disaster.” [p. 32, link to PDF of full report]

"...certain issues we were advised not to talk about"

Shimkus appears to have gone out of his way to involve himself with investigations into detainee abuse, but his claims in the TCP report that he didn't notice abuse of Guantanamo detainees because he wasn't imagining any abuse would be taking place is just plain lame. (Shimkus was also a prominent positively portrayed figure in Karen Greenberg's book, The Least Worst Place: Guantanamo's First 100 Days.) His involvement in the mefloquine decision, including his explanations to this author about his motivations and actions, are, as the IMAP/OSF report indicate, matters for a full investigation.

For instance, rather than Shimkus's claim that no one discussed the mefloquine matter with him, he told me in an interview in 2010 that he was told by unspecified others not to discuss certain aspects of the mefloquine decision.

“There were certain issues we were advised not to talk about,” Shimkus told me, explaining the reason the policy was never publicly disclosed (see link).

Shimkus claims that he was worried about a possible "public health disaster." Yet he told me, in a separate interview from that noted just above, that he did not bother to discuss the malaria matter with KBR contract personnel or management when such workers were brought to Guantanamo in later 2002 to work on building Camp Delta, even though those workers mostly came from India and the Philippines, and areas where malaria can be endemic. So far as I was able to investigate, not one of those hundreds of workers could be documented to have taken mefloquine at Guantanamo.

No one knows the reason why mefloquine was mass administered at Guantanamo. Was it just poorly thought out medical policy? Was it covert testing on the side effects of mefloquine, a drug that was under fire at that same time at the Department of Defense (see link)? Was it an attempt to disorient or chemically weaken the detainees upon arrival?

The last question is not so strange when you realize that for years the CIA stockpiled another anti-malaria drug, cinchonine, to use as a chemical "incapacitating agent."

Many I speak to are not hopeful about the chances for a needed investigation. But I think that it would be premature to call over the struggle to fully unmask the torture that took place and get some form of accountability. More likely is that it would be part of, or even help spark a larger social struggle against the national security state and forms of injustice and inequality that plague this society.

Crossposted from The Dissenter/FDL

KBR's Foreign Contractors at Guantanamo Spared Controversial Anti-Malarial Drug Given to Detainees

Originally posted at Truthout, authored by Jeffrey Kaye and Jason Leopold

The Defense Department has claimed it took the unprecedented step of forcing all "war on terror" detainees sent to Guantanamo in 2002 to take a high dosage of a controversial anti-malarial drug known to have severe side effects because the government was concerned the disease could be reintroduced into Cuba by detainees arriving from malaria-endemic countries Afghanistan and Pakistan.

But hundreds of contractors who were hired by Kellogg Brown & Root (KBR), at the time a subsidiary of Halliburton, the oil services firm formerly headed by Dick Cheney, from malaria-endemic countries such as the Philippines and India and tasked with building Guantanamo's Camp Delta facility in early 2002 did not receive the same type of medical treatment, calling into question the government's rationale of mass presumptive treatment of detainees with the drug mefloquine, a Truthout investigation has found.

India and the Philippines have higher risk profiles of transmission of the deadly falciparum variant of malaria than does Afghanistan. In India in 2002, there were 1.86 million cases of malaria, over 40 percent from the deadly falciparum strain, and most parts of the country are considered to have high transmission rates of the vivax form of the disease. Almost 1,000 people died of malaria in India in 2002.

In the Philippines, there is a great deal of variability of risk depending on the region of the country, but 57 out of 79 provinces are considered malaria-endemic. Confirmed cases of malaria in the Philippines from 2002 to 2005 went from approximately 38,000 to over 50,000 cases per year.

Numerous peer-reviewed journal articles and public health experts have linked mefloquine, also known by its brand name, Lariam, with severe side effects, including vertigo, nausea, vomiting, dizziness, anxiety, panic attacks, confusion, hallucinations, bizarre dreams, sores and homicidal and suicidal thoughts. 

Indeed, a 2002 study reported that upwards of 80 to more than 90 percent of all healthy volunteers administered treatment doses of mefloquine suffered either vertigo or nausea. According to the study conducted by Austrian researchers, "Participants suffering from severe (grade 3) vertigo (73 percent) required bed rest and specific medication for 1 to 4 days."

A formal policy memo issued in February 2009 from Army Surgeon General Eric Schoomaker removed mefloquine as a "first-line" agent, and changed the policy so that mefloquine would not be prescribed to Army personnel unless they had contraindications to the preferred drug, the antibiotic doxycycline. Nor could mefloquine be prescribed to any personnel with a history of traumatic brain injury or mental illness. By September 2009, the policy was extended throughout the DoD.

Last December, Truthout published an investigative report that, for the first time, revealed details of the government's previously secret policy that called for all detainees sent to Guantanamo to be given 1,250 milligrams - the treatment dosage - of mefloquine, regardless if they had malaria or not and without regard for their medical or psychological history, despite its considerable risk of exacerbating pre-existing conditions. The 1,250 mg dosage is five times higher than the prophylactic dose given to individuals to prevent the disease.

Defense Department spokeswoman Maj. Tanya Bradsher had told Truthout a "decision was made" to "presumptively treat each arriving Guantanamo detainee for malaria to prevent the possibility of having mosquito-borne [sic] spread from an infected individual to uninfected individuals in the Guantanamo population, the guard force, the population at the Naval base or the broader Cuban population."

Maj. Remington Nevin, an Army public health physician, who formerly worked at the Armed Forces Health Surveillance Center and has written extensively about mefloquine, previously told Truthout the use of mefloquine "in this manner ... is, at best, an egregious malpractice" and the "side effects [from administering the drug in this manner] could be as severe as those intended through the application of 'enhanced interrogation techniques.'"

Capt. Albert Shimkus, who was head of the Naval Hospital at Guantanamo and the chief surgeon for Joint Task Force 160, told Truthout the hundreds of contractors who arrived at Guantanamo in March 2002 to construct prison camps were the medical responsibility of the contracting agency, which was KBR.

Shimkus, who signed the Standard Operating Procedure (SOP) in January 2002 authorizing the 1,250 mg dosage of mefloquine for all Guantanamo detainees, said he was told by KBR personnel, during a meeting around that time at separate medical facilities used by the firm at the naval base, that contractors were taking malaria prophylaxis drugs and would remain on such drugs while they remained on the island.

Shimkus said he could not recall what anti-malarial drugs the contractors were taking, but he believed they were not given treatment doses of mefloquine.

Chemical prophylaxis of malaria is not necessary in areas where the disease is not endemic, except for a few weeks after leaving a malaria-endemic area, according to tropical disease experts.

Gabriela Segura, a spokeswoman for KBR, told Truthout that KBR provided "immunizations against diseases and harmful agents endemic to each employee's destination in accordance with the recommendations of Centers for Disease Control and Prevention, International SOS, and the World Health Organization."

However, Segura said KBR could not identify the anti-malarial drug administered to the corporation's contractors at Guantanamo.

Bradsher, the Defense Department spokeswoman, referred all questions about the treatment of contractors to KBR, stating that the firm is "responsible for its own contractors."

Shimkus said he never reviewed medical records or other documents pertaining to KBR contractors to verify they were being treated with anti-malarial medications, nor did he inquire about the medical status of any of the workers brought to Guantanamo. Instead, he said he relied on assurances from KBR.

"I was confident," Shimkus told Truthout, "that, based on the information we were receiving from [KBR], that the malaria situation was under control, and they understood the environment they were coming into, and they were all using chemical prophylaxis."

Relying on the contracting agency is consistent with a Defense Department document from Naval Facilities Engineering Command (NAVFAC) entitled "Special Conditions for Guantanamo Bay Projects."

The October 2004 document, which was issued while mefloquine treatment was still an active policy at Guantanamo, states that contractors "shall screen prospective employees with the objective to exclude those with admitted chronic disorders from traveling to Guantanamo Bay."

It notes that contracting firms such as KBR shall make "Every reasonable attempt ... to prevent personnel with chronic disorders, which may require treatment, such as cardiovascular defects, tuberculosis, mental health problems, and alcoholism, from being sent to Guantanamo Bay."

While the NAVFAC document puts primary responsibility for the health of contract workers onto the contracting agency, a KBR statement provided to Truthout puts the onus for extraordinary health measures on the Department of Defense.

As described by Segura, KBR's policy notes that it looks "to the client to determine if any added health measures are necessary for employees, contractors or subcontractors." According to their policy, "Any guidance as to additional health procedures will then be incorporated at the direction of the client."

According to a public health expert who previously spoke to Truthout about the questionable practice of administering high doses of mefloquine to detainees, the only anti-malarial drug that would have eliminated the malaria parasite at infectious stages of its life cycle was primaquine. That drug is only administered for two weeks, yet Shimkus indicated that KBR contractors took anti-malarial drugs for the entirety of their stay at Guantanamo, and that more than one drug was used, depending on the worker's country of origin. It's not known if foreign contract workers were given primaquine because Segura said KBR was unable to locate any individuals at the corporation who would be in a position to disclose the drugs the firm gave its contract employees.

Cuban Government Concerns 

In a second report Truthout published last December on the use of mefloquine at Guantanamo, Shimkus said one of the reasons the Pentagon took the extraordinary step of implementing a policy of mass presumptive treatment was to address concerns raised by Cuban government officials about the possibility of reintroducing malaria into the country.

The benefits of mass empiric treatment of detainees, although unprecedented, "outweighed the risks," Shimkus said.

An emailed request for comment sent to the Washington, DC office of the Cuban Interests Section, an organization established in 1977 to foster dialogue between US and Cuban diplomats, was not returned.

A Hurried Hiring Process 

The hiring of low-wage contractors to work at Guantanamo was fraught with controversy. A report published in Asia Times in July 2006 stated that KBR's hiring process was kept "under wraps by both the US and Philippine governments."

Using a Philippine recruitment agency with ties to KBR, Asia Times reported that the Philippines and the US agreed that "all worker travel documents and recruitment requirements would be expedited in just a few hours by US embassy officials."

"According to people familiar with the situation, the Guantanamo-bound Filipino workers were allegedly slipped out of the Ninoy Aquino International Airport without passing through standard immigration procedures and left Manila onboard a chartered flight to Cuba," Asia Times reported.

That story is backed up by a news report published in August 2002 by Filipino-American journalist Rick Rocamora, who interviewed one of the contract employees from the Philippines. According to Rocamora's account, "the Philippine Overseas Employment Administration [POEA] received a phone call from the US Embassy and the Philippine Ambassador in Washington D.C. to expedite approval."

The approvals, which reportedly can take some months to process, were rushed through within 24 hours and the workers "transported on a chartered DC-10 Greece-registered Electra Airlines direct to the US naval base in Guantanamo Bay with refueling stops in Dubai, Greece, and Portugal."

Segura, the KBR spokeswoman, said, "As a matter of practice, KBR provides medical mobilization physicals prior to employees deploying to international projects."

The speed with which the contract workers were recruited and sent to Guantanamo raises questions as to whether KBR, POEA and its subcontractors had sufficient time to assess the newly hired workers for malaria or other diseases. Neither POEA nor Anglo-European Services, cited in reports by Rocamora and Asia Times as the local recruitment agency for the workers in the Philippines, returned requests for comment.

Lingering Questions 

Defense Department officials have claimed US personnel stationed at Guantanamo were not given treatment or prophylactic doses of mefloquine or any other anti-malarial medication because their concerns about the disease rested solely on its reintroduction into Cuba by foreign nationals and not on malaria of Cuban origin.

However, the Defense Department's reasoning for developing a policy of mass presumptive treatment for detainees, and detainees only, using the drug mefloquine raises questions about other possibilities as to why the drug was administered.

A report by Seton Hall University School of Law's Center for Policy and Research last December, issued at the same time Truthout published details of its investigation, stated that treatment doses of mefloquine on all the detainees, without an accepted medical rationale by any public health official willing to publicly support the policy, could be attributed to a medical experiment, "gross medical malpractice" or possibly one of three other possibilities, any of which "would likely satisfy the legal definition of torture as articulated by the Department of Justice in 2002."

Shimkus has vehemently denied that mefloquine was used for any other purpose. He said the policy of mass presumptive treatment was enacted following discussions he and other military officials had with the Centers for Disease Control (CDC), the Navy Environmental Health Center (NEHC) and the Armed Forces Medical Intelligence Center (AFMIC) at Fort Detrick, Maryland, which is part of the Defense Intelligence Agency (DIA). The human intelligence division of DIA was one of the primary agencies involved in the interrogations of the detainees.

Shimkus said he also answered to a medical chain of command that ran through the United States Southern Command (SOUTHCOM), indicating that senior Pentagon officials would have been knowledgeable about the policy. He said he could not recall the name of the official to whom he reported.

CDC has refused repeated requests for comment. A spokesperson for the Navy and Marine Corps Public Health Center (formerly NEHC) indicated no response was available for publication at press time. Truthout's request for comment was being "coordinated through the Navy's Bureau of Medicine and Surgery and may require additional coordination and permission through the Chief of Naval Information offices in Washington, DC."

A defense official who spoke to Truthout on background said the role of AFMIC, now known as the National Center for Medical Intelligence (NCMI), is to provide "infectious disease risk assessments in support of US military and civilian force protection measures. NCMI's function does not include prescribing treatment or making treatment policies."

The defense official also noted the importance of using anti-malaria drugs "where malaria risks are heightened." However, he would not directly comment on what AFMIC told Guantanamo officials in 2002.

Ex-Gitmo Official Told Not to Discuss Policy on Antimalarial Drug Used on Detainees

by Jason Leopold and Jeffrey Kaye, reposted from Truthout

Military officials were instructed not to publicly discuss a decision made in January 2002 to presumptively treat all Guantanamo detainees with a high dosage of a controversial antimalarial drug that has been directly linked to suicide, hallucinations, seizures and other severe neuropsychological side effects, according to a retired Navy captain who signed the policy directive.

Capt. Albert J. Shimkus, the former commanding officer and chief surgeon for both of the Naval Hospital at Guantanamo Bay and Joint Task Force 160, which administered health care to detainees, defended the unprecedented practice, first reported by Truthout earlier this month, to administer 1250 mg of the drug mefloquine to all "war on terror" detainees transferred to the prison facility within the first 24 hours after their arrival, regardless of whether they had malaria or not.

The 1250 mg dosage is what is used to treat individuals who have malaria and is five times higher than the prophylactic dose given to individuals to prevent the disease. One tropical disease expert has said there is absolutely no "medical justification" to support the military's decision to presumptively treat all Guantanamo detainees for malaria with high doses of mefloquine.

Mefloquine is also known by its brand name Lariam. It was researched by the US Army in the 1970s during the Vietnam War and licensed by the Food and Drug Administration (FDA) in 1989. Since its introduction, it has been directly linked to serious adverse effects, including depression, anxiety, panic attacks, confusion, bizarre dreams, nausea, vomiting, sores, hallucinations and homicidal and suicidal thoughts.

Although there were two media reports in 2002 that quoted Shimkus saying "war on terror" detainees were given antimalarial medication, neither he nor any other military or Pentagon official ever disclosed to lawmakers or military personnel who raised questions about the efficacy of mefloquine, that mass presumptive treatment was the policy in place at Guantanamo.

"There were certain issues we were advised not to talk about," Shimkus told Truthout in an interview, explaining the reason the policy was never publicly disclosed. He could not recall who told him not to discuss the issue.

Shimkus, who is now an associate professor of national security studies at the Naval War College in Newport, Rhode Island, said officials from the Centers for Disease Control (CDC), the Navy Environmental Health Center (NEHC) and the Armed Forces Medical Intelligence Center at Fort Detrick, Maryland, which is part of the Defense Intelligence Agency, were all involved in the discussions that resulted in the issuance of a January 23, 2002, "Infection Control" Standard Operating Procedure (SOP) that called for the mass presumptive treatment of malaria using mefloquine.

[Added 11/12/2016: Standard Operating Procedure Number 37 (In-processing Medical Evaluation) for the same hospital spells out this therapy in more detail: upon arrival to Camp Delta, all detainees must undergo "empiric treatment" for malaria, where this treatment involves the administration of 1250 mg of mefloquine split in two doses: 750 mg at in-processing time, and 500 mg twelve hours later (see also Standard Operating Procedure Number 29 (Nursing)). - See "The Administration of Drugs with Psychotic Side Effects" at Center for the Study of Human Rights in the Americas.]

Detainees started arriving at Guantanamo two weeks earlier and were held in a detention center known as Camp X-Ray.

The "Infection Control" SOP, which was signed by Shimkus and has not been previously released, says, "detainees are native to a region plagued by a number of infectious diseases. It is estimated that a number of these detainees will carry one or more of these illnesses upon arrival... Empiric therapies will include... mefloquine 1250 mg."

Medical literature usually describes "empiric therapy," or presumptive treatment for malaria, as the administration or self-administration of antimalarial drugs for symptomatic individuals, or occasionally groups of at-risk patients, who do not have access to laboratories or medical facilities and in whom malaria cannot be formally diagnosed.

At Guantanamo, however, all detainees, whether they had symptoms or not, were given laboratory tests to determine if they had malaria, and doctors were accessible "24/7" in the event symptoms started to surface, Shimkus said, calling into question the rationale for mass presumptive treatment.

Shimkus said the NEHC bore the primary responsibility for recommending that mefloquine be administered to all detainees in treatment doses, but there was consensus among the various government agencies about using the drug in this way.

"There was no one that said, 'Captain, this is not the way to go,'" Shimkus said. "I did not do anything in isolation. Any policy would have been approved by a higher authority" up the medical chain of command.

Shimkus could not recall the names of the officials from the various government agencies who agreed with and signed off on the policy. Nor could he identify his immediate medical supervisor, a colonel at United States Southern Command (SOUTHCOM), which is responsible for contingency planning and operations in Cuba, who Shimkus said would have also been involved in the decision.

Cuban Government Concerns

Shimkus said one of the reasons that factored into the decision to presumptively treat war on terror detainees with mefloquine was concerns raised by the Cuban government.

In an interview with Miami Herald reporter Carol Rosenberg in February 2002, Shimkus said he and other medical officers stationed at Guantanamo met with Cuban doctors and government officials on February 8, 2002, to "reassure the government that suspected terrorist prisoners are not introducing malaria into" Cuba, "which has been free of the mosquito-borne disease for 50 years."

Rosenberg reported on February 22, 2002, that steps taken to prevent the spread of malaria at Guantanamo included "impregnating the uniforms of both prisoners and troops who handle prisoners with mefloquin [sic] and other agents to kill the parasite ... " The Herald's February 22, 2002, report was the first and only time mefloquine use at Guantanamo has ever been mentioned. But Rosenberg's report did not state that Shimkus had already signed a policy directive authorizing mass presumptive treatment.

Shimkus told Truthout he could not recall specific details of his discussions with the Cubans. He did not respond to follow-up questions about Rosenberg's characterization regarding the use of mefloquine.

Just three days prior to the publication of the Herald's report, Navy Capt. Alan "Jeff" Yund appeared before the Armed Forced Epidemiological Board (AFEB) and was queried about malaria at Guantanamo.

But Yund, the Navy's liaison officer to AFEB, did not disclose that mefloquine was being administered to detainees. He said he believed detainees who were infected with the disease would be treated on a case-by-case basis with a different antimalarial drug known as primaquine, and that other steps would be taken to protect against mosquitoes.

Yund told Truthout via email that he did not refer to mefloquine during the AFEB briefing because, "I do not recall being involved in any consultations regarding the use of mefloquine at Guantanamo and do not recall being aware that it was being used there."

Yund declined to comment further.

Shimkus could not say why Yund was unaware that mefloquine was being used as a form of mass presumptive treatment at Guantanamo.

The use of mefloquine at Guantanamo was not mentioned during numerous other AFEB briefings, particularly one held in May 2003, where concerns were raised by members of the board about the drug's severe neuropsychiatric side effects, which US military personnel who had taken mefloquine in 250 mg prophylactic doses had been complaining about.

Red Flags Raised

Shimkus said he was aware of the alternatives and noted that at one point the antibiotic drug doxycycline and Malarone were under consideration, but the latter had only been approved by the Department of Defense in 2000 and had not been in widespread use yet. Mefloquine, Shimkus said, was considered efficient and effective.

But at an April 16, 2002, meeting of the Interagency Working Group for Antimalarial Chemotherapy, which included Defense Department representatives, participants concluded that study designs on mefloquine were flawed or biased and based on "sensational or [at] best marketed information."

The Working Group, which included representatives from the State Department, the CDC and FDA, stated, "Sufficient evidence exists to raise the question whether the neuropsychiatric adverse events of mefloquine are frequent enough and severe enough to warrant limiting its use..." The group called for additional research, and warned, "Other treatment regimes should be carefully considered before mefloquine is used at the doses required for treatment."

Additionally, in October 2002, William Winkenwerder, the assistant secretary for defense, admitted that "recent press articles and scientific studies have raised concerns regarding the adverse effects associated with mefloquine use."

Winkenwerder's admission was made in a letter written in response to questions raised by John McHugh, then chair of the subcommittee on military affairs for the House Armed Services Committee. The letter said, "recent peer-review reports" showing adverse events levels associated with mefloquine are "much higher than previously reported." Winkenwerder told McHugh, now secretary of the Army, that the CDC had initiated a review in 2001, which was then still underway, of all chemoprophylactic drugs, including mefloquine.

Shimkus said he did not believe Winkenwerder was part of the consulting team who signed off on administering treatment doses of mefloquine to detainees. But Shimkus said the policy was "well-known in the [military] medical community." Winkenwerder did not respond to calls for comment.< The use of mefloquine as a mass presumptive treatment at Guantanamo continued until at least July 2005, despite the presence of ongoing warnings. In June 2004, the CDC issued a new set of guidelines on malaria treatment, which warned that mefloquine "is associated with a higher rate of severe neuropsychiatric reactions when used at treatment doses," and recommended that mefloquine be used "only when ... [other] options cannot be used."

As far back as 1990, the CDC warned in a set of recommendations for malaria prevention for travelers that mefloquine should not be used for presumptive self-treatment "because of the frequency of side effects, especially dizziness, which has been associated with therapeutic dosages of mefloquine."

"This was a one time treatment only [for detainees]," Shimkus said. "My focus on mefloquine was specifically for preventing malaria from occurring."

However, other Guantanamo documents obtained by Truthout say that on February 28, 2002, 59 detainees allegedly refused to take medication, including antimalarial drugs, and noted that the "series must start over." It is unclear whether this included readministration of mefloquine, or whether the "series" described included further antimalarial doses of primaquine or cholorquine, also administered to the detainees.

Maj. Remington Nevin, an Army public health physician, who formerly worked at the Armed Forces Health Surveillance Center and has written extensively about mefloquine, previously told Truthout the decision to administer high doses of the drug, even as a one-time treatment "is, at best, an egregious malpractice."

Nevin added, "many dozens of detainees, possibly hundreds" likely experienced side effects "as severe as those intended through the application of 'enhanced interrogation techniques.'"

Truthout was unable to locate a single malaria expert who was willing to go on the record to defend the government's policy of mass presumptive treatment of the disease using mefloquine or any other antimalarial drug.

Shimkus told Truthout that, "clinically," he could not recall if any detainees experienced any side effects associated with taking mefloquine, but if they did, that data would have been noted in their medical records.

"We have robust medical records," Shimkus said. "If anything occurred that was a cause for concern it would have been documented in their medical records."

But the government has refused to release Guantanamo detainees' medical records to the media or to their attorneys citing, among other reasons, privacy concerns.

As first documented in a separate report on mefloquine use at Guantanamo published earlier this month by Seton Hall University School of Law's Center for Policy and Research, medical files for detainee 693 released by the Defense Department in connection with his alleged suicide at the prison facility in June 2006, contradict Shimkus's assertions. Those records show that two weeks after the detainee was given mefloquine in June 2002, he was interviewed by Guantanamo medical personnel and reported that he was suffering from nightmares, hallucinations, anxiety, auditory and visual hallucinations, sleep loss and suicidal thoughts.

A Guantanamo medical officer who interviewed the detainee, however, did not state that the detainee may have been experiencing mefloquine-related side effects in notes he took evaluating the detainee's condition.

Shimkus dismissed the significance of the medical officer's failure to connect the detainee's psychological state to the possible side effects resulting from mefloquine, stating that the medical officer may have been unaware "the patient had taken [the drug], because there was a lot of turnover of staff at that point."

Scott Allen and Vince Iacopino, medical doctors affiliated with Physicians for Human Rights, a doctors' organization based in Cambridge, Massachusetts, said, "the questionable use of mefloquine for malaria prevention at Guantanamo underscore the need for transparency of detention policies and procedures" at the prison facility.

"Benefits Outweighed Risks"

Shimkus, who is a nurse by training, acknowledged that the mass presumptive treatment of malaria using mefloquin was unprecedented. However, he said the "benefits outweighed the risks."

When asked, Shimkus did not indicate that contraindications for the use of mefloquine, such as pre-existing cases of post-traumatic stress disorder, anxiety, seizures. or other mental illness, which would have heightened mefloquine's side effects, were ever pursued for the individual detainees. He simply reiterated that the benefits of administering treatment doses of mefloquine outweighed the risks.

Yet, when told that the Defense Department took a radically different approach a decade earlier, when thousands of Haitian refugees housed at Guantanamo were first tested to determine if they had malaria and, only then, were given a treatment dosage of a different medication, chloroquine, if they had the disease, Shimkus said war on terror detainees "were a different cohort of individuals."

"You have to remember that this was in the context of February 2002," Shimkus said. "The detainees came from Afghanistan and other areas that may have been chloroquine resistant."

Moreover, in two articles published in 2002, Shimkus claimed statistics showed that 40 percent of Afghanistan's population was infected with malaria. But according to figures from the World Health Organization, in 2002, the number infected in Afghanistan was about 13 percent.

Shimkus also indicated that malaria cases at Guantanamo could have led to a public health crisis at the base, and reintroduction of malaria into Cuba. Once an outbreak begins, Shimkus told Truthout, one "loses control" of the situation and there is an epidemic.

However, when the CDC examined the influx of tens of thousands of refugees to the United States from hyper-epidemic sub-Saharan Africa, where the falciparum form of malaria kills more than a million people yearly, they concluded that "sustained malaria transmission" in a nonmalarial endemic country, like the US, from this population "would be unlikely."

Still, the CDC called for mass presumptive treatment (with a drug other than mefloquine) of these refugees before they came to the US - mainly because they feared many US doctors wouldn't recognize malaria symptoms - but noted that such mass presumptive treatment from other parts of the world, including Afghanistan, was not recommended, because "the risk and cost of post-arrival presumptive treatment currently outweighs the potential benefits."

Of the more than 700 detainees held at Guantanamo, only four tested positive for malaria, all in January and February 2002.

But Shimkus still defended the mass administration of mefloquine, saying, "One [infection] is too many." Shimkus said he believes he and other military officials "made the right policy decisions based on the information we had to prevent the introduction of malaria" in Cuba and protect the health of the detainees.

Shimkus said after he retired from the military he became involved with the Open Society Institute, funded by the Soros Foundation, and has since taken a role in the work the organization has done to raise awareness about abusive interrogation measures contained in the Army Field Manual.

This work by Truthout is licensed under a Creative Commons Attribution-Noncommercial 3.0 United States License.

Reprint: Controversial Drug Given to All Guantanamo Detainees Akin to "Pharmacologic Waterboarding"

The following article, which I co-authored with Jason Leopold, is cross-posted from Truthout. It should be read in conjunction with the report by Seton Hall University School of Law's Center for Policy and Research , "Drug Abuse? An Exploration of the Government's Use of Mefloquine at Guantanamo." The Seton Hall study and the Truthout investigation were carried out independently. The Seton Hall paper largely examines the legal ramifications of DoD's blanket use of mefloquine on the Guantanamo detainees, in particular in regards to the statutes against torture, while the Truthout article concentrates on what went on inside DoD, and comparative instances of antimalarial measures in similar circumstances.

The Truthout article is the first in-depth look at what kinds of drugs and medical treatment were applied to the Guantanamo prisoners.

*    *    *    *

The Defense Department forced all "war on terror" detainees at the Guantanamo Bay prison to take a high dosage of a controversial antimalarial drug, mefloquine, an act that an Army public health physician called "pharmacologic waterboarding."

The US military administered the drug despite Pentagon knowledge that mefloquine caused severe neuropsychiatric side effects, including suicidal thoughts, hallucinations and anxiety. The drug was used on the prisoners whether they had malaria or not.

Interviews conducted over the past two months with tropical disease experts and a review of Defense Department documents and peer-reviewed journals show there were no preexisting cases where mefloquine was ever prescribed for mass presumptive treatment of malaria.

The revelation, which has not been previously reported, was buried in  documents publicly released by the Defense Department (DoD) two years ago as part of the government's investigation into the June 2006 deaths of three Guantanamo detainees.

Army Staff Sgt. Joe Hickman, who was stationed at Guantanamo at the time of the suicides in 2006, and has presented evidence that demonstrates the three detainees could not have died by hanging themselves, noticed in the detainees' medical files that they were given mefloquine. Hickman has been investigating the circumstances behind the detainees' deaths for nearly four years.

Click here to listen to Jason Leopold discuss this story on The Peter B. Collins Show.

All detainees arriving at Guantanamo in January 2002 were first given a treatment dosage of 1,250 mg of mefloquine, before laboratory tests were conducted to determine if they actually had the disease, according to a section of the DoD documents entitled "Standard Inprocessing Orders For Detainees." The 1,250 mg dosage is what would be given if the detainees actually had malaria. That dosage is five times higher than the prophylactic dose given to individauls to prevent the disease.

Maj. Remington Nevin, an Army public health physician, who formerly worked at the Armed Forces Health Surveillance Center and has written extensively about mefloquine, said in an interview the use of mefloquine "in this manner ... is, at best, an egregious malpractice."

The government has exposed detainees "to unacceptably high risks of potentially severe neuropsychiatric side effects, including seizures, intense vertigo, hallucinations, paranoid delusions, aggression, panic, anxiety, severe insomnia, and thoughts of suicide," said Nevin, who was not speaking in an official capacity, but offering opinions as a board-certified, preventive medicine physician. "These side effects could be as severe as those intended through the application of 'enhanced interrogation techniques.'"

Mefloquine is also known by its brand name Lariam. It was researched by the US Army in the 1970s and licensed by the Food and Drug Administration in 1989. Since its introduction, it has been directly linked to serious adverse effects, including depression, anxiety, panic attacks, confusion, hallucinations, bizarre dreams, nausea, vomiting, sores and homicidal and suicidal thoughts. It belongs to a class of drugs known as quinolines, which were part of a 1956 human experiment study to investigate "toxic cerebral states," as part of the CIA's MKULTRA mind-control program.

The Army tapped the Walter Reed Army Institute of Research (WRAIR) to develop mefloquine and it was later licensed to the Swiss pharmaceutical company F. Hoffman-La Roche. The first human trials of mefloquine were conducted in the mid-1970s on prisoners, who were deliberately inoculated with malaria at Stateville Correctional prison near Joliet, Illinois, the site of controversial antimalarial experimentation in the early 1940s.

The drug was administered to Guantanamo detainees without regard for their medical or psychological history, despite its considerable risk of exacerbating pre-existing conditions. Mefloquine is also known to have serious side effects among individuals under treatment for depression or other serious mental health disorders, which numerous detainees were said to have been treated for, according to their attorneys and published reports.

Dr. G. Richard Olds, a tropical disease specialist and the founding dean of the Medical School at the University of California at Riverside, said, in his "professional opinion there is no medical justification for giving a massive dose of mefloquine to an asymptomatic individual."

"I also do not see the medical benefit of treating a person in Cuba with a prophylactic dose of mefloquine,” Olds said. Mefloquine is "a fat soluble, and as a result, it does build up in the body and has a very long half-life.This is important since a massive dose of this drug is not easily corrected and the ‘side effects’ of the medication could last for weeks or months."

In 2002, when the prison was established and mefloquine first administered, there were dozens of suicide attempts at Guantanamo. That same year, the DoD stopped reporting attempted suicides.

By February 2002, there were at least 459 detainees imprisoned at Guantanamo. In March of that year, according to the book "Saving Grace at Guantanamo Bay: A Memoir of a Citizen Warrior" by Montgomery Granger, "the situation" at the prison began "deteriorating rapidly."

"There is more and more psychosis becoming evident in detainees ...," wrote Granger, an Army Reserve major and medic who was stationed at Guantanamo in 2002. "We already have probably a dozen or so detainees who are psychiatric cases. The number is growing."

"Presumptively Treating" Malaria

Though malaria is nonexistent in Cuba, DoD spokeswoman Maj. Tanya Bradsher told Truthout that the US government was concerned that the disease would be reintroduced into the country as detainees were transferred to the prison facility in January 2002.

A "decision was made," Bradsher said in an email, to "presumptively treat each arriving Guantanamo detainee for malaria to prevent the possibility of having mosquito-borne [sic] spread from an infected individual to uninfected individuals in the Guantanamo population, the guard force, the population at the Naval base or the broader Cuban population."

But Granger wrote in his book that a Navy entomologist was present at Guantanamo in January and February 2002 and during that time only identified insects that were nuisances and did not identify any insects that were carriers of a disease, such as malaria.

Nevertheless, Bradsher said the "mefloquine dosage [given to detainees] was entirely for public health purposes ... and not for any other purpose" and "is completely appropriate."

"The risks and benefits to the health of the detainees were central considerations," she added.

A September 13, 2002, DoD memo governing the operational use of mefloquine said, "Malaria is not a threat in Guantanamo Bay." Indeed, there have only been two to three reported cases of malaria at Guantanamo.

The DoD memo, signed by Assistant Secretary of Defense for Health Affairs William Winkenwerder, was sent to then-Rep. John McHugh, the Republican chairman of the House Veterans Affairs Subcommittee on Military Personnel. McHugh is now Secretary of the Army.

A Senate staff member told Truthout the Senate Armed Services Committee was never briefed about malaria concerns at Guantanamo nor was the committee made aware of "any issue related to the use of mefloquine or any other anti-malarial drug" related to "the treatment of detainees." 

When questions were raised at a February 19, 2002 meeting of the Armed Forces Epidemiological Board (AFEB) about what measures the military was taking to address malaria concerns at Guantanamo, Navy Capt. Alan J. Yund, the liaison officer to the AFEB, did not disclose that mefloquine was being administered to detainees as a form of presumptive treatment and indicated that infected detainees who may have had the disease would be treated on a case-by-case basis. 

Yund also said detainees were given a different anti-malarial drug known as primaquine and noted that "informed consent" was "absolutely practiced" prior to administering drugs, an assertion that contradicts claims made by numerous detainees who said they were forced to take drugs even if they protested. Yund did not return calls for comment.

Bradsher declined to respond to a follow-up question about who made the decision to presumptively treat detainees with mefloquine.

An April 16, 2002, meeting of the Interagency Working Group for Antimalarial Chemotherapy, which DoD, along with other federal government agencies, is a part of, was specifically dedicated to investigating mefloquine's use and the drug's side effects. The group concluded that study designs on mefloquine up to that point were flawed or biased and criticized DoD medical policy for disregarding scientific fact and basing itself more on "sensational or best marketed information."

The Working Group called for additional research, and warned, "other treatment regimes should be carefully considered before mefloquine is used at the doses required for treatment."

Still, despite the red flags that pointed to mefloquine as a high-risk drug, the DoD's mefloquine program proceeded.

In fact, a June 2004 set of guidelines issued by the Centers for Disease Control and Prevention (CDC) says mefloquine should only be used when other standard drugs were not available, as it "is associated with a higher rate of severe neuropsychiatric reactions when used at treatment doses."

According to the CDC, "'presumptive treatment' without the benefit of laboratory confirmation should be reserved for extreme circumstances (strong clinical suspicion, severe disease, impossibility of obtaining prompt laboratory confirmation)."

A CDC spokesman refused to comment about the "presumptive treatment" of malaria at Guantanamo and referred questions to the DoD.

Nevin said, if "mass presumptive treatment has been given consistently, many dozens of detainees, possibly hundreds, would almost certainly have suffered such disabling adverse events."

"It appears that for years, senior Defense health leaders have condoned the medically indefensible practice of using high doses of mefloquine ostensibly for mass presumptive treatment of malaria among detainees from the Middle East and Asia lacking any evidence of disease," Nevin said. "This is a use for which there is no precedent in the medical literature and which is specifically discouraged among refugees by malaria experts at the Centers for Disease Control."

Even proponents of limited mefloquine usage are seriously questioning the logic behind the DoD's actions. Professor James McCarthy, chair of the Infectious Diseases Division of the Queensland Institute of Medicine in Australia, who is an advocate of the safe use of mefloquine under proper safeguards, and takes it himself when traveling, told Truthout he was unaware of the use of mefloquine for mass presumptive treatment as described by the DoD, but could imagine it under certain circumstances.

However, when informed that lab tests were available and the detainees were screened for the blood product G6PD, used to determine the suitability of certain antimalarial drugs, McCarthy found the DoD's use of mefloquine at Guantanamo difficult to understand and "hard to support on pure clinical grounds as an antimalarial."

Treatment, Torture or an Experiment?

Another striking point about the DoD's decision to presumptively treat mostly Muslim detainees with mefloquine beginning in 2002 is that it is the exact opposite of how the DoD responded to malaria concerns among the Haitian refugees who were held at Guantanamo a decade earlier.

Between 1991 and 1992, more than 14,000 Haitian refugees were held in temporary camps set up at Guantanamo. A large number of Haitian refugees - 235 during a four-month period - were diagnosed with malaria. But instead of presumptively treating the refugee population at Guantanamo, the DoD conducted laboratory tests first and only the individuals who were found to be malaria carriers were administered chloroquine.

Another example of how the DoD approached malaria treatment differently for other subjects is in the case of Army Rangers who returned from malarial areas of Afghanistan between June and September 2002 and were infected with the disease at an attack rate of 52.4 cases per 1,000 soldiers.

However, the Rangers did not receive mass presumptive treatment of mefloquine. They were given other standard drugs after laboratory tests, according to documents obtained by Truthout.

Nevin said the DoD's treatment of Haitian refugees represented "a situation that arguably presented a much higher risk of disease and secondary transmission, but one which US medical experts stated at the time could be safely managed through more conservative and focused measures."

Why did the government use the "conservative and focused" approach in treating Haitian refugees and the Army rangers, but then revert to presumptive mefloquine treatment in the case of the Guantanamo detainees, who - a month after the prison facility opened in January 2002 - were stripped of their protections under the Geneva Conventions?

According to Sean Camoni, a Seton Hall University law school research fellow, "there is no legitimate medical purpose for treating malaria in this way" and the drug's severe side effects may actually have been the DoD's intended impact in calling for the drug's usage.

Camoni and several other Seton Hall law school students have been working on a report about mefloquine use on Guantanamo detainees. Their work was conducted independently of Truthout's investigation.

A copy of the Seton Hall report, "Drug Abuse? An Exploration of the Government's Use of Mefloquine at Guantanamo," says mefloquine's extreme side effects may have violated a provision in the antitorture statute  related to the use of "mind altering substances or other procedures" that "profoundly disrupts the senses or the personality."

Legal memos prepared in August 2002 by former DoD attorneys Jay Bybee and John Yoo for the CIA's torture program permitted the use of drugs for interrogations. The authority was also contained in a legal memo Yoo prepared for the DoD less than a year later after Secretary of Defense Donald Rumsfeld convened a working group to address "policy considerations with respect to the choice of interrogation techniques."

In September, Truthout reported that the DoD's inspector general (IG) conducted an investigation into allegations that detainees in custody of the US military were drugged. The IG's report, which remains classified, was completed a year ago and was shared with the Senate Armed Services Committee.

Kathleen Long, a spokeswoman for the Armed Services Committee, told Truthout at the time that the IG report did not substantiate allegations of drugging of prisoners for the "purposes of interrogation."

The medical files for detainee 693 released in 2008 shows that, two weeks after he first started taking mefloquine in June 2002, he was interviewed by Guantanamo medical personnel and reported he was suffering from nightmares, hallucinations, anxiety auditory and visual hallucinations, anxiety, sleep loss and suicidal thoughts.

The detainee said he had previously been treated for anxiety and had a family history of mental illness. He was diagnosed with adjustment disorder, according to the DoD documents. Guantanamo medical staff who interviewed the detainee did not state that he may have been experiencing mefloquine-related side effects in an evaluation of his condition.

Mark Denbeaux, the director of the Seton Hall Law Center for Policy and Research, who looked into the 2006 deaths of the three Guantanamo detainees, said in an interview "almost every remaining question here would be solved if the [detainees'] full medical records were released."

The government has refused to release Guantanamo detainees' medical records, citing privacy concerns in some cases, and assertions that they are "protected" or "classified" in other instances. The few medical records that have been released have been heavily redacted.

"A crucial issue is dosage" Denbeaux said. "Giving detainees toxic doses of mefloquine has mind-altering consequences that may be permanent. Without access to medical records, which the government refuses to release, the use of mefloquine in this manner appears to be grotesque malpractice at best, if not human experimentation or 'enhanced interrogation.' The question is where are the doctors who approved this practice and where are the medical records?"

Bradsher did not respond to questions about whether the government kept data about the adverse effects mefloquine had on detainees.

An absolute prohibition against experiments on prisoners of war is contained in the Geneva Conventions, but President George W. Bush stripped war on terror detainees of those protections. Some of the "enhanced interrogation techniques" also had an experimental quality.

At the same time detainees were given high doses of mefloquine, Deputy Secretary of Defense Paul Wolfowitz issued a directive changing the rules on human subject protections for DoD experiments, allowing for a waiver of informed consent when necessary for developing a "medical product" for the armed services. Bush also granted unprecedented authority to the secretary of Health and Human Services to classify information as secret.

Briefings on Side Effects

As the DoD was administering mefloquine to Guantanamo prisoners, senior Pentagon officials were being briefed about the drug's dangerous side effects. During one such briefing, questions arose about what steps the military was taking to address malaria concerns among detainees sent to Guantanamo.

Internal documents from Roche, obtained by UPI in 2002, indicated that the pharmaceutical company had been tracking suicidal reactions to Lariam going back to the early 1990s.

In September 2002, Roche sent a letter to physicians and pharmacists stating that the company changed its warning labels for mefloquine.

Roche further said in one of two new warning paragraphs that some of the symptoms associated with mefloquine use included suicidal thoughts and suicide and also "may cause psychiatric symptoms in a number of patients, ranging from anxiety, paranoia, and depression to hallucination and psychotic behavior," which "have been reported to continue long after mefloquine has been stopped."

Military Struggles

Cmdr. William Manofsky, who is retired from the US Navy and currently on disability due to post-traumatic stress disorder and side effects from mefloquine, said those are some of the symptoms he initially suffered from after taking the drug for several months beginning in November 2002 after he was deployed to the Middle East to work on two Naval projects.

In March 2003, "I became violently ill during a night live-fire exercise with the [Navy] SEALS," Manofsky said. "I felt like I was air sick. All the flashing lights from the tracers and rockets ... targeting device made me really sick. I threw up for an hour straight before being medevac'd back to the Special Forces compound where I had my first ever panic attack."

For three years, Manofsky said he had to walk with a cane due to a loss of equilibrium. Numerous other accounts like Manofsky's can be found on the web site lariaminfo.org.

In 2008, Dr. Nevin published a study detailing a high prevalence of mental health contraindications to the safe use of mefloquine in soldiers deployed to Afghanistan. Responding in part to concerns raised by the mefloquine-associated suicide of Army Spc. Juan Torres, internal Army presentations confirmed that the drug had been widely misprescribed to soldiers with contraindications, including to many on antidepressants.

A formal policy memo in February 2009 from Army Surgeon General Eric Schoomaker removed mefloquine as a "first-line" agent, and changed the policy so that mefloquine would not be prescribed to Army personnel unless they had contraindications to the preferred drug, the antibiotic doxycycline. Nor could mefloquine be prescribed to any personnel with a history of traumatic brain injury or mental illness.

By September 2009, the policy was extended throughout the DoD.

New prisoners are no longer arriving at Guantanamo and the prison population has been in decline in recent years as detainees are released or transferred to other countries. Currently, the detainee population at Guantanamo is a reported 174.

But Nevin said the justification the Pentagon offered for using mefloquine to presumptively treat detainees transferred to the prison beginning in 2002 "betrays a profound ignorance of basic principals of tropical medicine and suggests extremely poor, and arguably incompetent, medical oversight that demands further investigation."