Experts: DOD malaria drug policy for detainees is malpractice
By LEO SHANE III | STARS AND STRIPES Published: January 23, 2011
WASHINGTON — The rules governing medicine for detainees at Guantanamo are strict and specific: Minor aches get no more than 650 mg of Tylenol every six hours, sore throats get no more than one lozenge every four hours, itchy scalps mandate anti-dandruff shampoo for 15 minutes no more than twice a week.
And every detainee, regardless of their medical history, receives a heavy dose of mefloquine, an anti-malarial drug known to cause depression, paranoia and hallucinations — even if they’ve never shown any signs of carrying the disease.
Medical experts say the Defense Department policy of giving detainees large doses of mefloquine is poor medical practice at best and torture at worst. A report from Seton Hall University researchers last month said such a decision “is not medically justified” in light of the medications’ side effects, labeling the practice “gross malpractice or deliberate misuse of the drug.”
Researchers note that mefloquine has been used in the past by the CIA for “enhanced interrogation techniques” and “experimentation in behavioral modification,” suggesting that the medication may be another in a line of controversial practices at the naval base.
But Defense officials deny any such accusation, calling use of the drug a standard and accepted medical practice.
Mefloquine, better known by the brand name Larium, has been a medication of last resort among American physicians for years. In July 2009, Defense Department officials ordered military physicians to stop using mefloquine as their top malarial treatment because of its dangerous side effects. The Centers for Disease Control and Prevention have issued similar warnings.
But Pentagon officials confirmed that each of the 700-plus detainees who have been housed at Guantanamo has received the medication as part of the standard inprocessing procedure.
Upon entry, each detainee is given two doses of mefloquine totaling 1,250mg over a 12-hour period. They also receive a 400mg dose of albendazole, a parasite treatment drug with minor side effects such as dizziness and nausea. In certain cases, detainees may also receive later doses of primaquine, another anti-malarial with similar side effects to mefloquine.
Typically, when mefloquine is used to prevent malaria, physicians prescribe a 250mg dose. The larger 1,250mg dose is reserved for treatment of known cases of the disease and can stay in a patient’s system for weeks. The side effects can linger that long as well.
“The best I could say is that this is reckless disregard for the health of the detainees,” said Mark Denbeaux, an author of the university’s report and director of Seton Hall’s Center for Policy and Research. “They’re clearly not doing it for the health of the detainees, but for the health of others there.”
Malaria, a parasitic blood disease that can be fatal within 48 hours, is most commonly spread through human contact with mosquitoes. The World Health Organization estimates that nearly 1 million people are killed each year by the disease, with the hardest hit areas in Africa, Southeast Asia and the South Pacific.
But U.S. forces in Afghanistan routinely take other anti-malarial drugs — with fewer side effects — as a prophylactic. The CDC lists lower altitude areas of the country (anything under 6,500 feet) as a risk for contracting the disease.
A simple blood test could determine which Guantanamo detainees have malaria, Denbeaux said, and those individuals could be treated quickly and effectively without any risk of the disease spreading to guards or other personnel at the base.
According to documents released by the watchdog group TruthOut.org, the military does conduct a blood test of all detainees for malaria — along with screening for diseases like HIV and Hepatitis B — as part of the inprocessing, but not until after the mefloquine dose is administered.
Denbeaux said researchers could not determine the intent behind the Defense Department’s policy. The report notes that the Department of Justice’s definition of torture includes “drugs and actions that penetrate to the core of an individual’s ability to perceive the world around him, substantially interfering with his cognitive abilities, or fundamentally alter his personality.”
Seton Hall researchers contend the severe disorientation and vivid hallucinations sometimes caused by mefloquine fit that definition.
But Defense Department spokeswoman Maj. Tanya Bradsher called the practice “completely appropriate” for the treatment and prevention of malaria. Other malaria treatment medications such as chloroquine or doxycycline require doses administered over several days to fight off the disease. Mefloquine is administered in two doses just a few hours apart, making it easier to ensure that detainees receive a full treatment cycle.
In addition, Bradsher said mefloquine and primaquine are regarded as more effective for certain strains of malaria than other medications, and that the detainees’ health was a primary concern when officials decided to use the controversial drugs. However, the potential for spread of malaria to the base and larger region represents a even larger threat.
Cuba has no significant domestic threat of the disease. Bradsher said three prisoners — out of more than 700 — have arrived at the naval base with symptoms of malaria since the U.S. began using the facility for their detention in 2001.
“The potential of reintroducing the disease to an area that had previously been malaria-free represented a true public health concern,” Bradsher said in a statement. “Allowing the disease to spread would have been a public health disaster.”
For that reason, Defense officials treat all incoming detainees as if they have contracted the disease, opting for the treatment dosage instead of a preventative medicine regimen.
Defense officials did not say whether detainees in other areas, including Afghanistan, are also universally treated with mefloquine. But Bradsher strongly disputed that the department is using the medication at Guantanamo as part of a larger interrogation or torture process.
“The mefloquine dosage was entirely for public health purposes to prevent the introduction of malaria to the Guantanamo area, and not for any other purpose,” she said in the statement.
“Malaria is among the top three global infectious disease killers in the world. There are more deaths from malaria today than there were three decades ago and the disease is reemerging to areas where it had previously been eradicated.”
Officials from the Centers for Disease Control and Prevention said they were not consulted by the Defense Department on the treatment plan, with Defense leaders instead relying on the expertise of military physicians and researchers. A CDC spokeswoman would not comment directly on the Guantamo policy.
In 1995, before the resettlement of several thousand African refugees to the United States, the CDC recommended treating all of the immigrants — regardless of their symptoms — as presumptive malaria carriers and giving them appropriate treatment medication.
However, even then the agency recommended against using mefloquine, noting that “treatment dosages have been associated with a high frequency of side effects.”
In a 2009 report, the Department of Veterans Affairs’ War Related Illness and Injury Study Center recorded those extreme side effects at a rate of one per 2,000 patients and noted no long-term health effect from use of the drug. But they also noted that patients with a history of psychiatric illness may be more vulnerable to “psychiatric symptoms or developing psychosis.”
The Seton Hall report notes that no such psychological analysis was done on the detainees before giving them the malaria drugs.