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

Are Politics Why IMAP Won't Publish Until 2013 Their Report on Doctors and Torture?

In 2010, the Institute on Medicine as a Profession (IMAP), along with the Soros-financed Open Society Institute (OSI) convened a Task Force on Preserving Medical Professionalism in National Security Detention Centers. On June 1, 2012, I received an email notification that the TF report "is now complete." But much to my surprise, the report was not due for release, however, until "early 2013."

Entitled "Doing Harm: Physician Participation in Interrogation and Torture, it is the result of two years of analysis by the Task Force, which was comprised of human rights, legal and medical experts," the email said. "They analyzed the role that health professionals played in the torture and interrogation of detainees at Abu Ghraib and Guantanamo. This topic has never been investigated in such depth and contains original research, analysis and policy recommendations."

IMAP has published a brief excerpt from the introduction to the report at their website. Here it is in toto:

“Everyone concerned with the integrity of medical professionalism and respect for human rights considers the participation of physicians in the interrogation and torture of military prisoners to be an egregious and alarming violation of the precepts of medical ethics and international conventions. Medical oaths and international declarations unambiguously prohibit and condemn such behavior. Nevertheless, in the aftermath of 9/11, these violations occurred at the detention camps in Abu Ghraib and Guantanamo. How did physicians and other health professionals come to participate in these activities? Why were accepted principles and codes ignored? What we can we learn from these events to prevent future occurrences? These are the central questions this report addresses—and although their significance is self-evident, they are by no means simple to answer.”

The Task Force Includes a Guantanamo Official

Initially, the task force membership was not public, but at the insistence of Jason Leopold and myself, IMAP published the list of members on their website. It's a formidable listing of experts in medical abuse and torture and medical ethics. It includes anti-torture candidate for presidency of the American Psychological Assocation, Steven Reisner; physicians Vincent Iacopino and Brig. Gen. (ret.) Stephen Xenakis, who wrote a PLoS research article last year concluding that military medical personnel at Guantanamo "neglected and/or concealed medical evidence of intentional harm" of detainees; Physicians for Human Rights Chairman of the Board Robert Lawrence; former American Psychiatric Association president Steven Sharfstein; ethicist George Annas; Deborah Popowski from Harvard's International Human Rights Clinic, and a number of others.

Interestingly, the IMAP TF included a former Guantanamo medical official, Captain (ret.) Albert Shimkus, Jr., who had been Chief Surgeon for JTF-160 at Guantanamo until mid-2003, and commanding officer at the Naval Base Hospital during the same period. Shimkus was not a doctor, but a nurse practitioner. Currently he teaches National Security Affairs at the U.S. Navy War College.

Of much importance to me, and presumably my readers, he was the official who signed off on the medical SOP that dosed every detainee entering Guantanamo with treatment-level doses of the anti-malaria drug mefloquine (also known as Lariam).

The unprecedented use of the drug, whose controversial history of side effects was already a subject of debate and research within the Department of Defense and CDC, was criticized by some public health experts. It was also the subject of an investigation by the Seton Hall Law Center for Policy and Research, published the same time as Jason Leopold and I issued the first of our Guantanamo mefloquine reports. The bulk of the public health field, however, stayed quiet on the subject; none came out in support of the measure, however.

More recently, government documents show that anti-malaria drugs were once used by the CIA as chemical "incapacitants." It remains an open question whether mefloquine was used in such a fashion on the Guantanamo prisoners, but the fact that two suicides at the facility were tested specially for the presence of meflqoquine at autopsy years after the administration of mefloquine raises questions about use of the drug on these detainees, and in general on all the prisoners.

The TF members I spoke to were nonplussed by the presence of Shimkus on the panel. None of the TF members had reacted strongly to the mefloquine revelations, although two members, Iacopino and Dr. Scott Allen, did say "the questionable use of mefloquine for malaria prevention at Guantanamo underscores the need for transparency of detention policies and procedures” at the prison facility. At the time they gave this quote to Leopold and myself, we were unaware that they were on the IMAP TF panel with Shimkus, and they did not reveal that to us.

Another TF panel member told me that by April 2011, the TF had only met twice. Shimkus was present at both meetings, and seemed "regretful and decent."

Captain Shimkus has always been responsive to my queries to him about the Guantanamo-mefloquine story, although responsive doesn't mean fully open. He explained there were things that were classified and he was unable to talk about, or was told specifically not to talk about. In addition, he never seemed "regretful" about anything he did or policies undertaken from a medical standpoint at Guantanamo. He disagreed with the conclusions of Drs. Iacopino and Xenakis about medical neglect and/or cover-up at Guantanamo, and he maintained, in more than one interview, that he consulted on the mefloquine SOP and it was undertaken for public health reasons and was nothing more than that.

The Politics of Delay

According to IMAP's tax return covering 2009, IMAP spent over $70,000 on a project looking at "Medical Professionalism and Dual Loyalty," a task force of military/department of defense experts; legal and human rights experts, and medical experts; to develop institutional mechanisms for preventing involvement of health professionals in interrogation and detainee abuse." This certainly seems a noble undertaking.

By 2010, according to IMAP tax records, it would seem this project metamorphosed into the Task Force on Preserving Medical Professionalism in National Security Detention Centers, with expenses over $92,000. And now the TF has completed its work, but the report won't be published until 2013. On June 12 I wrote to IMAP Chief Operating Officer, Michael Pardy, and asked him why the big delay.

Pardy wrote back the next day, explaining, "The publication date is tentative. We are moving it along as quickly as possible."

I felt that was still too vague for reporting purposed, so I wrote back:

OK, but for the purposes of an article I'm writing, the announced tentative publication date is still early 2013, is that correct? I really don't understand if the report is "done," that the publication could take so long. Either you are much more poorly funded than I thought (and I don't believe that is the case), or it appears to me the publication is being held back until after the election for political purposes.

Also, I was wondering if you could say if the report intends to cover at all the issue of the Behavioral Science Consultation Teams [BSCT] run by the Department of Defense?

I have yet to get a reply. Other task force members I asked about the delay in publishing, or the BSCT issue either didn't know, or did not answer my query. One person did say that the medical-ethical controversies over use of doctors and the force-feeding of detainees would be addressed in the report.

There is nothing in the delay in publishing that is nefarious, necessarily. And who really cares, in the end, what IMAP publishes or not, as the details are meant for medical journals and the medical or public policy elite, and not read by the general public?

But the question of medical ethics in the context of the US military's "war on terror" and DoD and CIA history in relation to torture and interrogation, including use of doctors and psychologists in the interrogation of detainees, in the monitoring of torture, and the construction of individualized torture protocols, is of high relevance and interest to the public at large.

I suspect, as I mentioned in the email to Pardy, the delay is due to the elections, with the intent to bury the problematic torture issue since it embarrasses the administration before its more liberal or human rights supporters. The embarrassment stems from President Obama's policy of non-accountability for the Bush-era torture program. His administration does not support the "looking back" at these issues that would bring about prosecutions, more investigations, or other forms of accountability. And the administration's supporters and backers pretty closely toe the party line on such things.

But it is sickening to think that human beings suffer in isolation and under indefinite detention, endure brutal ERF beatings, not to mention ongoing interrogations under the Army Field Manual's Appendix M protocols, in part because it would be politically inopportune to highlight their abuse before November 2012. In essence, the issue of detainee abuse is subordinated to the exigencies of American electoral politics.

Appendix M, by the way, includes, besides isolation, use of sleep deprivation and forms of sensory deprivation, which the manual advocates using in combination with the techniques that induce "debility" in prisoners (for instance, dietary manipulation), as well as use of techniques that produce emotional abuse ("Ego Down") and fear-generating treatment or manipulation of phobias, all with the intention of breaking-down the detainee... for what? Guantanamo is a "strategic interrogation center," according to government sources, and the interrogations there are not about operationally imminent intelligence, e.g. the so-called ticking bomb.

The answer is: for production of intelligence agents for use by the government, as well as the production of more false confessions, and cooperation with show trials, just as, for instance, Stalin used such torture when similar forms of prisoner abuse and interrogation was used by the NKVD once upon a time. It is possible as well that certain forms of experiments are conducted on these prisoners under the auspices of field trials of various instruments, procedures, or detention policies.

IMAP should heed its supposed call for change in the area of medical ethics and quickly publish their findings for the public. At the very least, an Executive Summary of the report could be published online. There is no excuse not to do this.

A Guantanamo Connection? Documents Show CIA Stockpiled Antimalaria Drugs as "Incapacitating Agents"

Listen to my interview with Peter B. Collins discussing this story

A Truthout analysis of historical records concerning government research and nonmedical use of antimalarial medications has revealed that such drugs were the objects of experimental research under the CIA's MKULTRA program. Even more, one of these drugs, cinchonine, was illegally stockpiled by the CIA as an "incapacitating agent."

Antimalarial drugs were studied as part of the CIA's mind control program MKULTRA. Cinchonine, an antimalarial drug derived from chichona bark, was one of the drugs used by the operational components of MKULTRA, code-named MKNAOMI and MKDELTA. The CIA worked with researchers for the Army's Special Operations Division, a secret component of the US Army Chemical Corps based at Fort Detrick, to develop delivery systems for the drugs.

Revelations concerning CIA interest in use of antimalarial drugs would be of historical interest, as it has never been written about before. But such interest gains contemporary significance in the light of actions taken by the Department of Defense (DoD) in the "war on terror," and the fact that a key DoD expert on antimalarial drugs was a psychiatrist involved in training personnel for Guantanamo interrogations.

In January 2002, the DoD deliberately decided that all incoming detainees at Guantanamo would be given a full treatment dose of the controversial antimalarial drug mefloquine, also known as Lariam. The purpose was supposedly to control for a possible malaria outbreak, in deference to concerns from Cuban officials.

But specialists in malaria prevention have said they have never heard of such presumptive treatment for malaria by mefloquine in this type of situation. Furthermore, a summary of antimalarial measures at Guantanamo given to Army and Center for Disease Control (CDC) medical officials at a February 19, 2002, meeting of the Armed Forces Epidemiological Board failed to describe the mefloquine procedure approved a month earlier.

Was mefloquine used at Guantanamo to help produce a state of "learned helplessness" in detainees? Were experiments conducted on adverse side effects of mefloquine on the prisoners held there?
Some years ago, this might have been considered a crazy scenario to even consider. While there is no smoking gun that can prove mefloquine was used for nefarious purposes, a strong case can be made that use of the drug at Guantanamo was not related to malaria control.

Antimalaria Drugs and MKULTRA

The revelation concerning cinchonine came from hearings the Senate's Church Committee held in September 1975 on CIA "Unauthorized Storage of Toxic Agents." The agency's illegal stockpile of chemicals and drugs, which included the antimalarial drug cinchonine, was supposed to have been destroyed by order of President Nixon in December 1969.

At the time of the president's order, the US had also signed an international agreement that such chemical and biological weapons would be destroyed, so the revelation of the CIA's stockpiling of such substances was highly embarrassing to the US government at the time.

At the behest of Congressional investigators, the CIA provided an inventory of all "lethal" and "incapacitating agents" they had kept contrary to presidential order. On this list, the CIA indicated it held two grams of cinchonine, stored as an incapacitating agent, that is, a substance meant to temporarily disable an individual. Temporary incapacitant or not, the CIA inventory listing for cinchonine states, "Overdose leads to severe cardiac convulsions, nausea and vomiting."

In separate testimony from another Senate investigation, a CIA-linked researcher, Dr. Charles F. Geschickter, told Sen. Edward Kennedy in 1977 hearings that the CIA was interested in antimalarial drugs that "had some, shall I say, disturbing effects on the nervous system of the patients." Geschickter's CIA researchers became interested in these antimalarial drugs as part of the work they were doing in the CIA's MKULTRA program. Dr. Geschickter ran the Geschickter Fund for Medical Research, and the Kennedy hearings also revealed how the fund laundered money for MKULTRA projects.

According to MKULTRA documents released as part of a related Senate investigation in 1977, research into quinolines, the class of drugs that include cinchonine, quinine and the modern antimalarial drug mefloquine (Lariam), was part of MKULTRA subprojects 43 and 45.

The CIA prior to the Congressional investigations destroyed most records concerning MKULTRA and chemical, biological and bacteriological research. Moreover, according to Senate testimony by former CIA Director William Colby, many of the organizational directions concerning both research and operationalization of such weapons were never written down.

An Antimalarial "Incapacitant"

Cinchonine is a quinine-derived drug and similar in some ways to the artificial quinine derivative antimalarial drug mefloequine, also known as Lariam. Mefloquine, a product of Army research, has been the subject of numerous controversies over its side-effect profile, and as recently as 2009, the DoD significantly cut back on its use for the military.

The stockpiling of cinchonine as an "incapacitating" agent was directly contrary to Nixon's order that all such toxic and bacteriological stockpiles held by the DoD and the CIA be destroyed. Other incapacitating agents held by the CIA for years after the disposal order included the powerful hallucinogen BZ; the anticholinergic drug Cogentin; digitoxin; and Phencyclidine HCL, commonly known as "Angel Dust"; among other drugs.

The CIA's stockpile of dangerous substances also included numerous "lethal agents," including shellfish toxin; cobra venom; fish toxin; and numerous substances only known by their code names ("E-4640," "F-270" etc.). It is not known if any of the lethal or incapacitating agents were ever used, or if so, by whom or where. (The one exception the CIA admitted to was the use of an arsenic suicide pill provided to Francis Gary Powers, a U-2 pilot shot down over the Soviet Union in 1960. Powers did not use the pill.)

According to Senate testimony, the stockpile was discovered after a review of secret programs ordered by Colby. Originally, the various drugs and weaponized biological substances were kept at the Army's Fort Detrick compound and were apparently moved later to a CIA storage facility.

The neurological side-effects of mefloquine are similar to the side effects of cinchonine. Cinchonism (or quinism) includes such side-effects as blurred vision, tinnitus, skin rashes, vertigo, nausea, headaches and other even life-threatening serious health problems. Mefloquine has been cited for neurological, but also psychological side-effects, including depression, anxiety, panic attacks, confusion, hallucinations, bizarre dreams and suicidal and homicidal behavior. The effects can be long or short-term.

But even the "short-term" effects can be debilitating, as one military doctor, Captain Monica Parise, told a group of other physicians at a government meeting in May 2003. Parise told the meeting of the Armed Forces Epidemiological Board (AFEB) that "there are a host of other more acute less severe neuropsychiatric issues that occur short-term [with mefloquine], such as insomnia, strange dreams, fatigue, lack of energy, inability to concentrate and some people have reported that those effects have lasted a very long time."

Parise noted that it takes "three, four, or five months to really wash the drug out of your system," and that she'd "heard that there might be some data in DoD ... that might shed light" on how the drug had "ruined people's lives." As we shall see, a psychiatrist present at this same meeting was also involved in training other psychiatrists to assist Guantanamo interrogators.

Administering Mefloquine to All the Guantanamo Detainees

In December 2010, Truthout and Seton Hall School of Law's Center for Policy and Research revealed that it was medical standard operating procedure (SOP) to give all arriving detainees full treatment doses of the antimalarial drug mefloquine upon arrival at the US prison camp. The military's own newspaper, Stars and Stripes, followed up with their own story a few weeks later.

[Update, 6/9/2012: Both the Truthout and Seton Hall investigations also noted the CIA's MKULTRA research into the quinoline family of drugs. The Seton Hall report described how "potential use of these drugs in an interrogation setting was a stated purpose for the [CIA] study."]

A treatment dose of mefloquine is five times the amount taken weekly by those who use the drug for prophylactic purposes. Larger doses are associated with a higher percentage of side effects.

The Truthout investigation showed that at the time the SOP was put in place, internal discussions within the DoD and an Interagency Malaria Working Group were expressing strong doubts about the serious neuropsychiatric side effects of the drug. Despite this, the surgeon general of the JTF-160 Task Force at Guantanamo signed off on the unprecedented mefloquine protocol.

The chief surgeon, who also served as commander of the Navy Hospital at the base, was Capt. Albert Shimkus. Shimkus told Truthout in late 2010 that he had first sought consult regarding the use of malaria drugs from an assortment of agencies, including officials from the CDC, the Navy Environmental Health Center (NEHC) and the Armed Forces Medical Intelligence Center at Fort Detrick, Maryland. All three agencies have told Truthout they were not involved in this decision or had no documents related to such consultation.

Shimkus told Truthout in a phone interview last October that the US State Department "would have been involved" in discussions about malaria concerns at Guantanamo, though he maintained no State Department officials were directly involved in the "clinical decision making."

In June 2004, the CDC announced, "'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)." Hence, "presumptive treatment" - the mass administration of a drug without knowing whether or not it is actually necessary - is reserved for situations when there is no possibility of laboratory confirmation of malaria, but that was not the case at Guantanamo.

Yet, even a year later, the mefloquine SOP was renewed at Guantanamo.

DoD spokeswoman Maj. Tanya Bradsher 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."

According to Bradsher, "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." Nevertheless, when hundreds of contract workers from malaria-endemic countries such as India and the Philippines were brought by Halliburton subsidiary Kellogg Brown and Root (KBR) to build the new Guantanamo Delta Block in 2002, there was no DoD scrutiny of any exposure by these workers to malaria.

According to Bradsher, KBR alone was responsible for its own workers, belying a concern over possible reintroduction of malaria to Cuba, which, according to Captain Shimkus, had produced State Department concerns when it came to the arriving detainees.

In his October 2011 interview, Shimkus also said he sent "pretty detailed reports" regarding the mefloquine decision to JTF-160's Commanding Officer, Marine Corps Brig. Gen. Michael R. Lehnert. He had nothing further to say about a statement made to Truthout a year earlier in which he stated that he had been told not to talk about the mefloquine decision.

When Shimkus was asked if he was aware of any detainees who had suffered psychiatric problems because of drugs administered to them, he said, "Maybe. That's confidential," adding a moment later, "No for that."

He also rejected the opinions of two medical researchers who wrote in PLoS Medicine in April 2011 that "medical doctors and mental health personnel assigned to the DoD neglected and/or concealed medical evidence of intentional harm" to detainees. "They have an opinion and it should be out there," Shimkus said.

Army Mefloquine "Specialist" Trained Psychiatrists for Interrogations

A top psychiatrist working for the Office of the Assistant Secretary of Defense for Health Affairs (OASD-HA), Col. Elspeth Cameron Ritchie, traveled to Guantanamo in October 2002, purportedly to investigate a spurt of suicide attempts among the detainees. Within weeks, according to the AFEB minutes cited earlier, she attended an "experts" meeting on "Malaria Chemoprophylaxis" at the CDC in January 2003 that considered problems with the "neuropsychiatric adverse drug reactions" of mefloquine. Indeed, according to the AFEB speaker, Captain Parise, they specifically included a psychiatrist - presumably Ritchie - in their discussions.

Did Colonel Ritchie bring knowledge of the effects of mass mefloquine administration at Guantanamo to this meeting? We don't know and Colonel Ritchie, now retired from the military and chief clinical officer for the District of Columbia's Department of Mental Health, would not return a request for comment. A public spokesperson for OASD-HA told Truthout it had no connection with any decision to use mefloquine at Guantanamo.

It would be strange, if not highly unlikely that, given the widespread interest in mefloquine adverse reactions at the DoD and contemporaneous statements that the DoD was conducting research on this, that the effects of the Guantanamo mefloquine SOP were never examined.

Ritchie's involvement in mefloquine issues can also be ascertained by the fact that, in 2004, Ritchie, by then "Psychiatry Consultant" to Army Surgeon General Kevin Kiley, gave a presentation to the DoD's Deployment Health Clinical Center on the "Neuropsychiatric Side-Effects of Mefloquine."

Of convergent interest is the fact that, according to Dr. Ritchie, she taught psychiatrists slotted for assignment to the military's Behavioral Science Consultation Teams (BSCTs) working at Guantanamo and possibly elsewhere. She is, at this point, the only known person potentially linking military activities surrounding both mefloquine and interrogations or torture.

According to an Army surgeon general description of BSCT training during the period Colonel Ritchie was involved, such training included instruction in methods of inducing "learned helplessness."

"Learned helplessness" is a condition of near-total psychological breakdown produced by inability to escape an extreme set of stressors. Its study is associated with the work of psychologist Martin Seligman, who did research on the subject as far back as the 1960s. In the 1990s, all the Survival, Evasion, Resistance and Escape schools except the Navy school discontinued the use of the waterboard in their training program precisely because it tended to produce "learned helplessness" in its students, the opposite of the kind of effect they were seeking.

A Guantanamo Autopsy Tests for Mefloquine

The months-long period of time it takes for mefloquine to leave the system may have been involved with a decision to test a detainee at Guantanamo who had committed suicide for the presence of mefloquine in his bloodstream. But the detainee, whose autopsy report included toxicology results that show he was tested specially for mefloquine, had been at Guantanamo for five years at the time of his death.

Abdul Rahman Al Amri entered Guantanamo in February 2002 and would have been given a treatment dose of mefloquine at that time. We do not know why he would have been tested for its presence over five years later. All but one of the other detainees for whom we have autopsy reports due to purported suicides were not tested for mefloquine, showing such testing was not standard procedure.

Al Amri was also found dead with his hands bound behind his back, and his death as well as that of 2009 suicide Mohamed Salih Al Hanashi are under investigation by the UN Special Rapporteur for Extrajudicial Executions, primarily because of Truthout's coverage of these events.

A Plausible Hypothesis

The discovery that the CIA researched antimalarial drugs as part of its mind control program and, moreover, operationalized at least one of these drugs as an "incapacitating agent" means that the hypothesis that mefloquine was used for similar purposes at Guantanamo is not inconsistent with a known pattern of governmental behavior.

There are many reasons to question the supposed use of mefloquine at Guantanamo for purely public health purposes. Consider the following:

-- The mass use of treatment levels of mefloquine at Guantanamo was unprecedented.

-- The drug was limited to only one group of potential malaria carriers.

-- Use of mefloquine for presumptive treatment continued for years past the point when the DoD was already manifestly aware of the drug's dangers.

-- The mefloquine SOP was hidden from medical authorities at the Armed Forces Epidemiological Board.

-- Finally, there is the fact no government agency will admit to advising use of the drug, even when a Guantanamo medical officer states they were involved.

As a result of all the above, it appears highly possible that the motive for the drug's use was to psychologically disorient and physically debilitate all or some portion of incoming prisoners.

Copyright Truthout.org - Reprinted with permission (Original URL)

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.

Unreported Detainee Deaths at Guantanamo in Jan-Feb 2002?

Originally posted at Firedoglake/MyFDL

According to the transcript (PDF) of a February 19, 2002 meeting of the Armed Forces Epidemiological Board (AFEB), "[a] number of the detainees have died of the wounds that they arrived with" at Guantanamo. This statement came from Captain Alan "Jeff" Yund, a preventive medicine doctor and the Navy's liaison officer to the AFEB, as he discussed "mortuary affairs" at Guantanamo, part of a larger discussion on health issues at the new prison facility. [Update: See here for a transcript of the AFEB meeting, as the older link apparently is dead.]

During the meeting, Captain Yund identified himself as working directly with Admiral Steven Hart, the Director of Navy Medicine Research and Development, as well as "a number of other admirals."

Yund's full quote is as follows, on pg. 108 of the transcript (bold added):

Mortuary affairs is an important but hopefully small aspect of the activities of the [Guantanamo] hospital. A number of the detainees have died of the wounds that they arrived with. So there's attention being paid to doing the things with the body that would be appropriate for their culture.

In a December 7 email interview with Captain Yund, who is now retired, Yund stated he does "not recall that I was ever very directly involved in detainee health issues" at Guantanamo. Accordingly, he said the following in regards to his statement about detainee deaths:

"I did not make that statement from personal or direct knowledge. It may have come from CAPT Shimkus’ presentation, or possibly from conversations or meetings with other Navy Preventive Medicine personnel colleagues. It is not the type of statement I would have made without having learned it from a source I considered reliable."

The reference to "CAPT Shimkus" is to Captain Albert J. Shimkus, commanding officer of the U.S. Naval Hospital at Guantanamo at the time, and JTF 160 chief surgeon. Captain Lund explained that he remembered hearing a "a detailed and fascinating account" of "events and issues" at Guantanamo, though he couldn't remember the date or place. This is the "presentation" to which Captain Yund refers in his explanation above.

In a telephone interview on December 13 with Captain Shimkus, who now is an Associate Professor in National Security Decision Making at the U.S. Naval War College, Shimkus expressed shock over the claims there were any deaths at Guantanamo while he was there. (Captain Shimkus left Guantanamo in August 2003.) He said that "no deaths occurred" while he was there, but that he did speak at the time of the task force preparing for possible deaths. He could not offer any explanation for what Captain Yund reported.

In the AFEB transcript itself, there is no surprise or other comment or correction made on on Yund's announcement concerning detainee deaths. The meeting was also attended by other military medical staff, civilian medical advisers, and upper-levels of the DoD bureaucracy, including Admiral Hart, and Assistant Secretary of Defense for Force Health Protection and Readiness, Dr. William Winkenwerder, and his deputy, Ellen Embrey. The meeting, held at the Island Club, North Island Naval Air Station, San Diego, was chaired by Dr. Steven Ostroff from the Centers for Disease Control.

By all accounts, in the initial days of prisoner transfer to Guantanamo, a number of detainees arrived with serious battle wounds. Notes from a doctor working at the facility, dated February 22, 2002, which I reviewed, discuss the previous day's cardio-thoracic and neurosurgeries. A thoracotomy (excision of a portion of a lung) was said to have been performed on detainee "205." The same day's notes also describe an incident in which a detainee was handcuffed via a broken arm.

In response to my initial inquiry on 2002 detainee deaths at Guantanamo, Major Bradsher replied fully as follows:

The first detainee death at Guantanamo Bay was in June 2006. The [June 16] press
release is below:
http://www.defense.gov/releases/release.aspx?releaseid=9656

The press release refers to the "three detainees who died of apparent suicides on June 10, 2006," and is a summary of the disposition of the remains.

After receiving this first communication from DoD's press operations office, I asked for further clarification, and in particular "as to why a Captain at an Armed Forces Epidemiological Board meeting in Feb. 2002 would refer to earlier deaths at Guantanamo, ostensibly from battlefield wounds."

Major Bradsher responded, "I can't speak for Captain Yund. As I have stated before, the first detainee fatality in Guantanamo was in June 2006."

At this point, what we have is a mystery. There are no other reports regarding early battlefield deaths among the prisoners rendered to Guantanamo. We know that some of them arrived on litters, and needed immediate medical attention. We know that officials there even expected some deaths. But DoD maintains that no deaths prior to June 2006 occurred, and the principal reporter to the AFEB meeting on this subject, Captain Yund, does not remember the statement, though he notes "it is not the type of statement I would have made without having learned it from a source I considered reliable."

Dr. Steven Miles, author of Oath Betrayed: Torture, Medical Complicity, and the War on Terror, shared his reaction to news of the possible deaths reported here:

This is an enormously important event. I have tried, without success to have the DoD or the media, clarify the huge inconsistencies in prisoner death reporting to no avail. My article on this remains unpublished by the medical media and by Slate etc.

The uncertainty over what really occurred in the early days at Guantanamo was accentuated by recent revelations by Truthout.org and Seton Hall University of Law's Center for Policy and Research on the mass administration of the drug mefloquine to detainees who arrived at Guantanamo. Ostensibly described as an antimalarial measure, there are numerous reasons to question its use, not least because of its well-known high rates of neuro-psychiatric side effects, and also because such mass empiric treatment of mefloquine has never occurred and experts found such use potentially harmful and without medical justification.

Truthout has promised further investigation into the mefloquine scandal, including interviews with some of the principles involved, in a report to be published in the coming week.

There is a tremendous need for Congressional and/or independent investigations that have full mandate and subpoena power to ferret out the truth about what has occurred at Guantanamo and other U.S. "war on terror" prisons. The biggest obstacle to this, besides the Pentagon and the GOP, is the Democratic Party leadership itself, which refuses to undertake or fund such investigations, and whose leader in the White House, President Barack Obama, opposes -- against treaty obligations described in Article 12 of the Convention Against Torture -- such investigations.