An anti-malaria drug may have inflicted permanent neurological injuries on some servicemembers

In the beginning, Lloyd Duhon blamed his nightmares, nausea and vertigo on Somalia. He and other soldiers from the 10th Mountain Division worked long, hot days during Operation Restore Hope in 1992 and 1993. His symptoms had to be the result of dehydration and fatigue. 

The crazy dreams, dizziness and other problems never went away, though. And after losing his home, his family and his business, and attempting suicide three years ago, Duhon concluded that he has permanent neurological injuries from an antimalarial drug called mefloquine he was ordered to take during his deployment. The cruelest irony: the controversial medication, also known as Lariam, failed to protect Duhon. He was twice hospitalized with malaria almost immediately after he returned to the United States. “It’s painful, and it’s horrible,” Duhon says. “Anytime I get any kind of fever today, I really get dragged out.”

There’s another tragic twist for veterans who believe they were harmed by the drug. “We never needed mefloquine,” says Remington Nevin, a preventive medicine physician who served with the 82nd Airborne in Afghanistan. “There have always been safer drugs that did not have these adverse side effects.”

The FDA issued advisories about mefloquine’s side effects over the years, culminating in a “black box warning” in 2013 about the drug’s potential to cause permanent neurological and psychiatric injuries. DoD now acknowledges the drug can cause long-term health problems and has all but stopped using mefloquine. But VA maintains that there’s little evidence mefloquine issues persist after servicemembers quit taking the medication. 

“They get combative,” says Sheryll Lander, who was medically retired from the Army. “They don’t listen. I’m not looking for a check. I just want them to understand what this drug did to me and develop a course of action to help me manage it.” 

GIN AND TONIC Military commanders have long had to balance the risk of malaria, which still kills nearly half a million people a year, with the side effects of preventive medications. Antimalarial drugs were problematic even before tonic water became a popular way to give people a dose of quinine in the 19th century. Too much quinine, which gives tonic water its bitter taste, is poisonous. So the British invented the gin and tonic. “It was thought someone got drunk on gin before they drank enough tonic to get quinine poisoning,” says Nevin, a Vermont-based physician-epidemiologist and founder of the Quinism Foundation, which supports research and education regarding health problems caused by antimalarial medications.

The Japanese controlled Indonesia, where most of the quinine was grown, during World War II. That prompted the United States to launch a “mini-Manhattan Project” to search for alternatives as it prepared for combat in the South Pacific. In the meantime, it resorted to a synthetic quinine-like drug called atabrine, which proved important for winning the war against both malaria and the Japanese. That came with a price. 

“We knew that atabrine was quite poisonous,” Nevin says. “We knew it caused night terrors, panic attacks and insomnia.” The military kept that quiet because it feared people would refuse to take atabrine. Indeed, the United States would have lost so many troops to malaria that without atabrine it could not have taken Guadalcanal, Nevin says.

New antimalarial drugs called chloroquine and primaquine were developed during the World War II research program and given to U.S. troops in Korea and Vietnam. “But they had a lot of the same problems as atabrine,” Nevin says. “Everything we’re seeing with mefloquine we were seeing in World War II, Korea and Vietnam.” 

Mefloquine came to market in 1989 as a replacement for chloroquine, which was no longer effective against malaria. However, the FDA cautioned people to stop taking the drug if they experienced “acute anxiety, depression, restlessness or confusion.” The drug was widely used by U.S. troops in Somalia in the 1990s, those sent to Iraq until about 2004 and those serving in Afghanistan until about 2013. Soldiers took the medication once a week – a ritual that gave rise to terms like “Mefloquine Monday,” “Whacko Wednesday” and “Psycho Sunday.” And yet there’s often no mention of it in their individual medical records, which is crucial evidence for any future claims.

News reports about mefloquine’s dangerous side effects appeared in the early 2000s. UPI featured Navy veteran Bill Manofsky’s struggles to get medical treatment after taking mefloquine during a deployment to Kuwait in the run-up to the invasion of Iraq. “I looked like I had Parkinson’s disease,” Manofsky says, recounting some of his symptoms. 

Mefloquine was mentioned as a possible cause for a spate of murders at Fort Bragg in 2002. Elspeth Cameron Ritchie, a retired military psychiatrist with expertise in mefloquine issues and PTSD, was part of an outside team investigating why a handful of well-respected soldiers suddenly killed their spouses. While she didn’t think mefloquine was the primary cause for the killings – all the cases involved infidelity and other issues – she became concerned about the drug’s side effects. “I found increasing evidence, both in the literature and anecdotally, of severe neuropsychiatic problems,” says Ritchie, who presented her findings at the Army’s Force Health Protection Conference in 2004.

Ritchie’s concern solidified during a post-Army stint at VA, where she encountered veterans who experienced neuropsychiatric symptoms soon after starting mefloquine. Some had suicidal ideation even when they weren’t depressed, she says. 

Growing concern at the FDA and in the medical community prompted the military to effectively stop using mefloquine in about 2013. Other medications – including Malarone and doxycycline – became DoD’s first-line defenses against malaria. 

By then, the military had not allowed aviators to take mefloquine for years because of the risk of neurological and psychological side effects. “If we’re not deploying aviators on mefloquine, then why are we deploying tank drivers and riflemen on mefloquine?” Ritchie asks.

One of the reasons may be cost. Malarone, a safer alternative, is about three times as expensive as mefloquine. And the financial burden is borne by the pharmacy at the deploying soldier’s home base.  

VAGUE NUMBERS The medical community may be slow to acknowledge mefloquine concerns because no one knows how many users experience chronic neuropsychiatric side effects. “This is a relatively small problem in comparison to the burden of disease from, for example, Agent Orange,” Nevin says. But it’s significant for those who are suffering, particularly because mefloquine poisoning is often misdiagnosed as TBI and PTSD. That means they are far less likely to get effective treatment. “Talk therapy does nothing for mefloquine poisoning.”

Duhon knows this problem firsthand. A civilian doctor loaded him up on Xanax, Wellbutrin, Abilify and other psychotropic medications as decades of depression, dizziness and nightmares wore him down. “It was digging me deeper into a pit,” he says of the drug cocktail.

Duhon lost his computer business, his house and his car. His wife left and took their children. He ended up in a rented room in Orlando, Fla., and survived by replacing credit-card machines at big-box stores like Walmart along with other piece work. He earned $9,000 that year. 

By July 2016, he was too tired to continue and too alone to care. Duhon attempted to overdose on a bottle of Xanax and a fifth of vodka. When that failed, friends and family persuaded him to check into a treatment program at the Tampa VA, where he was weaned off Xanax and the other drugs.

VA decided he had PTSD. Months later, Duhon’s counselor concluded something else was causing his symptoms, because he wasn’t responding to treatment. That led him to the Quinism Foundation and Manofsky, the first veteran to receive a VA disability rating for mefloquine-related injuries. 

Manofsky hears lots of stories like Duhon’s in his volunteer work for the foundation. As many as half come from veterans who took mefloquine 25 years ago while serving in Somalia; suicide is frequently on their mind. “All have been misdiagnosed with PTSD, but it’s a physical injury to the central nervous system,” Manofsky says. “VA just keeps saying it’s PTSD and throwing drugs at them.”  

FINDING A FIX That’s part of Lander’s story. She deployed to Afghanistan in January 2013 – about six months before the FDA issued its black box warning about mefloquine. The Marine Corps unit she was embedded with gave her the medication after she had a bad reaction to doxycycline – one of the alternative antimalarial drugs approved by the military. The only mefloquine warning she recalls receiving was that “if I started to have bad dreams, I should disregard them.”

Stomach cramps that started with doxycycline intensified with mefloquine. “I had to go around base in a way I was always close to a john,” Lander says of her time at Camp Leatherneck. She figured that problem – along with tremors, vertigo, anxiety and depression – were byproducts of the war. 

Lander’s primary-care provider diagnosed PTSD once she returned, which didn’t make sense to her. She has mentored soldiers with PTSD and says their symptoms are different than what she experiences. “Do I have some trauma? Yes,” Lander says. “Do I think there’s an insurgent behind every tree and there are IEDs under every overpass? No.”

The Army prescribed PTSD medications anyway. That made her sicker. She quit taking the pills after a year of sitting at her computer, drooling on her keyboard. Then she saw a story in Military Times about antimalarial drugs causing brain damage. “The article talked about PTSD misdiagnosis, vertigo, tremors and rage,” Lander says. “By the time I finished reading, I could put a check mark by every one of the mefloquine-induced illnesses.” 

The Military Times article helped her find Nevin. He found evidence in her medical records that convinced a civilian ear, nose and throat specialist that Lander had central vertigo – a signature mefloquine injury. The Army and VA dismissed that diagnosis, and she was medically discharged for an unrelated injury. “I don’t believe the military or VA is going to acknowledge the problem with this drug,” Lander says. 

Going forward, Ritchie says VA should screen veterans for mefloquine use and then follow up on any related medical problems. Nevin would like to see more research on injuries caused by mefloquine and similar antimalarial drugs. He predicts that within a decade, many PTSD and TBI cases will be reclassified as mefloquine poisoning. 

Nevin is also concerned about the consequences of a new antimalaria medication called tafenoquine, which military scientists have shown to be even more neurotoxic than mefloquine. Nevertheless, it recently received full FDA approval. 

Duhon, meanwhile, is remarried, has a 100 percent VA disability rating and is focused on his children. He’s using physical therapy and yoga to heal, and plans to volunteer to help other veterans. 

“I’m having to do a lot of it dragging VA along kicking and screaming,” Duhon says. But he’s optimistic. “I’m on a path to what healing looks like.”  

Ken Olsen is a frequent contributor to The American Legion Magazine.