That dark reality got caught in the headlights in Fayetteville 10 years ago. The Nieves murder-suicide was followed at the same base that summer by two more domestic homicides by Special Forces soldiers returned from Afghanistan. By August, press attention to the possibility that mefloquine was involved forced the Army to announce its own investigation – an epidemiological consultation or, in the acronymic style favored by the military, an EPICON. That November, the EPICON team issued a report dismissing the drug as a factor without actually investigating it. Instead, the team blamed marital problems and poor access to mental health care in the military.

It was the beginning of a lost decade, in terms of recognizing mefloquine’s impact on the military.

Now, by invoking the specter of Agent Orange -- on the anniversary of D-Day -- Nevin all but pounded the witness table last week to call attention to what he believes is the scale, severity, and urgency of the problem. In effect, he and a handful of others are giving the military one more chance to do the right thing: Face up to the truth about the drug it invented, and try to help those who have been harmed.

Based on past pattern and practice, the chance of that happening without outside intervention is slim.

2.

I remember the phone call vividly.

It was a Friday in summer 2002, and I was at work at the UPI office in Washington, waiting to have dinner with a former White House reporter, Mark Kukis. A friend called and told me to turn on the ABC evening news. I watched Peter Jennings talk about a cluster of murder-suicides at Fort Bragg involving soldiers who had been in Afghanistan. Jennings asked, Was there something about this new war on terror – no front lines, no sure signs of victory, no end in sight – that was triggering violence and despair in the nation’s best soldiers? Such violence among elite troops, trained to conquer the worst kinds of stress, and even torture, was all but unheard of.

My friend knew that, with my UPI colleague Mark Benjamin, I’d been working on an investigation of violent and deadly side effects from the anti-malaria drug Lariam. Less than a month before the Nieves deaths, we published a long article connecting the drug with suicide and other violent and bizarre behavior, based on hundreds of pages of internal drug company safety reports we'd gotten our hands on. It began:

WASHINGTON, May 21 (UPI) -- Mounting evidence suggests the anti-malaria drug Lariam -- prescribed to Peace Corps volunteers, travelers and U.S. soldiers -- has triggered mental problems so severe that in a small percentage of users it has led to the ultimate side effect: suicide.

Now I wondered whether Lariam, rather than some exotic new version of combat stress, might be involved in the deaths. At Fort Bragg, was homicide the ultimate side effect?

By Sunday, I’d read enough to believe that was a real possibility. The situation had all the elements. First, there was malaria in Afghanistan, and Lariam would have been recommended by the CDC. Next, these were seemingly solid, even exemplary, soldiers. And finally, the attacks – rages, really -- were explosive, out-of-nowhere, and most of all, out of character – tip-offs to Lariam toxicity we’d seen time and again in the internal safety reports we'd examined, and elsewhere. Even though the marriages were troubled, there was no evidence of previous domestic violence. And suicide, as we’d just reported, was a rare but real outcome in some cases. The murder-suicides at Fort Bragg seemed all the more symptomatic.

So that Sunday I dialed the home number of an attorney, Thomas Maher, who had taken the case of Master Sgt. William Wright, the only one among the three Special Operations soldiers who had not killed himself after allegedly killing his wife.

After a brief introduction, I got to the point: “I have a theory of the case.”

“Which is?” Maher responded with what felt more like impatience than interest. I couldn’t blame him. The theory I was going to describe sounded so bizarre, even to me, that I decided to stall for better circumstances. “I’d rather tell you in person,” I said.

The next afternoon I was sitting on a stone ledge outside the Cumberland County Jail, talking with Maher, a lawyer who specialized in difficult murder cases. I laid it out for him:

Wright may have been taking Lariam.

Lariam can provoke homicidal rages.

Lariam could have made Wright psychotic and violent.

Therefore, Wright might have killed his wife in a rage that would never have reached murderous proportions but for the drug the Army had ordered him to take. (“But for” is an important foundation for a defense based on toxic exposure.)

It was just speculation, and Maher was appropriately skeptical. If you don’t know anything about the drug, it sounds like a “Twinkie defense” – blaming a malaria pill for making you strangle your wife to death while your three sons cowered nearby? Really? Nonetheless, Maher told me he would ask his client – he was seeing him again that afternoon.

Later that day, Maher called. Yes, he said, Wright was taking Lariam – a weekly pill you continued for several weeks after returning from a malaria zone -- but there were no particular effects Wright was aware of, except possibly a feeling of “floating” from time to time.

But something else had happened since our visit to pique Maher’s interest: He’d met with a group of families who knew the Wrights, and one of them volunteered, a propos of nothing: “I bet it was Lariam – it messes up all those guys.” No one had disagreed.

3.

In many ways, Fayetteville is the classic Army town. At various times referred to as Fatalville or Fayettenam, it was the site of the Jeffrey MacDonald case, the Army psychiatrist who killed his family and blamed it on hippies. It was where Seymour Hersh of The New York Times first heard about a Vietnam massacre by U.S. soldiers at a place called My Lai. It is full of payday-loan storefronts, Saturday night bars to take your money, a big new county jail to take in all the rowdy drunks, and plenty of churches for Sunday morning repentance.

Over the next couple of weeks, Mark Benjamin and I spent our days driving around Fayetteville and Fort Bragg, looking for neighbors, friends, family, fellow soldiers – anyone who might shed light on the three men’s behavior before the killings.

Before long, we’d confirmed that Wright and Nieves had taken the drug and were probably still on it when they committed the homicides, and that the third soldier, Sgt. Brandon Floyd, had also taken it on numerous deployments, though perhaps not as recently. What was new here seemed to be the length and frequency of Lariam use as the war on terror unfolded in malarial hot zones. A few weeks on this drug might be one thing, a few months – and then another few, and then another – might be something else.

And we’d found evidence in all three case of the strange behavior that was so often the tip-off. Wright's case was especially notable, whether he recognized it or not. From our reporting at the time:

FAYETTEVILLE, N.C., Aug. 17 (UPI) -- Friends of the three Fort Bragg soldiers suspected of killing their wives this summer say the men exhibited unusual anger and incoherence after returning from Afghanistan where they were given an anti-malaria drug associated with aggression and mental problems.

One of the soldiers [Wright] was "almost incoherent" and visibly shaking while describing marital problems to a neighbor. Another became unable to control his anger at his wife in public, startling those who knew him. A third puzzled his new neighbors with his strange behavior.

Soldiers at Fort Bragg said they are well aware of mental problems linked to the anti-malaria drug Lariam, which include aggression, depression, paranoia, hallucinations and suicidal thinking, even as official military spokesmen dismiss a connection between the drug and the events around Fayetteville this summer which have drawn national attention.

--

Before the end of the month, the Army announced it would send the EPICON team and – grudgingly –  consider Lariam as a possible factor.

WASHINGTON, AUG. 29 (UPI) -- WASHINGTON--The Army says it is "pretty sure" that the anti-malaria drug Lariam was not a factor in a recent string of homicides and suicides at Fort Bragg, N.C., and it may be eliminated as a suspect, a top Army official said.

Near Fort Bragg, the North Carolina base where four soldiers are suspected of killing their wives this summer, Army Undersecretary Les Brownlee told reporters this week that "most of the medical people" he has talked to believe Lariam played no role in the deaths.

"But we want to be sure," he said.

In November, the EPICON team released its report. As predicted by the Army Secretary, the report said Lariam had not been a factor in the cluster of killings at Fort Bragg.

The “cluster,” it turned out, was the key: In the EPICON charter written before the team ever got on the plane to Fayetteville, the Army had added two more homicides at Fort Bragg that summer to the scope of its investigation, the all-important "charter." In one, an Army cook at Fort Bragg who had never left the country stabbed his wife multiple times in her trailer, then set it on fire. In the other, the wife of an Army officer conspired with her boyfriend to kill him for the insurance money.

Presto – Lariam could not have been involved in every case in this cluster, so -- Change-o! -- Lariam could not have caused it. The Pentagon leaked the results to USA Today in late October with exactly that spin:

An Army investigation of possible medical and behavioral causes behind a series of domestic killings and suicides at Fort Bragg, North Carolina, has ruled out the antimalaria drug Lariam, officials said. Speculation about possible explanations for the killings has run the gamut from the stress of combat to psychotic side effects from Lariam.

That set the tone for the coverage that followed.

“Of particular note,” read a typical account, “the EPICON study determined that the anti-malarial drug mefloquine, commercially known as Lariam, was not a factor in the clustering of the homicides. There had been rampant speculation by the media shortly after the incidents that the drug's side effects had played a role in the killings.

"We could not find any evidence ... that Lariam had anything to do with the ... individuals' behavior," [Col. Dave] Orman said.

It was interesting to see our careful on-the-ground reporting over many weeks called “rampant speculation by the media” – by the media! To our minds, the only speculation had been the military’s – speculation that Lariam played no role.

Most startling to us was the EPICON team's failure to ask anyone close to the soldiers about their behavior leading up to the deaths. Of course, five of the six principals were dead, and Sgt. Wright, facing murder charges, might not have been available.  But as we discovered, the Army, and the town, was full of people willing to talk:

Friends of one of the soldiers said the report ignores mounting evidence that the drug might have played a role in some of the violence near Fort Bragg.

"No one talked to me from the Army at all," said Debbie Lown, an acquaintance of Master Sergeant William Wright, the one soldier who took Lariam in Afghanistan who did not commit suicide. Wright allegedly strangled his wife, Jennifer. Lown's husband, John, is also a former Special Forces soldier who said Lariam made him lose control of his anger.

... Jennifer Wright's father, Archie Watson, has described Wright's sudden, uncharacteristic fits of rage after returning. There was no history of domestic violence in their marriage.

The Army cited privacy concerns and ongoing legal proceedings in a decision not to interview friends, family or neighbors who think Lariam might have played a role.

--

Col. Orman was the leader of the EPICON team and a psychiatry consultant to the Army Surgeon General. On a conference call to explain the report, Mark Benjamin pressed him repeatedly: had the team really ruled out Lariam? Were they "sure" it wasn't involved? Well, no. "We are not in a position, nor did we have adequate information to say definitively that the possible ... side effects of Lariam played absolutely no role" in the deaths, Orman responded. "What we can say is that it does not explain the clustering of these cases in that period of time."

Well yes, you can say that, if that’s what your study is designed to say. (I’d link to the study here, but it is no longer is findable on the Army’s Website.)

--

From the beginning, a number of significant voices cried “cover-up” over the Fort Bragg investigation. As we reported:

"The Army does not want (the truth) released," said Tony Deibler, deputy director of U.S. embassy security in Kabul and a security expert for 26 years with the U.S. diplomatic staff. "If we (the government) admit this, we are opening ourselves up to a multi, multi, multi-billion dollar lawsuit. I love my country, but this is what drives that train."

Deibler said he has seen Lariam wreak havoc on soldiers for years, including one Marine at an embassy who hallucinated intruders attacking and shouted, "Get back, they're coming!"

Deibler said Marines guarding the embassy in Kabul take doxycycline -- an alternative to Lariam -- because of concerns about the side effects.

"Lariam is a bad drug," said Deibler. "You take these guys at Fort Bragg. I will bet you a year's pay that these guys were taking it and when they got back, they wigged out."

Even a Congressman weighed in: "Our military said there is no problem with (Lariam) because they developed it," said Rep. Bart Stupak, D-Mich. Stupak had been a critic of the drug’s manufacturer, Roche, since his high school-age son committed suicide while taking another of its products, the anti-acne drug Accutane. "The hardest thing to do is develop a drug and then admit there is a problem."

None of this carried much weight in late 2002, as the country basked in what seemed to be a quick and relatively painless victory in Afghanistan – a war that almost every American supported -- and the Bush Administration beat the drums for an invasion to deprive Iraq of its weapons of mass destruction (few disputed that, either). The stage was set for Lariam to be given to tens of thousands more troops in Iraq and Afghanistan, and for the Pentagon to swat down new concerns as they emerged:

-- The Army Surgeon General told Congress that reports of suicides in Iraq associated with Lariam came from “people with Internet mystique.”

-- When a soldier in Iraq began hallucinating and suffered a panic attack, he told superiors he was not fit for duty and begged for help, but the Army charged him with cowardice before the enemy, punishable by death. After he showed that Lariam toxicity was the probable cause, the Army quietly discharged him honorably, citing a medical issue but never mentioning Lariam.

-- After a Navy doctor in San Diego diagnosed eight service members with permanent vestibular damage and said Lariam caused it, something strange happened. He suddenly reversed his diagnosis to “unknown etiology,” saying noise from jet engines could have been the cause. Two of the soldiers involved said the doctor told them he was pressured from “the top” to make the change. (The doctor denied getting any pressure or saying that. The incident became the basis for a Law & Order SVU episode a few months later.)

4.

Late August 2002. Another phone call. John Lown, the Green Beret from Fayetteville, was on the line, telling me Bill Wright was acting flat-out crazy. From our story:

Fort Bragg suspect said to be delusional

By Mark Benjamin and Dan Olmsted

WASHINGTON, Aug. 31 (UPI) -- One of four soldiers suspected of killing his wife near Fort Bragg this summer appears to be suffering from worsening mental problems, an acquaintance who visits him weekly told United Press International.

Master Sgt. William Wright, a special operations soldier, had taken the anti-malaria drug Lariam for service in Afghanistan this year. The drug has been linked with severe mental problems including paranoia, confusion, psychosis and hallucinations and is part of an Army investigation into possible ties between the killings.

Wright, who is being held in the Cumberland County Jail in Fayetteville, N.C., talks of people trying to poison him, wakes up at night due to voices that appear real, and sometimes gets lost in a conversation, according to John Lown, who goes to the jail weekly on behalf of his Baptist church, which Wright also attended.

"He just seems paranoid. He alluded to some people who have given him something, like poison. He doesn't know if someone gave him something," Lown told UPI Friday after visiting Wright this week. Lown is a former Green Beret medic who says Lariam has caused anger and erratic behavior in himself and other soldiers.

 "He talks in circles," Lown said of Wright, adding that he has "a strange stare" and occasionally "babbles."

"His thoughts aren't clear. There's something really messed up with it," Lown said, adding that based on his weekly visits he believes the symptoms "are worsening, not getting better."

I called Cumberland County Chief Jailer Dan Ford, who I’d gotten to know when he gave me a tour of the new, state-of-the art jail where Wright was housed. Ford told me he wasn't aware of any reports of Wright having problems and hadn't seen anything out of the ordinary.

But another person close to Wright confirmed he was seriously disturbed. Could he be faking it, I wondered? That seemed unlikely, given that Wright had first displayed strange behavior before the killing, and seemed oblivious to it. “The reason I know he’s not faking it,” this person told me of Wright's current behavior, “is because he doesn’t think there’s anything wrong with him.”

--

The next time I heard about Wright was seven months later, on March 24, 2003, when someone forwarded me a CBS news story. “Suicide in Fort Bragg Jail."

An Army Special Forces soldier charged with killing his wife after returning from Afghanistan nine months ago hanged himself in a jail cell Sunday, officials said.

Master Sgt. William Wright was one of four soldiers at Fort Bragg suspected of killing their spouses in a six-week stretch last summer. The deadly spree forced the Army to re-evaluate how it provided support for soldiers with strained marriages and those readjusting after combat service.

Three of the four soldiers suspected of killing their wives were in Special Forces units. Each of those three have now committed suicide.

The rash of domestic killings led the Army to send a team of medical experts to Fort Bragg to study a wide range of health-related issues that might explain the killings. …

60 Minutes II Correspondent Vicki Mabrey reported in January that Wright was considering using Larium [sic] as part of his defense.

--

Lariam, I thought. It messes up all those guys.

I’ve heard, but don't know for sure, that Wright’s family reached a sealed, out-of-court settlement with the drug’s manufacturer  (it wouldn’t be the first time). When I was in Ohio a few months after that, I visited his wife’s grave.  I believe the three sons are in the care of her family. I wonder sometimes how they are doing.

5.

I’m no mind reader, so exactly why the military – and the FDA, and the CDC – have behaved the way they have regarding Lariam is beyond me, quite literally. But to my mind, by the summer of 2002 there were strong signs that the identified adverse events of Lariam were playing out on a very dangerous field – soldiers under stress, trained to kill, with guns.

In the 1960s and '70s, the Army was in a rush to replace a generation of drugs that were failing due to resistance from the malaria parasite. Reports from that time said there were more Vietnam casualties due to malaria than to combat (an eerie precursor to the statistic that there are now more suicides than combat deaths).

Once the Walter Reed researchers came up with a compound that appeared to work, the Army licensed it to Roche pharmaceuticals in what may have been the first public-private drug development partnership. Backed by the Army, the Swiss-based drug giant pushed it through the approval process worldwide (no animal testing was done before approval, a critical lapse). Lariam was cleared for use in Europe in 1985 and the U.S. in 1989, despite observations by an FDA reviewer of a high rate of vertigo, in retrospect pointing to the neurological and vestibular dangers of the drug.

Once approved, Lariam quickly saw action in U.S. military hot zones where deadly cerebral malaria was resistant to the old drugs, starting with the Somalia campaigns in the early 1990s. Just as quickly, Lariam became legendary for triggering bizarre incidents in otherwise reliable troops, including a Canadian soldier, part of the international coalition, who tortured a 16-year-old boy to death while his equally zoned-out compatriots laughed and took pictures. (The soldier later tried to hang himself – Lariam and suicide again – causing permanent brain damage that prevented him from being tried.)

Civilians began complaining of terrible problems as well, and the World Health Organization issued a report summarizing all sorts of mental and physical concerns. The official drug label warned of increasingly dire dangers until – not long after our April 2002 article – they cited rare reports of actual suicides, not just "suicidal ideation," or thinking. Suicide reports had been coming in since the early 1990s, but, with the assent of a CDC malaria official described as a “consultant,” the company for several years mentioned “depression,” not suicide, as a side effect. The rationale? Since depression could lead to suicide, there was no need to use the word.

The ability of malaria drugs to cause mayhem is no mystery.   They are not Twinkies. Mefloquine (note -quine) is part of a class of compounds –  analogs designed to mimic and enhance the malaria-fighting powers of quinine, the original therapeutic agent – that have long been known to trigger psychiatric problems. They breach the blood-brain barrier, are fat-soluble (the brain is made of fat), and can be absorbed in sensitive neurologic areas never meant to be exposed to toxins or anything else. Nevin has published recently on his theory that Lariam toxicity is a “limbic encephalopathy”; that might explain other strange effects of the drug, he believes, such as gastro-intestinal problems and even sudden-onset artistic capabilities. (Readers of this blog will recognize similarities to the toxic-insult theory of autism.)

While the Pentagon has cut way back on mefloquine’s use, the fact it is still prescribed to soldiers (arguably, to anyone at all) may be the most toxic legacy of the Fort Bragg and other investigative and regulatory failures. Roche, perhaps seeing the writing on the prescription pad, has stopped distributing it in the United States. The military is now hanging onto the argument that with proper screening of soldiers to weed out pre-existing mental problems or brain injuries, and careful monitoring of those taking the drug, it remains safe to use.

That, alas, is contrary to decades of experience in which travelers have suffered idiosyncratic and utterly unpredictable reactions, sometimes after only one pill, or after having taken it safely on a previous trip. The drug, it seems safe to say, is just not safe, especially when prescribed to anyone with a service revolver in their hand or on their nightstand.

Alternatives have always been available; the Pentagon now recommends doxycycline, a widely used antibiotic with a long safety record, as first choice for malaria prevention. Lariam advocates once protested that “doxy” needs to be taken daily, not weekly, making it easier to forget, and that it can cause sun sensitivity and yeast infections, concerns that rather pale in the face of violent death as a side effect.

Sen. Dianne Feinstein of California, alerted by service members from her state, has been trying for years to get the Pentagon to take a closer look; she got Remington Nevin his five minutes before the Defense Appropriations subcommittee last week. I couldn’t help but notice that the senator taking his  testimony was Daniel Inouye of Hawaii, chairman of the Defense Appropriations Subcommittee, the last member of the Watergate investigative committee still in the Senate.

Inouye asked Nevin two questions. The second one seemed calculated to make a point: "Where does mefloquine come from?"

In a word, he said it came from the Army.

--

Now, as Sgt. Robert Bales sits in isolation in a jail cell at Fort Leavenworth, Kansas, one can only wonder what role, if any, Lariam might have played in the massacre he allegedly perpetrated. The Army won’t say whether he took it, citing privacy concerns and pending criminal charges – the same factors  cited by the Fort Bragg EPICON team for not looking into Lariam even while exonerating it. Some who’ve followed the saga over the past decade see a possible clue in this: If Bales didn’t take mefloquine, why not just say so? Given the Army’s haphazard prescribing standards and recordkeeping, it’s also possible they just don’t know. In that case, blood tests that would be accurate for months should tell the story.

Some are raising their eyebrows over another development; last Friday, the military added allegations of steroid and alcohol use to Bales’ charge sheet, which already listed 16 homicides. Why, they wonder, did prosecutors bother to pile such relatively minor charges on top of mass murder? Is there some purpose in portraying Bales as so intoxicated – and suffering from an IED concussion, and serving multiple deployments, and behaving badly back home in Washington state, and having marital problems, and being accused of fraud in a business venture, and facing mortgage foreclosure, and coping with an injured foot – that claims of a psychosis induced by a prescription drug would be easier to discount?

After the past 10 years, you can’t blame people for wondering.

--

Dan Olmsted is Editor of AgeOfAutism.com. His reporting, with Mark Benjamin, on Lariam’s harmful impact on U.S. troops was named Best Wire Service Reporting of 2004 by the National Mental Health Association.