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An organization chartered by the U.S. Congress
November/December 2005
FEATURE
 
 

Ordered Into Madness
The Military Use of Lariam

 

BY RICHARD CURREY

On August 9, 2005, a Marine Corps discharge board at Camp Pendleton, California, directed that a career Marine named Matthew Hevezi be summarily discharged from the service.

Hevezi, a Gunnery Sergeant with 18 years of service, was a devoted Marine and believer in the code of the Corps, “Semper Fidelis.” He held the ethics of the Marines to be as reliable as the turning of the earth—until he suffered a bizarre reaction to an anti-malarial drug called Lariam and found his beloved service disinclined to honor his commitment and loyalty, or respond to his calls for help. Indeed, there seemed to be no stopping a service ultimately determined to show him the door.

The case of Matt Hevezi is a vivid illustration of the military’s failure to come to terms with Lariam, a lapse that comes at great cost to individuals and families ruined by debilitating reactions to a little white pill.

Malaria is an old nemesis for deployed troops, going back to the days of quinine as a preventative. By the 1970s there was growing resistance to conventional drug treatments. Despite the use of these medicines, malaria-causing parasites displayed an increasing capacity to sicken troops. A new drug clearly was needed.

DoD funded an aggressive search for that new drug. Many compounds were considered and evaluated until a drug called mefloquine emerged. DoD called on pharmaceutical giant Roche to manufacture and distribute the medication, which was approved by the FDA in 1989 and launched with the trade name Lariam.

Peculiar psychological effects were reported in the medical literature almost immediately.

The first report appeared in the respected medical journal Archives of Internal Medicine, describing a case of confusion and disordered speech in an individual who had taken the drug.

The second report came just 15 days later, claiming memory lapses after Lariam use. Three months after that, another report described an episode of acute psychosis following Lariam use.

These reports raised no particular concerns at the time. Lariam, many assumed, was an innocent bystander in these cases—a red herring. And case reports, by their very nature, are observational, speculative, and often subjective.

But the reports kept coming, each one offering another snapshot of Lariam-related behavioral oddities. People took Lariam and became disoriented, hostile; in some cases, psychotic or suicidal. The year 1996 saw 15 such reports in the scientific literature. Since then, news of Lariam’s connection with psychological and nervous system dysfunction have appeared ever more frequently.

Use With Care

Lariam has been administered to thousands of service members, although Pentagon records are fuzzy on how many have received the drug, where or under what circumstances, or how many took the drug as it was meant to be used. And while reports of Lariam toxicity led DOD to set limits on the drug’s use in 2004, it remains approved for use “in the correct circumstances. In places where we know that a strain of malaria is resistant to drugs other than Lariam, we use the Lariam,” said Dr. Michael Kilpatrick, Deputy Director of the Deployment Health Support Directorate in the Office of the Assistant Secretary of Defense for Health Affairs. “But the drug should be used with care. Individuals with a prior history of depression or other mental health issues must be carefully screened.”

One problem in establishing Lariam policy, according to Kilpatrick, is a paucity of “hard data.” But evidence-based research is beginning to appear that directly connects Lariam to malfunctions in balance and spatial orientation and interference with critical messenger proteins in the brain.

Particularly compelling is the news from the Walter Reed Army Institute of Research (the place where Lariam was born some 25 years ago) that Lariam “severely disrupts” calcium balance in the central nervous system—the brain and the primary nerve cells leading to and from the brain. The Army research team posited that this disruption may lie behind Lariam’s “neurotoxic effects,” noting that Lariam concentrates in the brain at elevated levels and there is a “higher incidence of adverse events observed when the drug is used at higher doses.”

“We know that Lariam distributes throughout the body, and that it can affect the brain,” said Dr. Kilpatrick. “There are recognized neurological and sensory side effects that can occur in some people. But what percentage of people is that? You look at multiple studies and see figures running from as low as 3 percent to as high as 60 percent. And how long do these symptoms persist? The studies we have don’t carry on long enough to tell us. I think for people who develop symptoms after using any drug, the questions are: Did those symptoms develop because of the drug, or would those symptoms have emerged anyway? And that’s the hardest part of trying to provide care [to Lariam-exposed people].

“We’re dropping back and taking a bigger look at Lariam,” Kilpatrick said. “We’re conducting more studies in military people. But the problem with this kind of science—particularly for those people experiencing a medical problem now—is that it takes time. We’re not talking weeks or months, we’re talking years. And because it’s a new field of inquiry, you get more questions than answers on the first round of research.”

Whatever the current state of the science, this much is clear: In the 16 years since Lariam was introduced, it has been increasingly implicated in a string of health effects that include seizure-like episodes, uncontrollable shaking, vertigo, memory lapses, frightening dreams, debilitating depression, paranoia, delusions and hallucinations, homicidal rages, and attempted as well as successful murders and suicides.

A Strange Turn

Gunnery Sergeant Matt Hevezi, a public affairs specialist and photojournalist, first took Lariam in the spring of 2001. The drug was dispensed prior to deployment to Thailand from his home base in Okinawa. He received no specific instructions other than to take the pill once a week. He was not asked about his medical history nor advised about potential side effects.

It was after returning to his family in Okinawa that life took a strange turn. Hevezi became convinced his landlord was trying to poison him. His wife, confused, assured him that no such thing was happening.

“A part of me,” Hevezi said, “knew I wasn’t making sense. But the idea seemed to have a strength all its own. It was almost as if somebody or some thing had got into my head and was beyond my control. I didn’t feel like I was me anymore. I began to feel a desperation about what might be happening. I became frightened, and that went beyond the landlord. I started to be afraid of my wife. I decided I couldn’t trust her. I felt the same way about guys I worked with: I thought they were out to get me.”

As his marriage deteriorated, Hevezi found solace in sleeping in his car. “I needed places where I had some relief and felt safe. Work was hard, home was a struggle, and I wasn’t handling things very well. Worst of all, I didn’t know what was going on.” Unable to put a finger on why his life was falling apart, he simply presumed this was what “going crazy” felt like, that madness must happen this way, arriving abruptly and without warning to destroy a man’s life.

A further complication for Hevezi is the military’s bias against those who acknowledge mental health difficulties. “I was avoiding going in for care,” Hevezi said. “I didn’t want to get labeled as weak.”

“I think it’s widely understood that a trip to the division psychiatrist is a career-ender,” said Landon Hutchens, a former Marine Corps major who served as operations officer for Hevezi’s unit in Okinawa and Thailand.

Hutchens, deputy director of Marine Expeditionary Force Public Affairs and Matt Hevezi’s supervisor for two years, observed that lip service is given to sensitivity about emotional issues inside the military—but the truth is otherwise. “If a Marine has an emotional concern,” Hutchens said, “even as legitimate as combat-related PTSD, that Marine better do everything possible to keep the problem private and solve it on his or her own terms.”

So Matt Hevezi, fearful of the taint that counseling or psychotherapy might bring, weathered his distress and frustration silently for months. He often slept less than four hours a night. “I would just wake up for no apparent reason. If I tried to go back to sleep, my mind ran away with fear and guilt and all kinds of bad thoughts,” he said.

Hevezi’s wife, Adriana, went from bewilderment to alarm. Her husband announced that he might die. He thought a colleague had nefarious secret plans. He would lay silent and alone, in the fetal position, for hours. Nothing in their relationship prepared Adriana Hevezi for this sort of behavior in her husband. Upset and in need of advice, she sought out a lieutenant colonel that other wives had recommended—a good man who could maintain privacy. Adriana confided that it might be best if she took the children and went home while her husband received needed medical attention in Okinawa.

But instead of honoring the confidence, the lieutenant colonel took Adriana’s concerns to the family advocacy office on base. The Hevezis were embroiled in a “family advocacy action” and Matt Hevezi was branded a “Level III abuser.”

In fact, Hevezi was never physically abusive. Adriana never made such a claim to the lieutenant colonel and later testified at her husband’s discharge hearing that “Matt never laid a hand on either the children or myself.” But the label stuck. Despite the struggle to bottle his emotional disarray, the suspicion of domestic abuse darkened the cloud over Matt Hevezi’s life and career.

And still Hevezi remained the most perplexed of all. Why was any of this happening? What was the trouble? How had he somehow lost himself?

A Very Dark Place

Adriana Hevezi returned to the States with the children while her husband stayed in Okinawa, doing the best he could but continuing to feel isolated and confused.

Back at Camp Pendleton in the summer of 2003, Matt Hevezi thought things might be looking up. He was still living apart from his family, but spending time with and enjoying them more than he had in months. He found a room to rent that was pleasant and comfortable. But underneath the positive exterior, Hevezi could not ignore the gnawing anxiety and persistent sadness that seemed to infect the core of his being. Late in 2003, the bottom fell out. “I became deeply depressed,” Hevezi said. “It was like sinking beneath the waves into a very dark place.”

Hevezi described the next few weeks of his life as “surreal. I would go home and crawl in my sleeping bag. I wasn’t eating, reading newspapers, watching TV—I didn’t want to do anything. It was a weird, ugly feeling, day after day. It was about three weeks into this when I overdosed on a muscle relaxant I’d been prescribed.”

His landlady found him. When she didn’t hear him one morning getting ready for work, she knocked on his door. No answer. She knocked louder. Still nothing. She let herself in to discover Hevezi unresponsive. A 911 call brought the ambulance that transported Hevezi to the Naval Hospital in San Diego. After the overdose was managed he was admitted to the psychiatric unit where a diagnosis of major depression was made. The causes were thought to be a genetic predisposition coupled with cumulative marital and deployment-related stresses. None of Matt Hevezi’s doctors asked if he had ever taken Lariam.

A Fellow Traveler

Hevezi himself knew nothing about Lariam until a Sunday in mid-February of 2005 when he happened across a newspaper article. Entitled “Worry Spreads Over GI Drug Side Effects,” the opening paragraph said that “some current or former troops claim that Lariam has provoked disturbing and dangerous behavior. The families of some troops blame the drug for the suicides of their loved ones.”

Hevezi found himself sitting straight up in his chair. The article told the story of an Army sergeant who became distraught after seeing the maimed body of an Iraqi soldier killed in a firefight. The sergeant, Georg-Andreas Pogany, later found himself consumed by an irrational but undeniable panic. Pogany, according to the account, felt disoriented and “not himself.” Yet when he sought help, he was sent home and charged with cowardice in the face of the enemy. “None of it made sense to Pogany until he learned more about the pills the Army gave him each week to prevent malaria,” the article said. “The drug’s manufacturer warned of rare but severe side effects, including paranoia and hallucinations.”

Hevezi read about the same symptoms that had dogged him for many months: fear, agitation, erratic behavior, intense dreams, flaring anger that receded to paralyzing depression, suicidal thoughts. But one passage in particular leaped out at him: Doctors at the Naval Hospital in San Diego had identified a disorder in the brain that appeared to disrupt balance in people who had taken Lariam. In other words, there was a valid suspicion on the part of military medical professionals that Lariam might exert a direct and damaging effect on the brain.

Hevezi stared at the article in disbelief. Not only was Lariam a regular fellow traveler in cases exactly like his, but research into the drug’s effects was going on at the very hospital where he had just spent three weeks. Could it be that his doctors had never heard about Lariam?

Hevezi learned from the Internet that Lariam research at the Naval Hospital in San Diego was led by a Navy doctor named Michael Hoffer. Hevezi arrived at Hoffer’s office, unannounced and without an appointment, on a Tuesday in late February 2005.

Hoffer was away, but a civilian was there, Dr. Derin Wester. “I asked Dr. Wester if he was part of the study,” Hevezi said. “He said he was. I asked him what he could tell me about Lariam. And he said he was not allowed to make any comments related to Lariam.” Receiving such a response after months of suffering and confusion angered Hevezi. “I got upset. I had tears in my eyes. I told him that I’m a Marine and I deserve help. I deserve answers.”

A secretary heard the men arguing, helped to defuse the situation, and Hevezi made an appointment to return for testing. But as he was leaving Wester’s office, he picked up a cell phone message from his sergeant major at Pendleton. The message informed him he was UA—absent without authorization. The sergeant major told him to report back to base immediately.

Hevezi, already upset by his encounter with Wester, felt he could not return to Pendleton if harassment awaited him. He went to the hospital’s mental health clinic. “I told them I was a repeat customer, and I needed help, right then and there.” A corpsman escorted Hevezi to the emergency room. From there he was admitted once again to the psychiatric unit.

This time around Hevezi raised the Lariam issue with his doctors, but “they all insisted there was nothing they could say. They said they didn’t know enough to comment. They told me to go to the hospital library and do my own research. I couldn’t believe what I was hearing. They were my doctors. The whole thing was starting to seem like some sort of charade.”

Bizarre Psychological Breakdowns

It was the courageous work of UPI reporters Dan Olmstead and Mark Benjamin that established Lariam’s connection to bizarre psychological breakdowns in the military, including the 2002 Fort Bragg murder-suicides. Three Green Berets, all of whom had taken Lariam, returned from Afghanistan and degenerated into bouts of rage before killing their wives and themselves. (The Army discounted Lariam as a contributing factor.)

There were other incidents, including a 1993 episode when Canadian troops in Somalia bludgeoned a local teenager to death with lead pipes. The soldiers involved had taken Lariam. Australian troops posted to East Timor between 1999 and 2002 have complained of delusions, paranoia, and suicide attempts after using Lariam.

Army Master Sergeant James Coons committed suicide on July 4, 2003, at Walter Reed Army Hospital after being medically evacuated from Iraq after a period of odd behavior. Coons hallucinated the face of a dead soldier in a mirror before taking his own life.

A Marine killed one of his buddies in Iraq in the course of a minor disagreement, also in 2003. In the same year an Army Specialist, Dustin McGaugh, committed suicide in Iraq for no apparent reason. On March 14, 2004, CWO Bill Howell, an Army Special Forces A-Team member and veteran of Iraq who had taken Lariam, went into a crazed rage at his home in Colorado, threatened to kill his wife, and then followed her outside with a .357 pistol, shouting that she “was going to watch this” as he put the gun to his head and fired.

On Feb. 3, 2005, another Army Special Forces soldier at Fort Bragg killed himself after shooting his ex-wife and her boyfriend. He had taken Lariam in Afghanistan.

Dan Olmstead, in a recent analysis of the Lariam debacle, noted that 2003 was the year when Lariam was still widely used by all service branches. “The Army confirmed that as many as 11 of 24 suicides in 2003 were in units where Lariam could have been prescribed,” Olmstead wrote. “Coons’s death at Walter Reed has just been listed as an Iraq casualty, so the number of suicides in Iraq and Kuwait for 2003 now stands at 25.”

But in the next year, 2004, when the military sharply limited the use of Lariam, Olmstead noted that suicides fell by more than half, to 12. “So far this year [2005],” Olmstead wrote, “there have been just three confirmed suicides, with two investigations still pending. That is an annualized rate of 7.4 per 100,000—almost two-thirds less than the 2003 suicide rate of 18.8.”

The Culprit

Matt Hevezi’s testing at the Naval Hospital in San Diego was positive for the same balance abnormalities detected in 18 other service members who had used Lariam. He was advised by Dr. Hoffer that while the testing was not proof of Lariam toxicity, it was very suggestive. Referred on for further evaluation to Dr. Dana Grossman, a civilian psychologist working for the Navy, Hevezi was told that “while all the scientific evidence wasn’t yet in, if she had to offer an opinion in my case, the culprit was Lariam.”

Hevezi was cautiously optimistic as his discharge hearing approached. Information about the risks of Lariam was extensive. He had the support of several colleagues and officers. He had been invited to the Deployment Health Clinical Center at Walter Reed, an invitation that further legitimized his claims. His request for a formal Physical Evaluation Board had been granted, with a hearing scheduled for September 22, 2005, at the Washington Navy Yard.

Everything was in order for the Marine Corps to do the right thing by a man who had served with distinction—particularly one whose troubles seemed to be the result of a drug taken in the line of duty. But in the end, Hevezi’s discharge hearing was fraught with inequities.

The proceeding was held at a time his civilian attorneys were unavailable. Detailed medical records were not accepted into evidence, nor is any expert medical testimony recorded in the official report of the hearing board. Michael Hoffer, the Navy doctor who told Hevezi his problems were likely Lariam-induced (and went on public record about Lariam’s risks in 2004) refused to testify, raising suspicions that he had been ordered not to. Dr. Grossman, the civilian psychologist who also advised Hevezi his problems were probably Lariam related, was not called before the hearing. A newspaper reporter attempting to cover the story was barred from the public hearing. And there were, oddly enough, “brig chasers” sitting in the hearing room. The presence of these armed and solemn MPs suggested there was something dangerous or even criminal about Gunnery Sergeant Hevezi. Capt. John Boucher, Hevezi’s attorney, objected to the stunt as “designed to influence the decision of the board members. Calling this tactic offensive would be an enormous understatement.”

Capt. Boucher later termed the entire hearing “a miscarriage of justice” in a formal letter of deficiency directed to Brig. Gen. Michael Lehnert, Commanding General of Camp Pendleton. Boucher outlined multiple violations of due process, described “substantial errors” and “fatal flaws,” and asked Gen. Lehnert either to convene a new hearing or put aside the discharge altogether.

It is unclear if Gen. Lehnert ever saw that letter. If he did, he chose to do nothing. Matt Hevezi walked through the gates of Camp Pendleton as a civilian—confused, distraught, and disappointed—on September 16, 2005.

Major Side Effects

Lariam has been taken, according to Roche Pharmaceuticals, by 25 million people, both inside and out of the military. While Roche and DoD are both quick to point out that most of these individuals have had no problems with Lariam, they also acknowledge that a minority will experience neurological and psychological problems that range between uncomfortable and fatal.

But what kind of minority? The Walter Reed Army Institute of Research places “major” side effects of Lariam (including psychosis, delusions, homicide, and suicide) at 1 in 10,000. More “minor” side effects, such as depression, memory loss, or confusion, are thought to occur in 25 percent of people who take Lariam. These estimates would suggest that millions of people have suffered some form of Lariam toxicity, many thousands of them major side effects. Most of those cases were presumably suffered through in silence and with puzzlement, or diagnosed as more conventional mental health problems and treated as such. Or ended in inexplicable tragedy.

“From everything I have read,” Matt Hevezi said, “DoD knew about Lariam’s risk—and told nobody. No doctor or corpsman I ever encountered before San Diego knew anything about Lariam. They didn’t know, or said they didn’t know, about possible side effects. I don’t think they were even talking among themselves about Lariam. And I don’t think this implies lazy or irresponsible medical personnel. I think this is all about DoD’s inability to get the word out.”

Dr. Kilpatrick acknowledges the challenge. “We’re starting to educate military leadership—because commanders have to be advocates for their troops’ health, and not just in the short term but over the long term. If people return from a deployment and are experiencing medical symptoms, particularly things that seem mysterious, commanders need to encourage them to seek care. If symptoms develop in-theater, they should be encouraged to get medical personnel as well as get their commanders to pay attention. Our leadership needs to listen. Many of the people I have either talked to or read about who are dissatisfied [with their medical treatment in the military] were in situations where their leadership didn’t support them in getting the care they needed, or didn’t listen to the medical advice that was given. We have a program in place, five years in the making, to educate the operational leadership that force health protection must be on their radar.”

Meanwhile, Matt Hevezi reflects on what he called “three years of hell. And why? If I’d known about Lariam, all my problems could’ve been addressed as soon as they cropped up. My difficulties might’ve been entirely circumvented. What I’ve gone through, in the light of what I know now, seems senseless. It never needed to happen.”

Lost to the Service

The timing of Hevezi’s discharge is of special note. The Physical Evaluation Board (PEB) was slated to hear Hevezi’s case on September 22. Preserving this would have involved delaying his discharge only five days, seemingly a small gesture to offer a career Marine with nearly two decades of service. A PEB would have considered Lariam’s role in Hevezi’s problems, and might have been instrumental in activating his transfer to the Army’s Deployment Health Clinical Center at Walter Reed, a facility specializing in the investigation and care of unexplained illnesses. But with his discharge pushed through before the hearing date, due process was denied a loyal service member who had made it clear he was asking for help and believed he could still be of value to the Marine Corps and his country.

Landon Hutchens said that “the military often creates untenable situations for talented people with a great deal to offer. Matt Hevezi’s predicament is a case in point, because now his terrific skills, his enthusiasm, leadership, and value are all lost to the service. This is a man with unlimited potential in his field—and he wanted to continue to bring that potential to the Corps. He had some troubles along the way, yes. But nothing, in my opinion, that demanded the treatment he received.”

Options remain. Matt Hevezi can appeal his case to the Board for Correction of Naval Records, see his discharge status revised, restore his opportunity to receive disability benefits, and his rights to continuing care with the VA reinstated—and his name and reputation cleared.

But none of that undoes the damage inflicted, a fact of life that former Gunnery Sergeant Matthew Hevezi must now live with.

   

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