Editorial Note: This post and the following one on the strange story of the Birth of Lariam come from Dr Sam Ramsay-Smith who has some questions he wants answered.
In October, ‘The Independent’ printed the news that the US Armed Forces had banned the use of the anti-malarial drug mefloquine, otherwise known as Lariam. To many this may mean little or nothing, but to quite a few people around the world, including myself, just the name of this drug is enough to strike fear into the heart.
To illustrate Lariam’s problems, BBC Radio 4 interviewed a young traveler who had taken it for a one month holiday to some tropic isle. His story was so extraordinarily similar to my own experience, and so frightening to listen to, that I started to write my own personal account of this evil drug.
The reason my account is worth hearing is because it concerns not a young lay-person, but a qualified doctor, a tropical surgeon, and an experienced traveller in the tropics, someone who really knows malaria from both sides of the hospital bed.
I had also spent a year at a senior level in the Wellcome Tropical Institute where I met 2 of the original researchers of mepacrine, a much earlier anti-malarial who, such was the urgency during the war of the 1940’s, told me that they even used themselves as the original guinea pigs and described how they both went yellow within days of trying it. Mepacrine was famous for this, but still it was used for the troops, so high were the casualty rates in the Far East at this time from both bullets and malaria.
Just like mepacrine, Lariam (mefloquine) was developed in great urgency and secrecy during the Vietnam War. At any one time during this protracted war at least 1% or more of the American army was out of commission as a result of malaria. Therefore, from 1963 to 1976 the US spent a fortune investigating new anti-malarials.
Malaria and me
The first time I ever got malaria was in 1965, just out of school, in the southern equatorial rain forest of Cameroun Republique, West Africa where malaria was rife. Jack Payne, the American missionary surgeon I was gifted to be working with then under the aegis of Voluntary Service Overseas had been a tropical surgeon for 17 years, and he knew and feared malaria like us all. So every Sunday morning we all took our Chloroquine and Paludrine tablets – religiously.
Even so, malaria hit me like a hammer one day when I was far out in the jungle with the pygmies, looking for gorilla spoor with Becky, a zoology student from UCLA. Neither of us had any curative anti-malarials with us, believing ourselves already protected. But as I became iller and iller over a few short hours with incessant vomiting and a head that was exploding, Becky ran to the pygmy chief for help. I was near-unconscious when he came into our banana leaf hut and produced some leaves which he told Becky to make a bouillon, and make me drink it. Even though I was vomiting fluently I managed to get some down, and it was enough, because the following morning, though weak as a dog I knew the fever had left me.
My greatest regret is that I never learned the name of this magic plant, but Jack had told me how the pygmies were absolute masters of this virgin jungle and had cures for many diseases, all of them derived from the plants and trees which encircled their lives.
The second time I got malaria was in 1974 deep in the Congo jungle in Kasai Province, when I was again also taking anti-malarial prophylaxis. It was then that I decided in future I would make do without these tablets of dubious efficacy and proven toxicity.
When I arrived in Kenya a year later to work with the Flying Doctors I had no anti-malarials with me. During a hard 5 months all over East Africa I never once got malaria, and from 1978 to 1984, again all over southern Africa I never took anti-malarials, and I never got malaria.
What I did always do was ‘cover up’ and use citronella oil. I wore long-sleeved cotton shirts in the evenings when the mosquitoes started biting most, and always wore long, thin cotton trousers with the bottoms tucked into socks, so my ankles were not exposed either. Any exposed skin I dosed with citronella oil.
This method of malaria prophylaxis was the result of many hours drinking Tusker beer and talking in various bars with old East African hands, and some serious research into the medicinal powers of plants. It served me well, even until 2006 when I went to the Ivory Coast for the first time during its civil war. Since that mission was for only 3 weeks, it was agreed with MSF that I would not need malaria prophylaxis on the understanding that I would take my own prophylactic measures.
The new malaria
During the years from 1965 to 1990 many resistant forms of malaria had developed worldwide which made old favourites like chloroquine quite useless against some species in certain areas, particularly southeast Asia. Meanwhile, during this same period the concept of global tourism had become a reality, and there was now also a constant and growing need from the international travel and tourism market. So there was a fortune to be made from any new anti-malarial drugs which did not actually kill the patients. However, not one of any currently available drugs was free from serious side-effects. Even the cinchona bark, from which quinine came, had the power to turn people deaf and cause tinnitus.
The very first time I ever heard the word Lariam was about 15 years ago. It was reported in the news that a young couple had recently gone to Sri Lanka for their honeymoon, following which the young man had committed suicide very soon after arriving home, for no understandable reason. Investigation of this case had pointed to the possibility of his prophylactic anti-malarial Lariam being involved in some way. Apparently this drug had a history of causing mental problems in some people. I was a bit surprised that a drug could make someone suicidal.
In December 2006 I set out for my second mission with MSF to Danané in the Ivory Coast. It was to be a 9-week trip. MSF recommended me to take Lariam as a first line anti-malarial prophylactic.
At this time I had been living in southern Spain. Dr Ana, my local GP, was happy to help me acquire all the vaccinations and medicines I needed and wrote me the prescription for Lariam which I started taking 2 weeks before I left Spain. I was pretty busy at this time arranging various things and made the mistake of NOT reading the information leaflet which came with the Lariam, mostly because it was in Spanish and I still found reading Spanish slow going. I said to myself as I took the first tablet, “I’ll read this once I get to Danane”.
The Ivory Coast was never an easy place to work and during this long civil war many public service structures including health had simply disintegrated. The direct toll of the war was also causing inestimable acute and long-term health problems, adding enormously to the general daily needs of these poor people. There was a huge amount of surgical work to do as well as training two young Ivorean surgeons.
From the first day I arrived back in Danané I began to suffer insomnia for no good reason. At first it was just boring, lying sweating under the mosquito net trying by every means to get to sleep. It was a new and scary phenomenon to me.
It soon started taking its toll on me. Day by day I became more exhausted, lethargic and irritable. Then my hands started shaking, uncontrollably – tricky for a surgeon. At the point when I thought I was going mad I went to see Steve, our project manager, and told him of my problem. It was suddenly a serious problem, both for me and for MSF.
Lauren a good and experienced nurse who knew the ropes turned up. She insisted I stop both Lariam and operating. I remember feeling both weird in the head and guilty because of my inability to help the team. After a few days I did start surgery again because there were so many burns patients needing everything from escharectomies to skin grafting and reconstructive surgery. However, I clearly remember now that my clinical decision making had gone to pot. I had lost my confidence and I know I made some bad clinical decisions.
Two days before I left, Lauren gave me another anti-malarial called maloquin to take for 2 weeks after I got back to Spain. I had terrible colic and diarrhoea which began exactly 6 hours after I took the first maloquin tablet in Abidjan and which lasted for a further 7 days in Spain. I am as certain as I can be that this further illness was directly related to maloquin.
Post Lariam twilight zone
Debilitated and disorientated, I entered a period of life I would rather forget. I had no energy. I no longer went walking. I spent hours every day lying on my bed just reading. I suffered alone. Even my friendships waned.
Then, in close succession my father and elder sister died and, even though not very well, I went back to England to look after my mother of 90 years. I spent every evening watching television with my mother. One could reasonably say that my life was a step ahead of permanent coma, but not far.
We are nothing without our friends. Rick suggested I go and see a shrink in Eastbourne for my persistent depression. He gave me Seroxat. It made no difference but a second treatment did.
It was another friend who sorted me out. Being a good doctor he took me back to Day 1 of my malaise. I talked out the evolution of my medical problems. “You fool !”, he cried excitedly, “How could you, an experienced doctor, not have been aware of the side-effects of Lariam?”, and he gave me the most critical of looks as if to say what an idiot I was for not properly appraising myself of this evil drugs side-effects.
As a psychiatrist he knew of all the mental and psychotic side-effects of Lariam from insomnia and abnormal dreams to tremor, ataxia and depression including its capability to cause suicide. It was an amazingly enlightening conversation and one which I shall always be eternally grateful for.
Back to Radio 4
Which is why the Radio 4 interview came as such a shock. It wasn’t just listening to a precise echo from far away of my own terrible experiences with Lariam which electrified me but the additional knowledge in this news item that all these neuropsychiatric problems could last at least 10 years, if not for ever. And some dozens of suicides have also now been directly linked to Lariam.
It was hearing this young, naïve man describing very well what had occurred to him since taking Lariam, which so exactly mirrored my own problems that prompted my present investigation. The moment he told of the uncontrollable shaking of his hands I shot out of my chair. And then he started talking of how his heart kept pounding. Three years after taking Lariam this young man is still receiving treatment for his profound depression and other problems he never had before.
His description reminded me of details I had forgotten. Day after day when I came back from Danané I would be lying on my bed reading but I would be forced to stop because of the palpitations in my chest, and every time I checked my pulse I became terrified at the unbelievable irregularity of both rate and volume. Something dreadful was going on but I had no idea why.
A year later, lying on my bed in Eastbourne, I was still getting these palpitations and was still devoid of energy, and by now believed that it was my years of reckless living which had now rendered me so feeble and my mental state so depressed I was not even interested much in seeing my old friends.
But now I had a mission to find out more about this drug…
Continued in The Strange History of Lariam.