Early on the morning of May 26, Kristen Williams and her daughter, Katie, arrived at a barn on the grounds of the Devon Horse Show, where elite competitors in full dress have entertained spectators for the last century on Philadelphia's Main Line.
Ms. Williams had paid thousands of dollars to lease a pony for Katie to ride in a hunter competition, a 12th birthday present. Soon after arriving, their trainer left to administer an injection to a nearby pony, Humble, that Katie's friend, also celebrating her 12th birthday, was scheduled to ride shortly.
Moments later, with Ms. Williams and her daughter watching, Humble collapsed and died. The death of a supposedly fit pony about to carry a young rider over hurdles was worrisome by itself, but circumstances surrounding the death made it even more so.
In the three days before Humble died, he had been scheduled to receive 15 separate drug treatments, including anti-inflammatories, corticosteroids and muscle relaxants, according to his medication chart.
"The average horse that walks in my clinic here doesn't get anything like that," said Dr. Kent Allen, chairman of both the veterinary and the drugs and medications committees of the United States Equestrian Federation, the sport's nonprofit governing body. "It gets a diagnosis and then gets a very specific, appropriate treatment."
The horse-racing industry has openly debated the influence of drugs on the safety and integrity of the sport, and has taken significant steps this year to minimize it. But in the cloistered equestrian world, medicating horses has attracted much less public attention.
Since 2010, random drug tests at various equestrian events, including the Olympic trials, have uncovered dozens of violations for substances like cocaine, antipsychotics, tranquilizers and pain medication -- even ginger placed in a horse's anus to make its tail stick out.
While show-horse trainers have abused some of the same drugs that have caused problems in racing, the Equestrian Federation has lagged behind in regulating how they are administered. Now, the circumstances surrounding Humble's death have become a rallying point for those who believe that the federation should more aggressively investigate drug use.
The federation says it responds promptly to drug concerns, citing its decision in February to ban a popular but potentially lethal drug that sedates horses, making them more manageable during competition. The group has also limited the use of anti-inflammatory drugs in competition. It randomly tests 10,000 to 12,000 horses annually. "We constantly look at issues in our sport and try to be proactive," Dr. Allen said.
Still, a review by The New York Times of federation records, police reports and interviews with veterinarians and others in the sport shows that despite its best intentions, the federation is ill prepared to deal with episodes like Humble's death.
At racetracks, only veterinarians are allowed to administer intravenous drugs, but on show grounds anyone can stick a needle into a horse before it performs. A year ago, the sport's top veterinary group recommended that no horse receive drugs within 12 hours of competition. The Equestrian Federation has yet to adopt that rule. Humble was injected roughly two hours before competition, records show.
The federation also has no detailed protocol on how to respond when a horse dies on show grounds. In Humble's case, there was no requirement that the vial and syringe be retained so its contents could be tested. And the federation relied on the mother of a competitor who saw Humble fall to collect evidence, hire a lawyer, and file a formal protest.
The federation, often referred to by the acronym USEF, convened a hearing panel, but it had no subpoena power and could not compel Humble's trainer, Elizabeth Mandarino, to fully answer questions about the pony's medical care, records show. The panel ultimately dismissed the protest, saying it did not have enough information to conclude whether Ms. Mandarino had violated federation rules.
Ms. Mandarino declined to be interviewed for this article, but her lawyer said in a statement that she had done nothing wrong, and that Humble had most likely died from an undiagnosed lung disease.
Federation officials point out that equestrian events run largely by volunteers cannot be compared to state-regulated horse racing, where access to the horses can be tightly controlled.
Even so, responding to questions from The Times, the federation's chief executive, John Long, said in a statement, "It is clear that the Mandarino case has highlighted significant limitations in the USEF's rules and procedures governing our investigative powers."
The group, which oversees about 2,500 events each year, has assembled a task force to investigate safety issues stemming from Humble's death, so that "the federation does not find its hands tied in the future when a matter of animal welfare like this presents itself," Mr. Long said.
Much of the concern about drugs centers on hunter competitions, where young riders and future Olympians develop their skills.
"This is only a ticking time bomb," said Julie Winkel, who runs a stable and has judged major shows nationally. "It's not only the wrong thing to do for the horses, but I think it's a very dangerous situation that we have created for the rider, handler, even grooms."
Calming the Horses
More than blue ribbons and prestige are at stake in equestrian competitions. Horses that win big events increase in value, rising into the hundreds of thousands of dollars.
Hunters are judged subjectively, with an emphasis on well-mannered horses that jump safely and smoothly over fences. Temperamental horses with unnecessary movement or exuberance show poorly. Time is not an issue.
For these reasons, calming drugs and supplements are popular on the hunter circuit, even though drugs that influence a horse's behavior are banned in competition.
Calming drugs allow horse owners to lease their animals to less skilled riders willing to pay thousands of dollars to compete. As one owner said, "It's like putting training wheels on a horse."
They also stunt the development of many young riders, according to George H. Morris, the show jumping chief of the United States Olympic team.
"There is more and more medication, more exhausted horses, and more incorrectly ridden horses," Mr. Morris said at a federation forum last year.
Besides creating an uneven playing field, some calming drugs can endanger horse and rider, and be difficult to detect in post-competition testing.
A prime example: an injectable calming supplement called Carolina Gold. The federation first heard of it from competitors early in the summer of 2011, according to Dr. Stephen Schumacher, the federation's chief veterinarian.
"The reason people were talking about it was because they were tired of getting beat by people using this substance," he said. "We were also hearing reports of horses falling down."
The federation learned that Carolina Gold had been used in horse racing, and that a veterinarian in South Carolina, Dr. Juan Gamboa, a rider and competitor himself, had been among those selling it. At the time the drug had not been banned in competition. Dr. Gamboa, who did not respond to requests for an interview, has served as a veterinary delegate for the Fédération Equestre Internationale, the sport's international governing body.
To see how Carolina Gold affected horses, federation officials injected one with the substance. "The horse nearly collapsed," Dr. Schumacher said. "It starts shaking and was really out of it." The reaction was so worrisome that the attending veterinarian refused to test it on any more horses.
The federation now knew the drug was dangerous, but there was a problem: it was undetectable in horses.
Dr. Alex G. Emerson, a Kentucky veterinarian who blogs about horses, wrote this year that he had long worried about Carolina Gold's "narcoleptic" effect. "How can half-asleep horses jumping three-foot wooden fences with a live human on their back be considered safe?" he wrote.
The federation eventually did develop a test for Carolina Gold and this year banned the sedative from competition. Within months, the drug had dropped in price to the point where "you couldn't give that stuff away," said the federation's Dr. Allen.
Not everyone heeded the warning. The federation recently fined and suspended two trainers for using the active ingredient, a tranquilizer, in Carolina Gold and has other cases pending.
Another calming substance that worries the federation is injectable magnesium sulfate.
"It is readily available on the lay market," said Dr. Midge Leitch, a veterinarian on two federation committees. "We've had a couple of quote-unquote suspicious deaths at performance horse competitions, which were probably related to inappropriate administration, either too fast or too much, which have an effect on heart rate and rhythm."
The federation says it cannot yet test for abnormal magnesium levels, partly because magnesium, unlike Carolina Gold, occurs naturally in the body.
"It has a low margin of safety and can cause toxicity at doses that are not much higher than those used to produce a sedative effect," said Dr. Rick Sams, who runs the drug testing lab for the Kentucky Horse Racing Commission.
The Equestrian Federation says magnesium in oral form does not affect performance. Yet marketers of oral supplements that include magnesium say otherwise. The makers of "Perfect Prep" products recommend using its "Extreme Formula" 90 minutes before a performance without fear that it will be "detectable as a foreign substance by the laboratory tests run by the governing bodies of high-level equine events."
The company's Web site included testimonials from trainers praising the formula's calming action. "Nice horses become even nicer and even the tough ones melt," one trainer says.
A week before Devon, Kristen Williams took Katie, her daughter, to a Florida show to try out Royal T, the pony she planned to ride at Devon. Katie's friend Katie Ray had also traveled to Florida to try out her pony, Humble. Both ponies were owned and trained by Ms. Mandarino.
Afterward, Ms. Williams said she was surprised that Ms. Mandarino's invoice listed $435 for unidentified "supplements." Katie Ray's mother, Carrie, had been billed $250 for unidentified supplements, records show.
At Devon, the following week, Ms. Williams came across the list of 15 scheduled drug administrations. All the drugs were legal. Saying she was shocked to see the horse so heavily medicated, Ms. Williams snapped a picture of the list with her cellphone. The following day, Humble collapsed and died after receiving another injection, this one not listed on the chart.
When told of the list of drugs, Dr. Rick Arthur, chief veterinarian for the California Horse Racing Board, said, "The treatment seems intensive even by racetrack standards, but I am unfamiliar with show-horse practices."
Dr. Allen, who has extensive show-horse experience, said most veterinarians he knew could not imagine using all these drugs, "particularly large amounts of them in multiple combinations."
The federation is realizing, he said, "that a very few trainers or owners are out there envisioning themselves as the veterinary managers of these horses, and they are giving a lot of medication with a small, very small, amount of knowledge, and to us that's scary."
Ms. Mandarino, who is not a veterinarian, told the police that she had given the pony the final injection. But according to a report filed by a federation steward, Carrie Ray, the mother of Humble's rider, said Ms. Mandarino implicated a groom, saying he must have missed the vein and hit an artery. Ms. Mandarino has said the medicine was Legend, used to treat joint problems.
"Does it bother me that somebody injected a horse that close to competition? Yes, it does bother me," said the federation's Dr. Schumacher. "We've got to find a way to enforce whatever we want to put in place to curb that behavior."
The burden for investigating Humble's death fell largely to Ms. Williams, who described herself as a relatively inexperienced "pony mom."
"What if Humble had made it to the ring and collapsed with Katie on his back?" Ms. Williams stated in her protest filing in June. "I am extremely concerned for the welfare of the animals and the innocent children that could potentially be victims."
In his statement to The Times, Mr. Long of the federation emphasized that without subpoena power, its inquiries relied on members' voluntary cooperation. He pointed out that Ms. Mandarino, through her lawyer, had refused to comply with requests for information and documentation of all substances given to Humble in the week before he died, and had even challenged the federation's right to make the request.
Ms. Williams helped gather statements for the hearing from people who said they had seen Ms. Mandarino giving injections to horses.
In one statement, Dina Hanlon-Fritz said that her daughter, who worked for Ms. Mandarino for two months in early 2011, had seen the trainer "injecting the ponies twice a day every day so they would behave in the show ring." According to the statement, Ms. Mandarino would yell at Ms. Hanlon-Fritz's daughter because she "wasn't able to get the blood off of the white ponies after so many injections."
In another statement, Nancy Baroody said that while boarding her pony with Ms. Mandarino earlier this year, she saw her administer an injection just before the start of a 7 a.m. show. "I walked out of the tent area in disgust," Ms. Baroody said.
And Wendy Brayman wrote that while she was with her daughter, who rode Humble in 2011, "just about everyone" associated with Ms. Mandarino was administering medicine. "I was often asked to get medicines from her drug chest," including Carolina Gold and magnesium, Ms. Brayman said.
Ms. Mandarino did not attend the hearing, citing a death in the family. Instead, she produced statements attacking the motives of her critics and offering praise from clients, federation members and veterinarians.
Ms. Mandarino always provided "the utmost care in veterinary medicine" for her ponies, wrote Alexis G. Newman, a federation member. Ms. Mandarino also produced statements from suppliers saying they had not sold her Carolina Gold or other banned substances.
A post-mortem exam of Humble found an anti-inflammatory and a muscle relaxant, though not in excessive amounts, and no illegal drugs. In addition to emerging lung disease, the exam concluded that the pony could have died from "an overwhelming allergic response to medications or environmental triggers," but said that was "speculative and impossible to confirm."
In the end, the federation hearing panel dismissed Ms. Williams's protest, saying it did not have enough evidence to decide if rules had been broken.
Ms. Mandarino filed an unsuccessful complaint against the federation's general counsel with the Kentucky Bar Association and has filed a lawsuit accusing an online publication, Rate My Horse PRO, and various individuals of conspiring to harm her business. Rate My Horse PRO, which says it is an advocate for horses, has filed papers seeking to have that lawsuit dismissed.
A growing number of people in the horse world see another way of thinking about a horse's behavior in the show ring. One approach that would reduce the incentive to medicate would be to change the judging criteria for hunters, said Ms. Winkel, the horse show judge and chairwoman of the officials committee for the United States Hunter Jumper Association.
This year, Ms. Winkel's committee called for judges to stop rewarding horses for robotic conformity.
"People are realizing that it's O.K. if horses are a little fresh and a little happy," Ms. Winkel said, adding, "Why don't we take a little more time and train these horses properly and educate their clients and give them better horsemen skills, other than to bring out a needle and a syringe every time we have a horse show."
Joe Drape contributed reporting.
This article originally appeared in The New York Times.