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Abstract
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An individual assigned to the U.S. Embassy in Cuba was awakened one night at home in Havana in 2016 by severe pain and a sensation of intense pressure in the face, a loud piercing sound in one ear with directional features, and acute disequilibrium and nausea. Symptoms of vestibular and cognitive dysfunction ensued. A handful of other cases involving colleagues with similar features began that year, and others in the next. Few people were aware of these cases until spring 2017. In addition, the mechanisms and origins were mysterious, and for these and other reasons, there was a delay in recognizing an important cluster of unexplained illnesses, and an early failure to investigate them in a concerted, coordinated, rigorous, and interdisciplinary manner.
In some ways, the problem presented here is an age-old one; that is, how to detect and recognize important anomalies or signals, in a complicated, "noisy" background. Public health systems have grappled with this problem for centuries. In the 1990s, the Centers for Disease Control and Prevention (CDC) conducted population-based surveillance for "unexplained death and critical illness" in persons less than 50 years of age, with features suggestive of infectious cause, at four sites in the United States, and found a surprisingly high incidence of 0.5 cases per 100,000 per year (Hajjeh et al., 2002). The most common clinical presentation was neurologic; a known infectious cause was discovered for only a minority of them; and no obvious relationships among cases were uncovered (Nikkari et al., 2002). But the landscape that countries face today in which the cases in question arise, is an even more complicated one. Not only must governments consider a wide variety of evolving natural causes in a rapidly changing world, but also an increasing threat of disease of deliberate human origin, both accidental and purposeful.
The cases of the Department of State (DOS) employees in Cuba and China have attracted much attention. Among the reasons and ramifications, the clinical features were unusual; the circumstances have led to rampant speculation about the cause(s); and numerous studies, along with the charged political setting, have had consequences for international relations.
The committee was asked by DOS to review the cases, their clinical features and management, epidemiologic investigations, and scientific evidence in support of possible causes, and advise on approaches for the investigation of potential future cases. The committee faced a variety of challenges in responding to these requests (see Section 2). In particular, much of the detail and many of the investigations performed by others were not available to it, either because they are classified for reasons of national security or restricted for other reasons (e.g., internal department deliberations, protected health information, etc.). Thus, the committee had only limited amounts and kinds of information. Despite these challenges, the committee arrived at a number of observations and recommendations, after carefully reviewing the information that was available.
First, the committee found a constellation of acute clinical signs and symptoms with directional and location-specific features that was distinctive; to its knowledge, this constellation of clinical features is unlike any disorder in the neurological or general medical literature. From a neurologic standpoint, this combination of distinctive, acute, audio-vestibular symptoms and signs suggests localization of a disturbance to the labyrinth or the vestibulocochlear nerve or its brainstem connections. Yet, not all DOS cases shared these distinctive and acute signs and symptoms. In fact, the cases are highly heterogeneous. Some patients described only a set of nonspecific, chronic signs and symptoms indicative of disruption of vestibular processing and/or cognition and diffuse involvement of forebrain structures and function, raising the possibility of multiple causes or mechanisms among different patients, as well as for the same patient.
Second, after considering the information available to it and a set of possible mechanisms, the committee felt that many of the distinctive and acute signs, symptoms, and observations reported by DOS employees are consistent with the effects of directed, pulsed radio frequency (RF) energy. Studies published in the open literature more than a half century ago and over the subsequent decades by Western and Soviet sources provide circumstantial support for this possible mechanism. Other mechanisms may play reinforcing or additive effects, producing some of the nonspecific, chronic signs and symptoms, such as persistent postural-perceptual dizziness, a functional vestibular disorder, and psychological conditions.
The committee is left with a number of concerns. First, even though it was not in a position to assess or comment on how these DOS cases arose, such as a possible source of directed, pulsed RF energy and the exact circumstances of the putative exposures, the mere consideration of such a scenario raises grave concerns about a world with disinhibited malevolent actors and new tools for causing harm to others, as if the U.S. government does not have its hands full already with naturally occurring threats. Because the committee was not able to assess specific scenarios involving malevolent actors, one strong suggestion is that follow-up studies on this topic be undertaken by subject-matter experts with proper clearance, including those who work outside the U.S. government, with full access to all relevant information. Second, the committee was concerned about the possibility of future new cases among DOS or other U.S. government employees working overseas, either similar or dissimilar to these, and the ability of the U.S. government to recognize and respond to these cases in a coordinated and effective manner. The next event may be even more dispersed in time and place, and even more difficult to recognize quickly. Toward this end, the committee offers a number of observations, best practices, and recommendations for clinical management, surveillance, and a systematic response in anticipation of future health events. These observations and recommendations should be reviewed and acted on now. It is imperative that the United States recognize and quickly respond to future cases with a well-coordinated, multi-disciplinary, science-based investigation and effective interventions. Finally, the committee is concerned about how best to manage the continuing care of those already affected, and how to strengthen the nation's commitment to the health and well-being of those who serve the country overseas. Both of these priorities need and deserve additional attention and resources.
DOI 10.17226/25889 |