IDECONTROLLEDI RELEASE IN PART 1 4 8 B1 B5 1 4 G B7 E 1 4 D B7 F B7 C B7 A B3 B6 1 4 C HAVANA CUBA ACCOUNTABILITY REVIEW BOARD JUNE 2018 EC ltBTh1 Of ORH U Table of Contents U Executive Summary 1 U Board U Consolidated Recommendations List - Prioritized 5 U Narrative 9- U Findings and Recommendations U AccountabilitY 2- l U Interagency Coordination f' 4 U Medical f§ U Communication and Information Sharing Q_ U Risk Benefit Analysis U Bureau of Diplomatic SecuritY ' 4 U List of 8 EC ltBTh1 Of ORH U EXECUTIVE SUMMARY q The Cuba Accountability Review Board was convened on February 8 2018 to investigate incidents resulting in the injuries to Embassy Havana community members during their service in Havana Cuba As of May 2018 we know 24 Embassy Havana community members have been medically confirmed to have sustained brain injuries while serving in Havana with the severity of injury ranging from mild impairment to injuries in a few patients so severe they may never be able to return to their previous jobs It is unknown at this time if any of these injuries are permanent The mechanism for the cause of the injuries is currently unknown We do not know the motive behind the incidents when they actually commenced or who did it 'Et The mandate of this Board is not to determine the mechanism or identify the perpetrator but to make written findings on the adequacy of security and recommendations related thereto While the Board found security at the mission was generally adequate at the time the incidents began U Per the statutory mandate the Board finds the following 1 €- The Board finds that the events were security related 2 U The security systems and security procedures were adequate despite significant vacancies in security staffing 3 -Gt The security systems and security procedures were properly implemented although traditional reporting mechanisms were not always used 1 4 0 81 4 83 5 The Board did not find any U S government employee engaged in misconduct or performed unsatisfactorily in a way that contributed to the incident As information developed all parties involved up to and including Secretary Tillerson prioritized the medical treatment and safety of those affected U In the course of this review the Board interviewed more than 116 individuals including members of the Embassy Havana community other State Department employees representatives of other government agencies and medical specialists The Board reviewed all available information but because traditional reporting channels were not always used we acknowledge the possibility that additional information exists to which to the Board did not gain access Beginning in November 2016 and continuing through late August 2017 some Embassy Havana community members and several temporary duty personnel experienced incidents they described as a loud piercing noise The majority of these incidents occurred in residences but several took place in hotels Many of those injured reported a piercing directional noise and sometimes a physical sensation or discomfort immediately prior to the onset of symptoms The affected individuals had varying combinations of cognitive vestibular and oculomotor dysfunction as well as sleep disorder and headache The last known incident in Havana that resulted in a medically confirmed injury is reported to have occurred in late August 2017 8 ECRETh'MOr'OitNf 1 ECRET ·NOf ORN -S - As of May 2018 there is medical confirmation that 24 USG and approximately 10 Canadian di lomatic communit members in Havana were in·ured -fry Also in late May 2018 Embassy Havana reported two additional incidents for which medical confirmation is pending In addition to Embassy Havana there were reports of similar incidents at several other posts Tashkent - and China which resulted in one recent medically confirmed case in in China I I The Department of State eventually arranged the medical evacuation of all affected employees and family members who requested it to the University of Pennsylvania Center for Brain Injury and Repair where they received comprehensive multiple disciplinary evaluations -Et The Department of State's response to these incidents was characterized by a lack of senior leadership ineffective communication and systemic disorganization No senior official was ever designated as having overall responsibility which resulted in many of the other issues this reports presents The interagency response was stove-piped and largely ad hoc In our report the Board makes recommendations on accountability interagency coordination communication and information sharing medical issues risk benefit calculations and security operations est I I I On September 29 2017 the Secretary of State ordered the departure of non-emergency personnel and family members No formal risk benefit analysis of USG presence in Havana was ever conducted Following six months on Ordered Departure Havana became an unaccompanied post in March 2018 1 4 0 B1 B3 B6 1 4 0 B1 B3 B3 1 4 0 B1 1 4 0 B1 B7 A B3 SUCRET ·NOf ORN 2 S ECRET N O FORn U BOARD MANDATE 1 U The extent to which the medical conditions with respect to which the Board was convened were security related EB The Board finds the events were security related The fact that to date June 7 2018 only American and Canadian diplomats and their family members have been medically confirmed to have sustained brain injuries as a result of service in Havana suggests a targeted action even though the mechanism of injury the perpetrator and the motive remain unknown 2 U Whether in this situation the security systems and security procedures were adequate U The Board finds the security systems and security procedures were adequate despite significant vacancies in security staffing 3 U Whether in this situation the security systems and security procedures were properly implemented -fry The Board finds the security systems and security procedures were properly implemented although traditional reporting mechanisms were not always used 4 U The impact of intelligence and information availability in this situation 1 4 0 B1 1 4 C B3 5 U Such other factors and circumstances which may be relevant to the appropriate security management of United States missions abroad 'Mtt f Based on the information available at this time the Board does not find that any U S government employee engaged in misconduct or performed unsatisfactorily in a way that contributed to the incident The deficiencies documented in this report are confined to the response to the incident U As the mechanism of injury has not yet been established nor has responsibility for the events been affixed the Board considers this report to be an interim response and an interim set of findings As the Board was concluding its review it learned of two additional incidents in Havana that are pending medical review Recent infonnation indicates the incidents have not ceased in Havana and are occurring elsewhere When the technical and investigative processes underway yield concrete results and a firm understanding of what happened to our personnel a final review should be undertaken to validate or revise our conclusions in light of new information 8fi CRETh'MOr'OitNf 3 SECRET77NO'FOm U The Board learned many communications related to the incidents did not travel in the usual Department of State channels and therefore there may be documentation that has not been made available Should additional documentation come to light it could alter the conclusions of this report SECRE'f77 MOflQltl q 4 S ECRET NOf ORN U CONSOLIDATED RECOMMENDATIONS LIST- PRIORITIZED U For additional detail regarding the Board's recommendations refer to the Findings and Recommendations sections 1 Sfff f Overall responsibility for the Cuba response needs to be assigned to the Deputy Secretary of State 2 U Although belated the Department needs to establish a Department-wide task force reporting directly to the designated senior official to develop a proposed strategy for the future state of Embassy Havana and remedy the deficiencies identified in this report The task force should report weekly to the Deputy Secretary of State and should have a broad mandate to include developing a strategy for future state of Embassy Havana and potential global response 3 e 1 4 0 B1 4 -BBP The Department of State in coordination with other USG agencies and academic medical institutions should provide the funding and resources necessary to conduct a comprehensive CDC- led medical and epidemiologic study of the clinical entity related to the incidents in Cuba The study should include all individuals who may have been exposed to incidents in Cuba including U S mission employees and their family members and any other American citizens who may have been exposed with case definitions and at-risk time frame to be detennined by the appropriate medical experts The study should also address possible counter measures and best available treatment modalities In addition to the currently identified cases and exposed adults the study should assess possible long term effects on young children or unborn children who may have been exposed 5 -s-Btt The Department of State Legal Adviser should immediately engage with the senior legal official at CDC to resolve disagreement that is impeding the sharing of medical records with the CDC to enable CDC to begin the medical study immediately 6 U The Department of State in coordination with other USG agencies should provide the resources and establish funding mechanisms to provide long term medical follow-up and required treatment to U S Mission personnel and families impacted by the incidents in Cuba The follow-up plan should be made available to all U S Mission medically affected personnel and families 7 U The Department should make pre-departure and post-assignment medical screenings a mandatory condition for assignment to or temporary duty in Havana 8 SftNF 1 4 0 B1 B3 S ECRET WWf ORN 5 ECRET ·NOf ORN 1 4 0 81 83 10 SB-lA The Department should review and revise if necessary its procedures for ensuring continued senior-level leadership at all times Under Secretary positions filled by individuals in an acting capacity need to have sufficient acting and delegated authorities and clarity about those authorities in order to fulfill their responsibilities 11 The Bureau of Diplomatic Security DS should appoint and appropriately resource a fonnal DS working group from across its competencies of counter-intelligence technology investigations and international programs with a designated accountable leader The working group should continue to examine the incidents actively participate in interagency working groups and consult with technology experts as needed to determine the cause and responsible entity as well as assist in the interagency development of a mitigation strategy and countenneasures The working group should report directly to the DS Assistant Secretary with a clearly defined formal reporting structure and schedule 12 Charge Havana in coordination with the Bureau of Diplomatic Security should ensure Embassy Havana's Emergency Action Plan is updated The update should include a section on managing and responding to such incidents The Department should determine if an expansion of this type of incident response plan is warranted for posts other than Embassy Havana and if so should develop worldwide guidance for inclusion in EAPs 13 -Et The Department should expand its procedures for conducting risk benefit analyses and staffing reviews to include posts that are not classified as High Threat High Risk for terrorism and assign responsibility for convening such a review when unanticipated risks such as the one that is the subject of this report develop at posts not on the HTHR list 14 U The Department should convene a high level review of the NSDD-38 process as it is currently implemented Following the review the Department should issue guidance to all employees and agencies regarding requirements and should hold agencies accountable 15 U The State Department should delegate standing authority to approve domestic medevacs to the Medical Director of the Bureau of Medical Services that can be utilized immediately in future medical situations that require medevac from one domestic location to another 16 Representatives from the State Department Bureau of Medical Services and HR should brief the appropriate offices at the Department of Labor DOL regarding the unique nature of the clinical entity related to the Cuba incidents in order to inform DOL decisions on worker's compensation claims that may be filed by those employees affected 17 U The Board strongly recommends the Department review its well-established and successful procedures for dealing with crisis situations and ensure leaders throughout the SECRETH-NOfORN 6 ECRET NOf ORN Department are aware of and implement them accordingly Examples of these procedures include Emergency Action Committee responsibilities and reporting requirements High Risk and High Threat Process SCORE Review Process and counter-intelligence incident reporting requirements 18 Every Chief of Mission who is not confirmed by the Senate should receive a Letter of Instruction from the Secretary that clearly details authorities and responsibilities for oversight and safety and security of American citizens and U S government employees The Bureau of Western Hemisphere Affairs should provide the Charge in Havana with a letter of instruction comparable to those given other chiefs of mission This letter should include specific guidance on the responsibility for safety and security of staff 19 -sf 'N lil INR should ensure that long term Charges chiefs of mission who are not Senate­ confirmed are included in their COM intelligence oversight briefings 20 U The Department should create a position modeled upon OPM' s Post-Combat Case Coordinator to allow for the centralization and longer-term comprehensive outreach and assistance to medically impacted Embassy Havana community members 21 I 1 4 0 I 22 I 23 'S The Department in coordination with interagency partners should request funding for mitigation countermeasure s once a confirmed mitigation strategy has been developed and should implement these measures promptly 24 The Department should ensure that the NSDD-38 processes are followed 25 - 26 WHA and S staff should create a timeline tick tock of communication decisions and actions taken to date June 7 2018 in response to the incidents The investigation into the incidents and Department's response should remain open until the Department determines what happened This timeline is a critical part of the discussion and lessons-learned process 27 U WHA should appoint a senior management officer to resolve any and all remaining management issues resulting from the Cuba incidents as well as any issues resulting from the Post's change in status following the ordered departure This senior officer should report 87 E 1 4 0 81 83 1 4 0 81 SUCRETiW OfORJ 7 S ECRET 'J' Of ORP directly to the Assistant Secretary and coordinate closely with the WHA Executive Director WHA should provide funding and staffing to facilitate these efforts 28 tEry The Secretary of State should advise employees and his counterparts at other agencies represented at missions overseas that he expects complete transparency and prompt notification regarding any episode that results in harm or increased danger for USG employees 29 fE1- The Secretary or his designee should ensure that Chiefs of Mission Deputy Chiefs of Mission and Principal Officers are personally responsible for Emergency Action Plans Additionally the Department of State should re-issue guidance reminding Chiefs of Mission that Emergency Action Committee EAC meetings should be convened whenever information surfaces indicating the potential for harm to USG employees or American citizens EAC meetings must allow for and encourage robust discussion and information sharing by all entities represented and make a determination as to the proper dissemination of said information 30 WHA leadership should designate a senior official within the bureau to be responsible for ensuring that all involved parties are promptly notified of any event action or decision that affects those impacted by the Cuba incidents to date June 7 2018 and in the future 'ECRET -NOf ORJ i 8 EC ltBTh1 Of ORH U NARRATIVE U Introduction SN W As of May 2018 24 Embassy Havana community members have been medically confirmed to have sustained brain injuries during their service in Havana Cuba with the severity of injury ranging from mild impairment to injuries in a few employees so severe they may never be able to return to their previous jobs Although the majority of those injured reported a piercing directional noise and sometimes a physical sensation or discomfort immediately prior to the onset of symptoms the mechanism of injury remains unknown as does the precise timeframe during which the injuries were sustained In their article published in the February 2018 issue of the Journal of the American Medical Association the University of Pennsylvania medical experts described the cluster of symptoms associated with these brain injuries as a possible novel clinical entity Affected individuals had varying combinations of cognitive vestibular and oculomotor dysfunction as well as sleep disorder and headache These individuals appeared to have sustained injury to widespread brain networks without an associated history of head trauma The last known incident in Havana that resulted in medically confirmed injury appears to have occurred in August of 2017 although reports of other possible incidents continue to trickle in both from Cuba and from other posts At the time of this report there are two additional incident reports from Embassy Havana Medical confirmation is pending Although a number of private American citizens contacted the Bureau of Consular Affairs with concerns that they might have been victims of similar attacks in Cuba B6 1 4 0 B1 B3 g t W As of May 2018 there is one medically confirmed report regarding a Consulate Guangzhou employee who described incidents in Guangzhou China similar to those experienced by Embassy Havana community members and whose injuries were confirmed by medical experts to match those of the Havana victims 1 U Board Circumstances and Mandate cet An incident that results in the convening of an accountability review board is usually over by the time the board convenes and usually it is reasonably clear what has happened and when Although there may be unresolved questions about exactly who was responsible for the event resulting in injury or death or the precise motive for an attack prior boards knew in considerable detail what happened to cause the death or serious injury This accountability review board faced a significantly different challenge We do know that USG and Canadian diplomatic community members 2 were injured but we do not know how We do not know what happened 1 18 Beijing 927 2 Based on official Canadian government reports 9 S ECRET ' 1 OfORH when it happened who did it or why These significant unknowns complicated the challenge of evaluating the adequacy of security and making recommendations U While the Board heard many theories about what might have caused the injuries some plausible and others less so and much speculation about who might have been responsible and their motives it is not our mandate to discover the mechanism or identify the perpetrator The mandate of the accountability review board is to make written findings on the extent to which the incident was security related whether security systems and procedures were adequate whether security systems and procedures were properly implemented and the impact of intelligence and information availability The Board is further charged to make recommendations related to its findings Si' ·Nf Medical confirmation of injury to an employee at Consulate Guangzhou and two I ' i a i 'ed incident reports from Embassy Havana emerged as the Cuba ARB rejrt B1 1 4 G U Incident Summary Beginning probably in November 2016 and continuing at least through late August 2017 some Embassy Havana community members and several temporary duty personnel experienced incidents described as a loud noise primarily in their residences these incidents resulted in medically documented brain injuries to 24 people I 1 4 0 B1 B3 However_ beginning in late March 2017 I --- --------- IPost leade ship took ad inistrative actio s to protect the community members from this unknown threat beginning with liberal curtailment policies in March 2017 at the same time the Bureau of Medical Services focused on understanding the nature of the injuries and organizing specialist evaluation and treatment Initially individuals reporting symptoms or concerns were medavaced to Miami for evaluation and referral B7 E -- ------ ---- In August 2017 two TDY personnel experienced medical injury from an incident at a Havana hotel -BHNfi 1 4 0 B1 B3 'ECRET -NOf ORJ i 10 --- At the end of September the Secretary of State ordered the departure of all non­ emergency staff in response to the health attacks In March 2018 after six months of ordered departure Havana was designated an unaccompanied post S' EH t To date June 7 2018 24 members of the Embassy Havana community have been medically confirmed to have been affected as a result of permanent assignment or temporary duty in Havana Beginning in August 2017 21 of these individuals consented to comprehensive multi-disciplinary evaluations at the University of Pennsylvania Center for Brain Injury and Repair some have also received follow up treatment or rehabilitation as indicated U Initial Reports 1 4 0 B1 B3 'St7'NF- I 1 4 0 B1 B3 B6 Sfflf Impacted Group Broadens Several individuals believed they may have been impacted as early as November 2016 Post leadership took administrative actions to protect employees from this unknown threat beginning with liberal curtailment policies in March 2017 At the same time the Bureau of Medical Services focused on understanding the nature of the injuries and organizing specialist evaluation SECRET WWfORN 11 S ECR ET ' 1 0f ORH and treatment both at Post and in the U S 87 E 87 A The group of affected individuals continued to grow throughout the spring of 2017 as medical understanding of the injuries advanced and additional incidents were reported U Medically confirmed Havana incidents drawdown and aftermath The last Havana incidents resulting in medically confirmed injury took place at the end of August 2017 Two additional incidents reported on May 27 2018 are pending medical confirmation at the time of this report -------- ------ At the end of September the Secretary of State ordered the departure of all non-emergency staff in response to the health attacks The decision to draw down the staff in Havana does not appear to have followed standard Department of State procedures and was neither preceded nor followed by any formal analysis of the risks and benefits of continued physical presence of U S government employees in Havana After six months of ordered departure Havana was designated an unaccompanied post in March 2018 tsBl f Risk Benefit Analysis or Lack Thereof S#NF As noted above the cause of injury to Embassy Havana community members has not been identified I IThe State Department has had such a process for a number of years however no such -- analysis has been done to date June 7 2018 for Cuba Of the many Department leaders interviewed by the Board no one could explain why this has not happened except to suggest that 1 4 0 81 83 1 4 0 81 83 1 4 0 81 ce Since March 2018 Embassy Havana has been an unaccompanied post In Ju yo 2017 t e A mmistration published its revised Cuba policy which listed four key objectives enhancing compliance with U S law in particular provisions that govern the embargo and ban on tourism holding the Cuban regime accountable for human rights abuses and oppression furthering the national security and policy interests of the U S and those of the Cuban people and laying the groundwork to empower the Cuban people to develop greater economic and political liberty SECR ETN-MOFOltNf 12 S ECRET NOf ORN 1 4 0 B1 B3 B7 A B7 E B3 1 4 0 B1 B7 A B7 E B3 3 mTBI mild traumatic brain injury 'ECRET NOf ORI'i 13 S ECRET ' 1 OfORH U Adequacy of Security through February 15 2017 For the purposes of making a finding on whether security systems and procedures were adequate and properly implemented we find it useful to divide the assessment into two time periods the time before officials at Post and in Washington had the first unverified information ofinjury February 15 2017 and the period after Before February 15 2017 the Board assesses security at the U S Embassy in Havana to have been adequate '----- The Board assesses that the security systems and procedures were generally adequately implemented at Post before mid-February 2017 1 4 0 81 87 A 87 E 83 1 4 0 81 83 1 4 0 81 1 4 0 81 83 1 4 0 81 SBE f- Shortcomings in Department's response after February 15 2017 For the period after February 15 2017 the Board found serious deficiencies in the Department's response in areas of accountability interagency coordination and communication at all levels both at Post and in Washington These deficiencies contributed to the confusion surrounding the events and delayed effective coordinated action The Board finds the lack of a designated official at the Under Secretary level to manage the response to be the single most S'EettETN-MOf ORH 14 S ECR ETh1 0rO lU significant deficiency in the Department's response To this day no senior official at the Department has been assigned responsibility for leading and coordinating efforts to assess past incidents and prevent mitigate future events No Department of State task force was formed €ti 1 4 0 B1 B3 S#Nfi- There was no interagency working group · established to deal with this issue Nor was a dedicated internal State De artment workin WHAhas 1 4 0 B1 -------------------------------------- convened monthly interagency meetings since May 2017 and while helpful these meetings are primarily for sharing information As WHA does not have the authority to direct action or task other State bureaus these meetings do not serve to inform decisions or drive coordinated action in response to the health incidents -5-ffl'fF- Regarding implementation of security programs and procedures post February 15 the intermittent reporting poorly understood nature of the incidents the vague symptomology headache nausea dizziness fatigue combined with the delayed confirmation of medical injury severely delayed the recognition of these general reported medical symptoms as being connected to security incidents As of this report the who what when and sometimes the where behind these incidents is still unknown The Board found the securit ro rams and rocedures adequate during this time S ECR ETh'-t OrORJ 15 B3 1 4 0 B1 B3 S ECRET NOf ORN 1 4 0 B1 B3 The Emergency Action Committee EAC an Embassy Front Office responsibility is an essential element of security policy infrastructure I 1 4 0 B1 Once the EAC cable was received the Department's response tempo increased although in a stove-piped and inadequately coordinated manner in the absence of an Under Secretary for Management or a designated responsible Department official 4'Nf However within the Bureau of Diplomatic Security individual directorates and office s engaged adequately within their areas of expertise supporting Post's security program and oarticioating in Washington based meetings_ I I 1 4 0 B1 B7 E B7 A B3 4NODIS 17 Havana 29 5 Emergency Action Cable EAC 17 Havana 31 SeCR-ET NOf ORJ 16 1 4 0 81 87 E 83 SBl ij Community Reactions widespread differences of opinion 1 4 0 81 81 83 ce The Board finds the delay of almost six weeks between first knowledge of injury and the first briefing of Embassy staff to be unfortunate and the exclusion of family members from this knowledge to be unjustified given the incidents were taking place at residences Despite the delay the University of Pennsylvania medical team assessed that there was no indication that a delay negatively impacted medical treatment or recovery 1 4 0 81 SECRET -HOfORJ 17 S ECRET ' 1 OfORH I 1 4 0 81 1 4 0 81 83 1 4 0 81 -E I In exploring the guidance given to the COM regarding his responsibility for the security of all executive branch employees the Board learned the COM did not have a letter of instruction Presidentially-appointed Senate-confirmed ambassadors all receive a letter of instruction from the President detailing their responsibilities Typically the responsibility for the 6 17 Havana 67 SECRET1W Of ORJ' 18 S ECRET NOf OR H safety and security of American citizens and U S government employees features prominently in these letters In other posts where a COM is not Senate confirmed the Department sometimes issues a letter of instruction from the Secretary of State which serves a similar purpose While the COM attended the Ambassadorial Seminar at FSI and stated he was familiar with the provisions of the Presidential letter regarding security responsibilities the Board finds the absence of a formal instruction in Cuba to be vulnerability € WHA Role De Facto leadership but insufficient authority and response cet While various bureaus and individuals took action to address their specific part of the problem everyone the Board interviewed agreed there was no official in charge As a result a whole-of-government comprehensive effort to identify the mechanism of injury and perpetrators to understand the universe of potentially affected individuals to treat and rehabilitate the injured employees as well as to deal with the many administrative issues associated with this anomalous event never emerged Even a whole of State Department effort never got off the ground despite some early attempts to provide consistent support for potentially affected employees e The Bureau of Western Hemisphere Affairs was frequently cited by those interviewed as the de facto lead bureau within the State Department WHA leaders attempted to fill some of the gap created by the lengthy vacancies at the Under Secretary level and convened a number of meetings for the purpose of sharing information They were largely unsuccessful at actual coordination in part because they did not have the authority to direct action on the part of other bureaus They were almost invariably in a reactive mode and never put forward a cohesive plan of action for the future They were also hampered by their very limited access to the senior leadership of the Department 1 4 0 B1 Communication uncoordinated and inadequate e Overall the Department of State failed to maintain effective communication with employees evacuated from Havana both medical evacuees and those evacuated for the ordered departure again in part because no one was assigned this responsibility While there was the occasional uncoordinated ad hoc communication there was no systematic plan for tracking communication and providing definitive guidance on various issues of concern to the Havana community Employees who left Post in September 2017 under ordered departure learned about the March 2018 decision to make Havana an unaccompanied post by reading about it in the press As far as the Board could determine there was no advance notice to the Embassy Havana community regarding the journal article about the novel clinical entity was going to be published in the Journal of the American Medical Association 8fi CRETh'-t OFORJ I 19 S ECRET ' 1 OfORH €1 The Board understands that the Bureau of Medical Services MED is largely constrained in its dealings with both the injured employees and the broader universe of those potentially affected by medical privacy laws and policies these are based on an assumption of confidential communication with individual patients This caused MED to be poorly positioned to take on the administrative responsibility for dealing with a group such as those injured in Havana and is a cause of frustration to some in the group A working level representative from the Human Resources bureau M DGHR had previously been named as a point of contact to assist employees in identifying the appropriate entity or responsible individual to address issues that arose particularly issues related to worker's compensation she continues to fill her primary role without the authorities necessary to address the myriad of other administrative and procedural issues faced by employees in treatment tE1 MED role strong performance concern about delay in engaging CDC -Et The Bureau of Medical Services MED performed strongly and making patient evaluation treatment and rehabilitation its priority gets high marks for dealing with an unprecedented situation in a competent professional manner It took some time for MED officials to understand what they were dealing with medically which is understandable given that this is a novel clinical entity however once they confirmed that employees were dealing with brain injuries MED set in motion processes to identify and deliver the best possible evaluation and treatment and dealt with myriad of issues associated with the unprecedented nature of the events in Havana including supporting domestic medevacs The facility selected for evaluation and treatment the Center for Brain Injury and Repair at the University of Pennsylvania Perelman Medical School UPenn is a world-class medical center with a cutting edge program in brain injury diagnosis and treatment and one of only five NIH-designated centers nationwide The vast majority of the injured employees expressed to the Board their confidence in the care they received at UPenn MED then obtained the required authorities to expand medevac procedures to include medevacs within the U S to enable patients to travel from domestic locations to the medical center of excellence for evaluation and treatment The bureaucratic approval process required by MED to obtain domestic medevac authority for the Cuba medevac patients took time and added to the administrative burden for MED Even though there was delay in completing evaluations and beginning treatment medical providers at the University of Pennsylvania expressed to the Board their professional view that this delay would not have a significant negative impact on successful rehabilitation On the other hand agreement with the CDC to do the necessary epidemiology study has not been finalized the Board urges the Department to take the steps necessary to speed up this process and to allocate funding to support this critical endeavor Further the Board recommends the Department develop a long term plan for follow-up not only with the existing patient group but with anyone who served or visited Havana during the identified period and share their plan in writing S'EettETN-MOf ORH 20 SECltE T i1 IOf ORN U FINDINGS and RECOMMENDATIONS ACCOUNTABILITY U Finding #1 -Ej No senior official has ever been assigned overall responsibility for leading and coordinating the State Department's response to the Cuba incidents ljj- Discussion No senior official was identified as having ownership of the issue overall As a result there was no accountability for 1 determining what had happened 2 ensuring that standard bureaucratic procedures were used 3 communicating with and responding to the affected and potentially affected employees 4 using authorities to overcome bureaucratic obstacles There was no one in a position to drive interagency coordination or to direct needed action across bureau lines within the State Department -5 There was no Department-wide task force formed The establishment of a task force could have alleviated many of the shortcomings identified in the report Standard Department of State procedures which have been used effectively in other crises were not utilized The problems caused by lack of ownership were compounded by the many vacancies in key positions the incumbents of which would normally have provided leadership Given the recent confirmed report of medical injury to an employee at Consulate Guangzhou China reporting a similar incident it is critical that there is a focal point for monitoring and formulating the Department's response globally - HH fj Recommendation #1 Overall responsibility for the Cuba response should be assigned to the Deputy Secretary of State St NF Recommendation #2 Although belated the Department needs to establish a Department-wide task force reporting directly to the designated senior official to develop a strategy for the future operation of Embassy Havana and to remedy the deficiencies identified in this report The task force should report weekly to the Deputy Secretary of State and should include in its mandate 1 4 0 B1 1 4 0 B1 8fi CRETh'-t IOFORJ I 21 1 4 0 81 U Recommendation# 3 The Department should create a position modeled upon OPM's Post­ Combat Case Coordinator with formal responsibility for the centralization and longer-term comprehensive outreach and assistance to medically impacted Embassy Havana community members U Finding #2 Vacant senior positions and lack of clarity regarding delegated authorities delayed an effective response U Finding #3 Individuals filling Under Secretary and Assistant Secretary Positions in an acting capacity during an extraordinarily prolonged transition were hampered by the rescinding of delegated authorities and the ensuing confusion regarding those authorities that were eventually re­ delegated U Finding #4 ce Seriously constrained communication between the senior leadership of the Department and Acting Under Secretaries and Assistant Secretaries with the exception of P inhibited action f -Discussion The political transition related to the change of administration was underway when knowledge of the incidents surfaced and most of the Under Secretary positions were vacant Political transitions take place routinely every four or eight years and crises sometimes break out before a new administration is fully staffed Typically very senior and experienced Assistant Secretaries are designated as acting Under Secretaries to cover the responsibilities while the appointment process for new Under Secretaries is underway The absence of fully­ empowered acting senior leaders at the Under Secretary level seriously compromised the Department of State's ability to respond effectively and in a coordinated way to the Cuba incidents Below the level of the Under Secretaries almost all of the relevant Bureaus were led by acting Assistant Secretaries for most or all of the period under discussion in this report They reported they were unsure of the extent of their authorities and had limited access to the senior leaders in the Department In addition they reported that they were provided little or no formal guidance The combination of lack of formal guidance and fear of overstepping their roles served to put Acting Assistant Secretaries in a reactive rather than a pro-active posture SECRET WWfORN 22 5 t C ltE 'f i1 0f O RH Normally the Under Secretary for Management would have played a key role in coordinating the response of a number of bureaus to a situation like the Cuba incidents While the Under Secretary for Management position was filled by two individuals in acting capacities neither one believed he had the authorities necessary to coordinate the response The July 2017 decision rescinding many delegated State Department authorities by the then-Secretary of State followed by the limited and poorly documented re-delegation of some of those authorities created widespread confusion about authorities It resulted in understandable concern and hesitation on the part of persons in acting positions who feared exceeding their authorities HH fj Recommendation #4 The Department should review and revise if necessary its procedures for ensuring continued senior- level leadership at all times When Under Secretary positions are filled by individuals in an acting capacity they need to have sufficient delegated authorities and clarity about those authorities in order to fulfill their responsibilities U Finding #5 The Charge in Havana did not have a formal instruction documenting his responsibilities for the safety and security of staff comparable to the Presidential letter of instruction provided to Senate-confirmed Chiefs of Mission 'tHtfj Recommendation #5 Every Chief of Mission who is not confirmed by the Senate should receive a Letter oflnstruction from Secretary that clearly details authorities and responsibilities for oversight and safety and security of American citizens and U S government employees The Bureau of Western Hemisphere Affairs should provide the Charge in Havana with a letter of instruction comparable to those given other chiefs of mission This letter should include specific guidance on the responsibility for safety and security of staff 'E C ltE 'f77' MOflOltl q 23 U FINDINGS AND RECOMMENDATIONS INTERAGENCY COORDINATION Ul Finding_ #1 1 4 0 81 U Discussion U Embassy Havana S ' 'Uf1 1 I 1 4 0 81 83 U Washington D C -sHNr- 1 4 0 81 83 U Recommendation #1 The Board strongly recommends the Department review its well established and successful procedures for dealing with crisis situations and ensure that leaders throughout the Department are aware of and implement them accordingly Examples of these procedures include Emergency Action Committee responsibilities and reporting requirements High Risk and High Threat Process SCORE Review Process and counter-intelligence incident reporting requirements U Recommendation #2 The Department should convene a high level review of the NSDD-38 process as it is currently implemented Following the review the Department should issue 'ECRET -NOf ORJ i 24 guidance to all employees and agencies regarding requirements and should hold agencies accountable -8#N li Recommendation #3 I et Recommendation #4 The Department in coordination with interagency partners should request funding for mitigation countermeasure s once a confirmed mitigation strategy has been developed and should implement these measures promptly 1 4 0 81 83 U Finding #2 c 1 I I 1 4 0 81 83 Recommendation #5 INR should ensure that long-term charges chiefs of mission who are not Senate-confirmed are included in their COM intelligence oversight briefings Recommendation #6 The Department should ensure that the NSDD-38 processes are followed 5' E C'ltBTH-HOfORN 25 S ECRET NOf OR H U FINDINGS AND RECOMMENDATIONS MEDICAL U Finding #1 U The Bureau of Medical Services MED did a competent and professional job responding to an unprecedented medical situation and has provided high quality evaluation and treatment for Embassy Havana personnel for this novel clinical entity U Discussion Throughout the events in Havana MED focused on providing the needed medical care to the individuals affected They established a broad medevac policy that provided or offered medevac of all persons who were affected or exposed or thought they may have been affected or exposed to the U S for specialty evaluations Medical screening either at Post or by medevac was offered for all who thought they might have been affected Protocols were put in place to inform and screen those who were traveling to or returning from the U S mission in Havana MED instituted consultation and networking with multiple experts from U S medical academic centers and USG agencies to ensure that their actions were informed by the best medical expertise available MED identified a recognized center of excellence at UPenn as the designated referral center for comprehensive evaluation and treatment U Finding #2 U The Bureau of Medical Services is not resourced or funded to provide long term medical follow-up and required treatment to U S Mission personnel and families impacted by the incidents in Cuba U Discussion The long term prognosis and medical requirements for those affected by the incidents in Cuba remain unknown The required medical and epidemiologic investigation and patient follow-up will require a highly specialized multiple disciplinary efforts coordinated with USG agencies and academic institutions The Bureau of Medical Services will need the dedicated staffing and funds to oversee and coordinate this and provide care for those affected over the long term U Recommendation #1 The Department of State in coordination with other USG agencies should provide the resources and establish funding mechanisms to provide long-term medical follow-up and required treatment to U S Mission personnel and families impacted by the incidents in Cuba The follow-up plan should be made available to all U S Mission medically impacted personnel and families U Finding #3 U The board considers the engagement of CDC expertise in the medical and epidemiological investigation of the incidents in Cuba to be critical going forward t i Discussion The State Department formally requested CDC assistance in December 2017 CDC has determined that work on the Cuba events qualifies as a Public Health Response which 3UCRET ' -HOfORN 26 S ECRET NOf ORN includes provisions for access to medical records when necessary for public health purposes At the time of this report progress in CDC's medical investigation is still pending because of Department legal concerns regarding sharing of the medical records required to conduct the required studies authority for which CDC already has This is significantly delaying the start of the required medical studies -s-Bl J Recommendation #2 The Department of State Legal Adviser should immediately engage with the senior legal official at CDC to resolve disagreement that is impeding the sharing of medical records with the CDC to enable CDC to begin the medical study immediately Recommendation #3 The Department of State in coordination with other USG agencies and academic medical institutions should provide the funding and resources necessary to conduct a comprehensive CDC-led medical and epidemiologic study of the clinical entity related to the incidents in Cuba The study should be inclusive of all of those individuals who may have been exposed to incidents in Cuba including U S mission employees and their family members and any other American citizens who may have been exposed with case definitions and at-risk time frame to be determined by the appropriate medical experts The study should also address possible counter measures and best available treatment modalities In addition to the currently identified cases and exposed adults the study should access possible long term effects on young children or unborn children who may have been exposed U Finding #4 C I l '_ TT n· I -· i 1 4 0 81 83 S#N li Recommendation #4 The Deoartment of State Bureau of Medical Services and the U Finding #5 The Board finds that within the group of individuals medically impacted by the incidents in Havana there is lack of clarity whether their conditions will be accepted by the Department of Labor as qualifying for worker's compensation St C'ltE 'fh'NUFOR N 27 U Discussion Federal employees may file claims with the Department of Labor DOL under the Federal Employees Compensation Act FECA for work related illness or injury An accepted claim may entitle the employee to lifetime medical expenses for treatment of the work related illness or injury Because of the unique nature of the clinical entity related to the Cuba incidents concerns were expressed to the board regarding whether DOL will accept their cases as qualifying for worker's compensation Meeting and consultation between State MED and HR with DOL may be effective in establishing procedures covering this situation 8fH J Recommendation #5 Representatives from the State Department Bureau of Medical Services and HR should brief the appropriate offices at the Department of Labor DOL regarding the unique nature of the clinical entity related to the Cuba incidents in order to inform DOL decisions on worker's compensation claims that may be filed by those employees affected U Finding #6 U The lack of standing authority for the Department of State Medical Director to approve medical evacuations between domestic locations when required added additional steps and bureaucratic time requirements to the medevac process U Discussion Under the State Department Medical Program medical evacuations from overseas posts are provided when required for medical care But in unusual circumstances sometimes medical travel from one location in the U S to another is required for the appropriate specialty evaluation or care This was the case for many of the individuals in the Havana cohort who were referred to UPenn To accomplish these medevacs the Medical Director was required to request special authority which was then granted specific only to the Cuba events In the future when another event occurs which requires domestic medevacs State MED will need to repeat the same administrative process specific to that event U Recommendation #6 The State Department should delegate standing authority to approve domestic medevacs to the Medical Director of the Bureau of Medical Services that can be utilized immediately in future medical situations that require medevac from one domestic location to another U Finding #7 U The medical screening for assignment to or temporary duty at Embassy Havana is optional U Discussion Although State MED has developed pre-assignment screening to establish baseline information for employees heading to Havana and post-assignment screening to provide an early indication of any changes that could signal possible injury these screenings are currently optional for employees Given that the incidents are still under investigation it is critical to gather as much information as possible In addition these screenings provide additional protection for employees These screenings should be mandatory for all employees permanently assigned to or traveling TDY to Havana 5' eC'ltl 1' 177'MO'F Or M 28 5 E CKET 1 Of OIU U Recommendation #7 The Department should make pre-departure and post-assignment medical screening a mandatory condition for assignment to or temporary duty in Havana SECRET ·HOf ORJ 29 S ECRETh1 0r'Ofd' U FINDING and RECOMMENDATIONS COMMUNICATION AND INFORMATION SHARING U Finding #1 €1Both at Post and in Washington response to the incidents was characterized by excessive secrecy that contributed to a delayed response 1 4 0 B1 B3 ft - Recommendation #1 The Secretary of State should advise employees and his counterparts at other agencies represented at missions overseas that he expects complete transparency and prompt notification regarding any episode that results in harm or increased danger for USG employees €j Recommendation #2 The Secretary or his designee should ensure that Chiefs of Mission Deputy Chiefs of Mission and Principal Officers are personally responsible for Emergency Action Plans Additionally the Department of State should re-issue guidance reminding Chiefs of Mission that Emergency Action Committee EAC meetings should be convened whenever information surfaces indicating the potential for harm to USG employees or American citizens EAC meetings must allow for and encourage robust discussion and information sharing by all entities represented and make a determination as to the proper dissemination of said information U Finding #2 -C WHA's reliance on informal consultation with the Department's leadership made it difficult for the Board to develop an accurate picture of decision making regarding the incident ff J Discussion Informal communication between WHA and the senior leadership of the State Department contributed to the lack of coherence in the response Normal Department reporting channels and methods were routinely disregarded in the response to the Cuba incidents WHA officials were instructed to limit distribution of information to a select group of officials As a result accountability was never clearly established and there was no coordination within the Department The most frequent communication with the senior leadership was to the Secretary of State's chief of staff via email Contemporaneous documentation of these interactions is scant S'EettETN-HOf ORN 30 S ECRET 'J' O PO e Given that this is an unprecedented event it would be helpful to have an accurate record of what was done by whom when and why In order to learn the right lessons from this incident it is essential to have an accurate written record € Recommendation #3 WHA and S staff should create a timeline tick tock of communication decisions and actions taken to date June 7 2018 in response to the incidents The investigation into the incidents and Department's response should remain open until the Department determines what happened This timeline is a critical part of the discussion and lessons-learned process U Finding #3 'e Communication with employees was disorganized and often ineffective Responsibility for maintaining such communication was never clearly established fej Discussion Communications with the potentially impacted Embassy community and later with the evacuated staff lacked coordination and ownership there was no clarity about who was responsible for communication This resulted in inconsistent or a lack of notifications Many individuals expressed their frustration with the Department's failure to provide timely relevant information and assistance to the Embassy Havana community The Board was advised by the WHA executive director that under a drawdown it is the drawdown post's responsibility to keep track of and maintain communication with evacuated staff Even under normal circumstances this seems counter-intuitive -Recommendation #4 WHA leadership should designate a senior official within the bureau to be responsible for ensuring that all involved parties are promptly notified of any event action or decision that affects those impacted by the Cuba incidents to date June 7 2018 and in the future 1 4 0 81 U Finding #4 'e € -Discussion I 1 4 0 81 U Recommendation #5 WHA should appoint a senior management officer to resolve any and all remaining management issues resulting from the Cuba incidents as well as any issues resulting from the Post's change in status following the ordered departure This senior officer SECitl 'fh' NOf ORN 31 S ECRET NOf ORN should report directly to the Assistant Secretary and coordinate closely with the WHA Executive Director WHA should provide funding and staffing to facilitate these efforts SUCRET WWf ORJ i 32 S ECRET NOf ORN U FINDING and RECOMMENDATIONS RISK BENEFIT ANALYSIS U Finding #1 No formal comprehensive review of policy objectives and risk was conducted although Embassy Havana was placed in unaccompanied status with significantly reduced staffing effective March 2018 €j Discussion I 1 4 0 B1 Despite what is described as unprecedented reports of medical injury from an unknown cause s to Embassy Havana diplomatic community members between February and August 2017 and the June 16 2017 issuance of the National Security Presidential Memorandum NSPM- 5 entitled Strengthening the Policy of the Unites States towards Cuba the decision to draw down Embassy staff in Havana was neither preceded nor followed by a formal risk benefit analysis Neither the Department's High Threat High Risk Post Review HTHR Process nor the former Vital Presence Validation VP2 Process were enacted I I The Board found wide pread confusion among those interviewed about how a review of a post that was not HTHR would occur and who could or should initiate such a review tj Recommendation #1 I I 1 4 0 B1 I Recommendation #2 The Department should expand its procedures for conducting risk benefit analyses and staffing reviews of posts that are not classified as High Threat High Risk for terrorism and assign responsibility for convening such a review when unanticipated risks such as the one that is the subject of this report develop at posts not on the HTHR list € Recommendation #3 I 1 4 0 B1 S ECRET WWf ORN 33 EC ltBTh1 Of ORH U FINDINGS AND RECOMMENDATIONS BUREAU OF DIPLOMATIC SECURITY U Finding #1 Although individual Directorates and Office s within the Bureau of Diplomatic Security DS responded to the Cuba incident reports based upon their areas of expertise DS' response would have benefited from the formation and resourcing of a fonnal internal DS multi­ disciplinary working group S Vi¥Ji Discussion 1 4 0 81 85 87 A 87 E 83 J N Jl Recommendation #1 The Bureau of Diplomatic Security should appoint and appropriately resource a fonnal DS working group from across its competencies of counter­ intelligence technology investigations and international programs with a designated accountable leader to continue to examine the incidents actively participate in interagency working groups and consult with technology experts as needed in an effort to determine the cause and responsible entity as well as assist in the interagency development of a mitigation strategy and countermeasures The working group should report directly to DS' Assistant Secretary with a clearly defined fonnal reporting structure and schedule U Finding #2 EB-Embassy Havana's Emergency Action Plan EAP is in need ofreview and updating Q Discussion In light of the incidents in Havana Cuba that resulted in medical injury to USG and Canadian government community members and Embassy Havana's current status as an unaccompanied post Embassy Havana's Emergency Action Plan requires a thorough review and update € -Recommendation #2 Charge Havana in coordination with the Bureau of Diplomatic Security should ensure that Embassy Havana's Emergency Action Plan is updated The update should include a section on managing and responding to the incidents The Department should detennine if an expansion of the incident response plan is warranted for posts other than Embassy Havana and if so should develop worldwide guidance for inclusion in EAPs 9UCRETN-t'8FORl- 34 S ECRET ' 1 OfORH U Finding #3 S7'rNf7 S «NP Discussion I 1 - - SfJNF Recommendation #3 1 4 0 LJ B1 B7 E B3 U Finding #4 cstftfAI SIIHfj Discussion ---------------------------- I l 8 IHF Recommendation # 4 I 1 4 0 B1 B7 E 5' E C'ltE Th' MOfORH 35 5 t C ltE T i1 Of O R1 U LIST OF ATTACHMENTS 1 '5ttt t Timeline Summary compiled by the Bureau of Western Hemisphere Affairs at the request of the Cuba Accountability Review Board Cuba ARB 2 U JAMA article dated February 12 2018 entitled Neurological Manifestations Among US Government Personnel Reporting Directional Audible and Sensory Phenomena in Havana Cuba 3 U Memorandum dated April 11 2018 from Deputy Legal Adviser to ARB Chair entitled ARB Questions Related to the Exercise of M Authorities from January 21 2017 to present 4 I -9 'fN-F 17 Havana 67 dated June 6 2017 entitled · -- 1 4 0 81 5 U National Security Decision Directive NSDD 38 dated June 2 1982 entitled Staffing at Diplomatic Missions 6 Department of State's High Treat High Risk Post Review Process effective January 2 2018 7 U l Ii 8 Sf 'NF 18 Beijing 927 May 21 2018 Beijing EAC Convened Reference Victim of Auditory or Sensory Phenomena 9 17 Havana 31 April 4 2017 Embassy Havana convene emergency action committee meeting 87 A 87 E 83 5 t CRE iJJN OF ORN 36 Attachment 1 WHA Timeline of Events Related to Health Incidents This timeline reflects WHA' s best understanding of events as they were described and reported at the time they occurred New information will be added as it becomes available or is requested the totality of reported incidents and the medical determinations of all 24 victims are not included in the chronology because of either medical privacy concerns or because their information was not reported to WHA or Post by MED 1 4 0 B1 B3 1 4 0 B1 B3 B6 1 4 0 B1 B5 3EeKH H6r'aKNiH6BI3 Classified by WHA SBO Francisco L Palmieri E O 13526 Reasons 1 4 b d Declassify on February 21 2043 5'1 Clt E 'fh OFOR1'V-NODIS SECR-BHCf l'OFORI Cf O IS Page 2 of22 1 4 0 B1 B3 B6 1 4 0 B1 B5 B3 1 4 0 B1 B6 B5 B3 February 15 2017 February 16 2017 February 17 2017 1 4 0 B1 B6 B3 1 4 0 B1 B3 1 4 0 B1 B6 B3 1 4 0 B1 B3 1 4 0 B1 B6 1 4 8 1 4 0 B1 1 4 0 B1 B3 SECRETHf'Wf ORl' f '8DIS Page 3 of22 SECRET7 NO'FO rtN7NODIS February 21 2017 February 23 2017 February 24 2017 I 1 4 0 B1 B3 1 4 0 B1 B5 1 4 0 B1 March UNK 2017 March 21 2017 March 24 2017 I II I I 1 4 0 B1 B3 B6 1 4 0 I B1 B5 B3 1 4 0 B1 B6 B3 I I I I 1 4 0 B1 1 4 0 B1 B3 March 27 2017 I I B5 I I 1 4 0 B1 r CK ETHHOFO Rlq i ODIS Page 5 of22 1 4 0 B1 B3 1 4 0 B1 B6 1 4 0 B1 B7 A 1 4 0 B1 1 4 0 B1 B7 A 1 4 0 B1 B6 1 4 8 1 4 0 B1 SECRE IJJN OFOR N ·NODI£ B1 B5 1 4 0 B1 1 4 0 B1 4 0 1 6 A 7 C 1 4 0 B1 B6 B3 1 4 0 B1 B3 1 4 8 1 4 0 B1 SECRET ' 'J'Wf ORl' f '8DIS Page 6 of22 gr CR ET fHOFOR N mDIS Dnrtnrs Rn11pnfarh inn Shi ihi izhiiml B5 April 8 2017 - DipNote 808 170407 pdf I 1 4 8 1 4 0 B1 April 11 2017 Embassy holds all hands meeting 1 4 0 B1 I B7 A I April 12 2017 1 4 0 April 13 2017 April 14 2017 Embassy staff has DVC with MED RMO P B1 B6 B5 I 1 4 0 B1 I B7 A April 17 2017 I US Embassy Havana holds first meeting with Embassy spouses j I I 1 4 0 B1 April 18 2017 170419 - Havana Written Guidance doc April 19 2017 I Embassy holds all hands meeting WHA to be shared with employees at Post and future assignees to Havana WHA CCA WHA EX M staff HR CDA and MED meet regarding notifications for personnel transferring to post WHA EX begins briefing employees PCSing to Havana HR CDA begins notifying officers assigned to Havana 1 4 0 B1 B3 gr CR ETh1 0FOR N ·NODIS Page 7 of22 SUCRETh'NOFORlq i ODt WHA holds DVC with Embassy Havan I I 1 4 0 B1 B7 A 1 4 0 B1 B5 April 20-24 2017 April 21 2017 I ' 17-HAVANA-41 - EAC - 170420 pdf April 22 2017 I I I Post all hands meeting with I I Post sends second EAC cable 1 4 0 B1 B3 1 4 0 B1 B3 1 4 0 B1 B7 A B7 E April 24 2017 WHA EX and WHA CCA brief to USDA FAS and APHIS on incidents I B6 April 25 2017 ·- · DipNote 381 - 170425 pdf April 26 2017 170425 IM to Son attacks as subnittec WHA CCA sends up Start briefing individual TDYers to Havana 1 4 0 I B1 I 1 4 0 I B1 B6 1 4 0 B1 1 4 8 April 28 2017 Embassy all hands meeting I Page 8 of22 1 4 0 B1 B7 A B3 I 1 4 0 B1 SECRE I JJN OF Qf J'q J'NUDIS 170428 - Medical Exanination Trip RepI contact Ops Center for NODIS cables May 1 2017 May 2 2017 17-HAVANA-49 EAC - 170502 pdf May 5-13 2017 May 8 2017 Management Notice formalizing no-fault ct May 9-12 2017 May 10 2017 Non-paper details that eleven embassy-affiliated personnel had medically confirmed symptoms NODIS cable Written guidance for staff amended and distributed subsequent to May 1 meeting with M L WHA equities and MED Post holds EAC meetin l'i Havana 49 Post issues ··············--····················· in all hands meeting with options for departure to Embassy staff compassionate curtailment separate maintenance allowance Management Notice formalizes curtailment options first announced and in force since March 29 University of Miami Dr Hoffer and medical associates visit Post to conduct medical screenings B5 1 4 8 1 4 0 B1 B6 B7 A B7 E 170510 - Notes from May 10 Meeting with May 12 2017 170512 - Notes from May 12 Meeting with May 15 2017 diplomats AM approved by P regarding expulsion of two Cuban 1 4 0 B1 B7 A B7 E B3 SECREf HOf ORN -I1 WDIS Page 9 of22 fi CR ET fHOFOR N mDIS 87 A 87 E 87 A 87 E May 16 2017 May 17 2017 May 19 2017 All hands meeting to discuss medical results from Dr Hoffer' s screenings in Havana I I I 86 86 87 C 1 4 0 81 85 87 A 87 E May 22 2017 DipNote 1129 170522 pdf - DipNote 1130 - 170522 pdf May 23 2017 I 8 6 87 C 1 4 8 1 4 0 81 1 4 0 81 I requiring expulsion of Cuban diplomats Frank 1 4 0 - Hernandez Silva and Joel Lago Oliva I I 81I ' I I DipNote 17-777 170523 pdf May 25 2017 I 87 A 83 1 4 0 81 83 170525 - Notes from May 25 Meeting with Pending copy of I DipNotc 1158 May 30 2017 IM to S on expulsions - as subrritted docx June 5-6 2017 tq qtj ¢tpµJ$jgij$ I 1 4 8 81 86 I 87 C 87 A 1 4 0 81 1 4 0 81 87 A SUCRETh'NOFORlq HODIS June 7 2017 1 4 0 81 1 4 8 DipNote 158-32 - 170607 pdf June 8 2017 June 9 2017 - - DipNote 1290 - 170609 pdf 1 4 8 1 4 0 81 1 4 8 81 1 4 0 81 83 June 13 2017 June 14 2017 June 16 2017 June 21 2017 170621 - Notes from June 21 Meeting with June 26-30 2017 July 3 2017 July 6 2017 I I All hands meeting at Post All hands meeting at Post I All hands meeting at Post 1 4 0 81 86 1 4 0 81 85 83 1 4 0 81 1 4 8 83 1 4 0 81 8 A 83 1 4 0 81 83 July 7 2017 COM DeLaurentis finishes tour Acting Charge Hamilton assumes COM duties Page 11 of 22 r CK ETHHOFO Rlq i ODIS July 11 2017 July 13 2017 DAS Creamer leads townhall meeting at Post 1 4 0 81 I 1 4 0 81 83 f--J-ul_y_l-4 -2-0l-5 87 E July 17 2017 170717 - Notes from July 17 Meeting with August 3 2017 170803 Notes from August 3 Interagenq August 5 2017 1 4 0 81 83 1 4 8 1 4 0 -------- ----------------------------181 August 8 2017 Department received first press inquiry regarding incidents August 9 2017 First article published on incidents August 11 2017 IM to Son attacks docx August 12 2017 August 14 2017 All hands meeting at Post 1 4 8 1 4 0 81 1 4 8 1 4 0 81 1 4 0 81 87 A l ---1--r -------------------- ----- August 15 2017 5fi' CitE Th1 0FORI'q '-I'mDIS Page 12 of22 1 4 0 81 83 86 SECREi77 0r'OIUM ODIS August 17 2017 1 4 0 B1 B3 August 22 2017 August 23 2017 August 23-24 2017 August 24 2017 August 25 2017 FSI conducts resilience training DVCs with focus groups from Embassy Havana three sessions in advance of full resiliency training ultimately postponed because of the hurricane All hands meeting at Post 1 4 0 B1 B3 B6 1 4 0 B1 B3 1 4 0 B1 August 30 2017 170830 - Notes from August 30 Interagenc August 31 2017 1 4 0 B1 B5 B3 1 4 0 B1 B7 A September 1 2017 17-HAVANA-107 - EAC 170901 pdf Post holds All Hands meeting EAC held I 1 4 0 B1 B3 September 4-7 2017 t--S-e-pt-em_b_e_r-5 -2-0-17------i------------------ --1 i 1 4 0 B1 A 17-HAVANA-109 - EAC 170905 pdf September 6 2017 PostEAC Post EAC ·f1 ·1m ·1 i irl· · ··y··i·j·1··1 T·· T 1· 1 4 0 B1 SECR£'fh1q0fi'OltN7'NODIS Page 13 of 22 gr CR E'Ph'-r OFOR N -NOBIS --- 17-HAVANA-113 - EAC - 170906 pdf September 7 2017 Post EAC Clliti Y P4ll$ 17-HAVANA-115 - EAC 170907 pdf September 13 2017 September 14 2017 170914 - Notes from Septerrber 14 Interai September 15 2017 CIA informs A A S Palmieri of its decision to withdraw its personnel from Havana for the foreseeable future 1 4 0 B1 B3 September 18 2017 1 4 8 1 4 0 B1 B3 170918 - Notes from Septerrber 18 Interai 17 HAVANA 111 rrsg September 19 2017 PostEAC and all hands 1 4 0 B1 aft as pr gr CR Erh'-r OFORN ·NODIS Page 14 of 22 SECRETh'NOFORJ V·NOBIS September 20 2017 September 21 2017 All hands meeting at Post 1 4 0 B1 B5 I Septemb er 25 201r7n Post EAC sIB uuHd u-C f B1 14 0 17-HAVANA-117 - EAC - 170925 pdf September 26 2017 September 29 2017 Secretary Tillerson meets with Cuban FM Rodriguez regarding incidents in Washington All hands meeting at Post October 2 2017 17-HAVANA-129 - EAC - 171002 pdf -LZ H4VANA-127 - L_J- 171002 pdf 17-HAVANA-119 - Policy Paper pdf October 3 2017 October 4 2017 Secretary Tillerson Orders Departure of Non-Emergency Personnel from Havana 1 4 0 B1 1 4 0 B1 1 4 0 B1 B3 State briefs Rep Newhouse by phone about his planned travel to Cuba SeCRETHl' Of OltN7 qon1s Page 15 of 22 9r CK ETNMOFO R1q i ODl9 October 5 2017 l J i 1 4 0 B1 B3 I I October 11 2017 Post EAC -- 17-HAVANA-121 - EAC -171011 pdf October 12 2017 October 16 2017 17-STATE-56655 - ALDAC pdf October 19 2017 October 20 2017 October 23-27 2017 October 30 2017 • ' DipNote 303-64 171030 pdf WHA hosts townhall and reception for evacuees PPP - I I Secretary Tillerson meeting with Havana evacuees I 1 4 0 B1 B3 1 4 0 B1 1 4 0y 3 B1 B7 A B3 1 4 0 B1 October 31 2017 Congress requests GAO investigate response to health attacks November 1 2017 1 4 0 B1 B3 MED holds townhall with evacuees SECRE I 7 NOP OltN NUDIS Page 16 of 22 November 2 2017 November 9 2017 November 14 2017 November 20 2017 171120 Notes from Noverrber 20 Interag November 21 2017 17-HAVANA-133 - HSR 171121 pdf November 22 2017 ·' --- 17-HAVANA-135 - EAC - 171122 pdf November 30 2017 Acting A S Palmieri meets with evacuees PostEAC First request received from GAO 1 4 0 B1 B3 1 4 0 B1 B7 A B7 E B3 B7 A B3 1 4 0 B1 B6 1 4 0 B1 B7 A December 11 2017 I I I SECREiJ71qOr101Uq ' r ODIS Page 17 of22 1 4 0 B1 1 4 0 9r CK ETHHOFO RH HODl9 81 87 A December 14 2017 17-HAVANA-145 - EAC - 171214 pdf December 15 2017 January 3 2018 January 5 2018 Investigation Update January 9 2018 PostEAC PDAS Palmieri Dr Rosenfarb DS DAS Todd Brown testify before SFRC in open hearing Todd publicly discloses I 1 4 8 81 87 A 1 4 0 81 87 A 83 83 January 10-11 2018 20180110 - Meeting Notes on US Canada January 16 2018 1 4 0 81 1 4 8 87 A 83 January 17 2018 --· fa 18-HAVANA-1 EAC - 180117 pdf January 22 2018 February 2 2018 Post sends EAC SECRET 'f Of 0RJG 'r ODl9 Page 18 of 22 1 4 0 81 1 4 8 1 4 0 81 87 A 83 1 4 0 81 87 A I 83 February 9 2018 February 13 2018 ARB convenes 1 4 0 81 I February 15 2018 February 21 2018 March 1 2018 JAMA article published Post ends ordered departure OD I 1 4 0 81 87 A 83 1 4 0 81 March 5 2018 March 8 2018 20180308 Notes on Interagency Meeting I 1 4 8 1 4 0 81 I I 1 4 0 81 85 I Cf s H fart111I I m Yijij' r1 18-HAVANA-17 HSR - 180308 pdf 27 arch 15 l - 87 A 18-HAVANA-27 HSR - Update 180315 March 9 2018 March 14 2018 1 4 8 81 I 1 4 0 81 I 83 SECRE'fh1 Of OR1 q 1 ODf3 Page 19 of 22 SHCRBTN-T 10 PQRJ l lDi ODlg 4 8 4 0 1 6 1 4 0 B1 B5 B3 1 4 0 B1 B5 1 4 0 B1 B6 1 4 0 B1 B5 9ECRfffh'-r OF0R1q 'i ODl9 May 22 2018 20180522 - Notes from May 22 Phone C AM 3 docx CCA meets with EAP CM EAP press CA EAP EX to coordinate response and advise EAP rollout evening Mission China holds town halls across Embassy and consulates in China congress notified and warden message sent after $ ijppgpy¢$ bti6rt i AM Press aware I I 1 4 0 B1 B5 B7 A B3 1 4 0 B1 B6 May 23 2018 S briefs Congress at budget hearing mentions Guangzhou incident and promises to lead interagency task force May 25 2018 D-led task force holds first meeting 1 4 0 B1 tM-a-y 2-7 -2-01-8 -- --B6 B7 A r May 28 2018 May 29 2018 EAC convened 1 4 0 B1 18-HAVANA-39 - HSR 180529 pdf 18-HAVANA-41 - EAC 180529 pdf 1 4 8 1 4 0 B1 Page 21 of 22 5fi' Cltt 'fh1 0r'OKN1'1 0Df3 Page 22 of22 1 4 0 B1 B3 1 4 0 B1 B5 B3 Attachment 2 Research JAMA I Preliminary Communication Neurological Manifestations Among US Government Personnel Reporting Directional Audible and Sensory Phenomena in Havana Cuba Randel L Swanson II DO PhD Stephen Hampton MD Judith Green-McKenzie MD MPH Ramon Diaz-Arrastia MD PhD M Sean Grady MD Ragini Verma PhD Rosette Biester PhD Diana Duda PT DPT Ronald L Wolf MD PhD Douglas H Smith MD IMPORTANCE Fram late 2016 through August 2017 US government personnel serving on diplomatic assignment in Havana Cuba reported neurological symptoms associated with exposure to auditory and sensory phenomena OBJECTIVE To describe the neurological manifestations that followed exposure to an unknown energy source associated withauditory and sensory phenomena DESIGN SETTING AND PARTICIPANTS Preliminary results from a retrospective case series of US government personnel in Havana Cuba Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms the individuals reported a similar constellation of neurological symptoms resembling brain injury These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment EXPOSURES Report of experiencing audible and sensory phenomena emanating from a distinct direction directional phenomena associated with an undetermined source while serving on US government assignments in Havana Cuba since 2016 MAIN OUTCOMES AND MEASURES Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations Additional objective assessments included clinical tests of vestibular dynamic and static balance vestibulo-ocular reflex testing caloric testing oculomotor measurement of convergence saccadic and smooth pursuit eye movements cognitive comprehensive neuropsychological battery and audiometric pure tone and speech audiometry functioning Neuroimaging was aIsa obtained RESULTS Of 24 individuals with suspected exposure identified by the US Department of State 21 completed multidisciplinary evaluation an average of 203 days after exposure Persistent symptoms 3 months after exposure were reported by these individuals including cognitive n 17 81% balance n 15 71% visual n '18 86% and auditory n 15 68% dysfunction sleep impairment n 18 86% and headaches n 16 76% Objective findings included cognitive n ' 16 76% vestibular n ' 17 81% and oculomotor n '15 71% abnormalities Moderate to severe sensorineural hearing loss was identified in 3 individuals Pharmacologic intervention was required for persistent sleep dysfunction n 15 71% and headache n 12 57% Fourteen individuals 67% were held from work at the time of multidisciplinary evaluation Of those 7 began graduated return to work with restrictions in place home exercise programs and higher-level work-focused cognitive rehabilitation CONCLUSIONS AND RELEVANCE In this preliminary report of a retrospective case series persistent cognitive vestibular and oculomotor dysfunction as well as sleep impairment and headaches were observed among US government personnel in Havana Cuba associated with reports of directional audible and or sensory phenomena of unclear origin These individuals appeared to have sustained injury to widespread brain networks without an associated history of head trauma JAMA 2018 319 11 1125-1133 doi 10 1001 jama 2018 1742 Pul llished online Fel lruary15 2018 Editorial page 1098 mJ Author Audio Interview Related article page 1079 Supplemental content Author Affiliations Author affiliations are listed at the end ofthis article Corresponding Author Douglas H Smith MD Department of Neurosurgery and Center for Brain Injury and Repair University of Pennsylvania Perelman School of Medicine 3320 Smith Walk 105 Hayden Hall Philadelphia PA 19104 smithdou@upenn edu 1125 Research Preliminary Communication Clinical Findings and Outcomes in US Government Personnel Reporting Directional Sensory Phenomena in Cuba Cuba began presenting to their embassy medical unit after experiencing unusual auditory and or sensory stimuli of variable intensity and character with associated onset of varied neurological manifestations Initial signs and symptoms pointed toward injury of the auditory system leading to the establishment of a triage program at the University of Miami centered around otolaryngology evalua­ tion Eighty embassy community members underwent initial evaluation between February and April 2017 and 16 individuals were identified with similar exposure history and a constellation of neurological signs and symptoms commonly seen following mild traumatic brain injury also referred to as concussion 1 Exposures continued with time and 8 additional individuals were identified who had similar findings The US Department of State Bureau of Medical Ser­ vices subsequently convened an expert panel in July 2017 which came to consensus that the triage findings were most likely related to neurotrauma from a nonnatural source and recommended that further investigation into this novel clus­ ter of findings was necessary The University of Pennsylvania's Center for Brain Injury and Repair was subsequently selected to coordinate multidis­ ciplinary clinical evaluation treatment and rehabilitation of individuals identified during initial triage and additional pa­ tients with exposure The purpose of this preliminary com­ munication is to describe preliminary findings from 21 pa­ tients who were exposed to the same nonnatural source 1 Key Points Question Are there neurological manifestations associated with reports of audible and sensory phenomena among US government personnel in Havana Cuba Findings In this case series of21 individuals exposed to directional audible and sensory phenomena a constellation of acute and persistent signs and symptoms were identified in the absence of an associated history of blunt head trauma Following exposure patients experienced cognitive vestibular and oculomotor dysfunction along with auditory symptoms sleep abnormalities and headache Meaning The unique circumstances of these patients and the consistency of the clinical manifestations raised concern for a novel mechanism of a possible acquired brain injury from a directional exposure of undetermined etiology an abbreviated list of objective measures used during clinical assessments and supplements for additional information 2 29 Cognitive Neurobehavioral and Mood Evaluations When clinically indicated comprehensive neuropsychologi­ cal assessments were conducted by experienced neuropsy­ chologists who were not blinded to patient status Neuro­ psychological test batteries included assessment of the following domains 1 auditory attention 2 auditory and visual working memory 3 auditory and visual memory 4 visual-spatial perception 5 visual-motor construction 6 motor function 7 language function 8 executive func­ tion 9 processing speed 10 academic achievement Methods Design This retrospective study was approved by the institutional re­ view board of theUniversity of Pennsylvania's Perelman School of Medicine which waived the need for informed consent The participants signed general consent forms for treatment permitting use of their data in research Because of security and confidentiality considerations individual-level demo­ graphic data cannot be reported Clinical Approach The US Department of State directly referred individuals with suspected exposure to the University of Pennsylvania for comprehensive evaluation and treatment A multidisci­ plinary team was convened consisting of physical medicine and rehabilitation occupational medicine neurology neuro­ radiology and neurosurgery Each specialist independently obtained clinical histories and conducted comprehensive assessments Reported signs and symptoms were extracted from these interviews Based on individual clinical indication additional refer­ rals were made to vestibular physical therapy neuro­ optometry neuropsychology occupational therapy speech therapy audiology otorhinolaryngology and sleep medicine for focused evaluation and treatment Patients were referred to the University of Pennsylvania for clinical care as opposed to enrollment in a structured research study The Box shows 11 reasoning 12 mood functioning and 13 effort Box and eAppendix in the Supplement Following neuropsycho­ logical testing individuals with cognitive deficits were referred for cognitive rehabilitation with occupational therapy speech therapy or both depending on the indi­ vidual clinical indication Cognitive rehabilitation was inten­ tionally not started prior to completion of neuropsychologi­ cal testing to avoid affecting results Balance and Vestibular Evaluations Clinical evaluations identifying balance abnormalities prompted referral to vestibular physical therapy Focused vestibular evaluation included expert clinical assessment and the use of validated measures of static and dynamic balance Box 1-5 21 Also per clinical indications patients were referred to audiology for comprehensive evaluation of the peripheral vestibular system including caloric reflex testing Indi­ viduals confirmed to have a unilateral peripheral vestibu­ lopathy ie relative vestibular reduction of 25% on caloric reflex testing underwent magnetic resonance imaging MRI of the head with and without gadolinium contrast with focus on the internal auditory canals in addition to the MRI sequences detailed Oculomotor Evaluations Individuals found on clinical evaluation to have abnormalities of oculomotor function were referred to neuro-optometry for further evaluation and treatment Oculomotor function was 1126 JAMA March 20 2018 Volume 319 Number 11 Jama com Clinical Findings and Outcomes in US Government Personnel Reporting Directional Sensory Phenomena in Cuba Preliminary Communication Research quantified using the following standard optometric clinical measures Box 25 26 Vergence testing included step vergence with prism bar vergence facility with prisms and near point of convergence Accommodative testing in nonpresbyopic pa­ tients included amplitude of accommodation accommoda­ tive facility with plus and minus lenses and accommodative lag Pursuit and saccadic testing was done qualitatively to assess accuracy of tracking eye movements and whether symptoms were provoked as with Vestibular Ocular Motor Screening 29 Saccadic speed and accuracy were quantified using the Developmental Eye Movement test 26 28 a timed visual-verbal test Diagnoses of accommodative vergence and or saccadic pursuit dysfunction were made using stan­ dardized criteria in conjunction with symptomatic reporting which were quantified using the Convergence Insufficiency Symptoms Survey 27 Auditory Evaluations Audiometry evaluations were performed prior to referral for care at the University of Pennsylvania However when pa­ tients had balance function testing as described here com­ prehensive audiology evaluation included both pure tone and speech audiometry Box Examples of Standardized Measures Used in Clinical Assessments• Cognitive Boston Diagnostic Aphasia Examination2 California Verbal Learning Test-2nd Editi on1 Grooved Pegboard4 Test of Memory Malingering' Trail Making Test Parts A and B6 Wechsler Adult Intelligence Scale-lV7 Wechsler Memory Scale-lV8 Mood Beel Depression Inventory 2nd edition 9 Beck Anxiety Inventory10 11 Frontal Systems Behavior Scale 12 Post-Traumatic Stress Disorder Checklsi t13 ·14 Balance and vestibular Functional Gait Assessment15 Activities-Specific Balance Confidence ' Balance Error Scoring System '7 Clinical Test of Sensory Organization and Balance18 9 Imaging Evaluations Dizziness Handicap lndex 20 Computerized Dynamic Post urography21 22 Initial conventional MRI sequences were acquired at 3T on a Siemens Magnetom Prismafit scanner and included high­ resolution sagittal 3-dimensional MP-RAGE T2 SPACE and Caloric reflex test23 ·24 Vision and oculomotor Formal Evaluation of Vergence and Accommodatio n25 26 FLAIR SPACE coronal 2-dimensional T2-weighted imaging axial2-dimensionaldiffusion-weighted imaging and axial T2 gradient echo Resulting images were clinically interpreted by neuroradiology clinicians Results There were 21 individuals evaluated 11 women and 10 men with a mean age of 43years Multidisciplinary evaluations be­ gan anaverage of203 days range 3-331days median 189 days interquartile range 125 days following exposure Table 1 Exposure For 18 of the 21individuals 86% there were reports of hear­ ing a novel localized sound at the onset of symptoms in their homes and hotel rooms Table 2 Affected individuals de­ scribed thesounds as directional intensely loud and with pure and sustained tonality Of the patients high-pitched sound was reported by 16 76% although 2 10% noted a low-pitched sound Words used to describe the sound include buzzing grinding metal ' piercing squeals and humming ' The sounds were often associated with pressurelike n 9 43% or vibratory n 3 14% sensory stimuli which were also experienced by 2 of the 3 patients who did not hear a sound The sensory stimuli were likened to air baffling in­ side a moving car with the windows partially rolled down Both the sound and sensory stimuli were often described as directional in that the individuals perceived a distinct di­ rection from which the sensation emanated hereafter re- Convergence Insufficiency Symptoms Survey27 Developmental Eye Movement Test26 28 Vestibular Ocular Motor Screening29 a Measures were used based onclinical indications therefore every patient did not complete all measures in this abbreviated list ferred to as directional phenomena Further the directional phenomena appeared to be localized to a precise area as in­ dividuals n 12 57% noted that after changing location the sensation disappeared and the associated symptoms re­ duced Five individuals 24% reported covering their head and or ears although doing so did not result in attenuation of the directional phenomena Accurately determining the dose and duration of expo­ sure has been difficult because of the limitations of patient recall Some patients were awakened by sounds and were unsure of the start of the event The shortest reported event involved two 10-second pulses reported as a single exposure episode whereas other patients reported that they perceived sound continuously for longer than 30 minutes Owing to security concerns further details of potential dosage cannot be provided Of the affected individuals 20 95% reported immedi­ ate onset of neurological symptoms associated with direc­ tional phenomena eTable 1 in the Supplement One indi­ vidual awoke from sleep with acute symptoms including headache unilateral ear pain and hearing changes butdid not perceive directional phenomena From days to weeks after ex­ posure individuals reported that they experienced the onset Jama com JAMA March 20 2018 Volume 319 Number 11 1127 Research Preliminary Communication Clinical Findings and Outcomes in US Government Personnel Reporting Directional Sensory Phenomena in Cuba Table 1 Demographics of Patients Evaluated at the University of Pennsylvania• Potentially identifying information intentionally omitted for security and privacy concerns Table 2 Exposure Descriptions of the Directional Phenomena Associated Sound Associated Sensory Stimuli Duration 3 mo Patient No Reported High Pitch Low Pitch Reported Pressure Vibration Movement Attenuation' Persistent Symptoms Objective Findings Required Treatment 1 X X X X X X 2 X X X X X X 3 X X X 4 X X X X X X X 5 X X X X X X X 6 X X X X X X X X 7 X X X X 8 X X X X X X 9 X X X X X X X 10 X X X X X X X 11 X X X X X X X 12 X X X X X X X 13 X X X X X X 14 X X X X X X 15 X X X X X X X X 16 X X X X X X 17 X X X X X X X X 18 X X X 19 X X X X X 20 X X X X X X 21 X X X X X No % 18 86 16 76 2 10 12 57 9 43 3 14 12 57 20 95 18 86 18 86 a Patients reported attenuation of sound pressure or vibration when moving to a different location ofadditional cognitive neurobehavioral mood and physical symptoms Twenty individuals 95% reported that they ex­ perienced persistent 3 months symptoms and18 individu­ als 86% exhibited objective clinical manifestations in 6 pre­ dominant domains Table 3 Cognitive Neurobehavioral and Mood Findings Persistent cognitive manifestations were reported by 17 indi­ viduals 81% Subjective symptoms included memory prob­ lems n 16 76% feeling mentally foggy n 16 76% im­ paired concentration n 15 71% and feeling cognitively slowed n 14 67% Table 3 In addition they reported neu­ robehavioral difficulties including irritability n 14 67% ner­ vousness n 12 57% feeling more emotional n 11 52% and sadness n 5 24% For at least 6 individuals 29% a clear change in work performance was noted by supervisors and col­ leagues eTable 1 in the Supplement Individuals also re­ ported a good day-bad day pattern where significant cog­ nitive or physical exertion would be followed by exacerbation of their symptoms for several days Cognitive symptoms as well as disequilibrium and headache reportedly were also fre­ quently exacerbated by cardiovascular exercise Multidisciplinary evaluations raised concern for cogni­ tive impairment in 16 individuals 76% Prior to referral 4 of these individuals underwent neuropsychological evaluation data not shown as generated outside of the University of Pennsylvania Repetition of comprehensive neuropsycho­ logical testing is precluded within 1 year due of practice effects when material is presented within this timeframe With previous exposure to material the individual may score higher on a repeated neuropsychological evaluation within 1 year Neuropsychological assessments were performed on 10 individuals after referral Of those interpretation was ongo­ ing in 4 at the time of this publication Per their preference 2 individuals did not complete neuropsychological testing For the 6 individuals with complete neuropsychological testing data and analysis at the University of Pennsylvania all had significant areas of cognitive weakness and or impair­ ment eTables 2 3 and 4 in the Supplement Impairments were found in executive function n 6 motor function n 5 auditory and visual memory n 4 visual-spatial perception and visual-motor construction n 4 auditory attention and working memory n 3 language n 3 pro­ cessing speed n 4 and reasoning n 1 All individuals 1128 JAMA March 20 2018 Volume 319 Number 11 Jama com Clinical Findings and Outcomes in US Government Personnel Reporting Directional Sensory Phenomena in Cuba Preliminary Communication Research Table 3 Prevalence of Persistent Symptoms and Objective Findings• Subjective Objective Domain Symptom No % Finding No % Cognitive and behavioral Combined 17 81 Neuropsychological testing indicated 16 76 b Difficulty remembering 16 76 Neurapsychologic il testing performed at Penn 10 48 Mental fog 16 76 Neuropsychological testing outside Penn 4 19 Difficulty concentrating 15 71 Neuropsychological testing not yet performed 2 10 Feeling slowed 14 67 Cognitive rehabilitation 13 Irritability 14 67 Feeling more emotional 11 52 Balance and vestibular Combined 15 71 Vestibul ir physical therapy referral 17 81 Balance problems 14 67 Static postural stability 16 76 Dizziness 13 62 Dynamic b ilance 16 76 Nausea 7 33 VOR dysfunction Unililternl rnlork impairment 15 71 4 31 ' Vestibular rehabilitation 17 81 Vision and oculomotor Combined 18 86 Neuro-optometry referral 15 71 Visual problems 16 76 Convergence insufficiency 11 52 Light sensitivity 13 62 Smooth pursuit dysfunction 11 52 Difficulty reading 12 57 s ccadic dysfunction 10 47 Eye strain 11 52 Neura-optometric rehabilitation 14 67 Auditory Combined 15 68 Audiology referral 13 62 Sound sensitivity 14 67 Moderate to severe SNHL 3 23 ' Tinnitus 12 57 Heoring aid provided 3 14 Hearing reduction 9 43 Ear pressure 8 38 Sleep Combined 18 86 Pharmacologic il intervention 15 71 Drowsiness or fatigue 16 76 Decreased sleep duration 15 71 Trouble falling asleep 14 67 Headache Combined 16 76 Pharmacological intervention 12 57 With cognitive t isks 13 62 With therapy 11 52 Due to photophobi i 9 43 Due to phonophobia 6 29 Over ill Combined subjective 20 95 Combined objective 18 86 Abbreviations Penn University of Pennsylvania SNHL sensorineural hearing loss VOR vestibulo-ocular reflex • Persistent defined as presence more than 3 months after exposure b Neuropsychological characterization ongoing Start of cognitive rehabilitation held until neuropsychological testing performed 'Of 13 patients tested thus far during persistent symptom evaluation demonstrated a high level of effort during testing and had in the subacute and persistent stages acute stage during intact cognitive domains including visual working memory and academic achievement Neurobehavioral function was evaluated using the Frontal System Behavior Scale a self-report measure of frontal lobe dysfunction Specifically comparing before and after expo­ sure retrospectively via patient recall and self-report indi­ viduals noted apathy n 5 executive dysfunction n 4 and disinhibition n 2 Two individuals met criteria for post­ traumatic stress disorder and endorsed severe levels of anger on the Brief Mood Survey 1 of whom also endorsed moderate to severe levels of depression and anxiety Balance and Vestibular Findings Individuals described acute nausea n 7 33% and dizziness n 5 24% during exposure which continued to progress or hours following exposure subacute stage days to weeks after exposure patient recall and persistent stage more than 3 months after exposure Specifically more than 3 months after exposure individuals reported a higher prevalence of dizziness n 13 62% and nausea n 7 33% in addition to general balance problems n 14 67% Table 3 These symptoms were exacerbated by walking quickly tasks involving head movements complex visual environments or in some cases while simply standing still Balance symptoms were also worsened with eyes closed or in low light conditions Clinical examinations raised concern for balance impair­ ment in17 patients 81% prompting referral to vestibular physi­ cal therapy Focused vestibular evaluations demonstrated im­ pairments in static postural stability n 16 76% dynamic Jama com JAMA March 20 2018 Volume 319 Number 11 1129 Research Preliminary Communication Clinical Findings and Outcomes in US Government Personnel Reporting Directional Sensory Phenomena in Cuba balance n 16 76% and the vestibulo-ocular reflex n 15 71% eTables 5 6 and 7 in the Supplement Patients with the most severe balance impairments on clinical evaluation under­ went caloric reflex testing which demonstrated peripheral vestibular dysfunction in 4 ofl3 patients evaluated MRI find­ ings focusing on the internal auditory canals on these 4 pa­ tients were normal Taken together these balance symptoms and evaluation findings areconsistent with central and in some cases peripheral vestibular abnormalities Oculomotor Findings Of the individuals with persistent symptoms 16 76% re­ ported visual problems Table 3 Light sensitivity n 13 62% and difficulty reading n 12 57% were also frequently re­ ported Eye strain n 11 52% was experienced particularly with reading and was associated with headaches disequilib­ rium and nausea Clinical examinations raised concern for oculomotor dys­ function in 15 individuals 71% prompting referral to neuro­ optometry The most common findings confirmed on focused oculomotor evaluation were convergence insufficiency n 11 52% abnormal smooth pursuits n 11 52% andsaccadic dys­ function n 10 47% eTables 8 and 9in the Supplement Simi­ lar to vestibular testing that provoked symptoms oculomotor examination elicited headache and disequilibrium Auditory Findings At the onset of the directional phenomena affected individu - als reported hearing a loud sound n 18 86% associated with ear pain n 7 33% and tinnitus n 6 29% Within days to weeks following exposure individuals continued to report tin­ nitus n 12 57% and ear pain n 5 24% with the addi­ tion ofa change in hearing n 7 33% and sensitivity to noise n 5 24% More than 3 months after exposure sound sen­ sitivity was the most common auditory concern n 14 67% followed by tinnitus n 12 57% and ear pressure n 8 38% While 9 individuals 43% reported persistent hearing re­ duction pure tone audiometry including pure tone average and word identification revealed moderate to severe senso­ rineural hearing loss in 3 individuals 23% eTable 10 in the Supplement who were fitted with hearing aids For 2 indi­ viduals the moderate to severe sensorineural hearing loss was unilateral and corresponded with the side of peripheral ves­ tibular dysfunction on caloric testing Otoscopy and tympa­ nometry findings were unremarkable Sleep Individuals commonly reported issues withsleep n 18 86% including reduced sleep duration n 15 71% and difficulty falling asleep n 14 67% In addition individuals experi­ enced significant daytime fatigue n 16 76% Most indi­ viduals required pharmacological intervention to improve sub­ jective report of sleep architecture n 15 71% eTable 11 in the Supplement Headaches At the initiation of directional phenomena exposure 8 indi­ viduals 38% reported immediate onset of headache while 5 24% reported intense head pressure In the days to weeks fol­ lowing exposure 17 individuals 81% developed headaches with 16 76% experiencing persistent headaches longer than 3 months after exposure Table 3 In the persistent stage headaches were reported to be ex­ acerbated or associated with cognitive tasks n 13 62% re­ habilitative therapies n 11 52% photophobia n 9 43% and phonophobia n 6 29% Patients with antecedent head­ aches were able to differentiate the character of these head­ aches from that of their standard headaches Headaches were generally reported to improve with medications n 12 57% and appropriate therapies for oculomotor and vestibular im­ pairments eTable 11 in the Supplement Imaging MRI neuroimaging was obtained in all 21 patients Most patients had conventional imaging findings which were within normal limits at most showing a few small nonspe­ cific T2-bright foci in the white matter n 9 43% There were 3 patients with multiple T2-bright white matter foci which were more than expected for age 2 mild in degree and 1 with moderate changes The pattern of conventional imaging findings in these cases was nonspecific with regard to the exposure insult experienced and the findings could perhaps be attributed to other preexisting disease processes or risk factors Advanced structural and functional neuroim­ aging studies are ongoing Rehabilitation and Return to Work Individualized rehabilitation programs were developed which included combinations of neuro-optometric rehabili­ tation n 14 67% vestibular physical therapy n 17 81% and cognitive rehabilitation with speech pathology and or occupational therapy n 13 62% The most symptomatic patients n 14 67% requiring multiple therapies did not return to work Vestibular physical therapy sessions focused on balance retraining static and dynamic posture control with substitu- tion via visual and somatosensory systems gaze stabiliza - tion exercises habituation smooth pursuits and saccadic eye movement exercises Patients treated with vestibular reha­ bilitation have demonstrated a positive response with im­ proved balance and reduction of disequilibrium Formal neuro-optometric rehabilitation including ma­ nipulation of disparity vergence and accommodative ampli­ tude and latency has been used to treat ocular motor defi­ cits Rehabilitation for abnormal smooth pursuit and saccadic dysfunction was coordinated between neuro-optometric re­ habilitation vestibular physical therapy and occupational therapy Vestibular physical therapy focused on oculomotor function with the body in motion and occupational therapy emphasized functional tasks such as visual scanning in a simu­ lated work environment Following comprehensive neuropsychological testing a formal cognitive rehabilitation program was initiated in the form of occupational therapy and or speech therapy Early return to work with intensive cognitive loading led to an exacerbation of neurocognitive vestibular and visual 1130 JAMA March 20 2018 Volume 319 Number 11 Jama com Clinical Findings and Outcomes in US Government Personnel Reporting Directional Sensory Phenomena in Cuba Preliminary Communication Research symptoms in7individuals 33% Individualized return to work plans were designed to reintegrate individuals using a step­ wise process and appropriate work modifications were largely determined to continue to work or return to full duty even when encouraged by health care professionals to take sick leave While not systematicallyexcluded viral etiologies chemi­ cal etiologies or both associated with acute onset of persis­ Discussion Preliminary findings are described of a case series of indi­ viduals stationed in Havana Cuba nearly all of whom re­ ported directional audible and or sensory phenomena that was followed by the development of a consistent cluster of neu­ rological signs and symptoms The clinical manifestations may represent a novel clinical entity which appears to have resulted from a widespread brain network dysfunction ie cognitive oculomotor and central vestibular as seen in mild traumatic brain injury or concussion 30 as well as in­ jury to the peripheral vestibular system in some cases It is currently unclear if or how the noise is related to the re­ ported symptoms In particular sound in the audible range 20 Hz-20 000 Hz is not known to cause persistent injury to the central nervous system and therefore the described sounds may have been associated with another form of exposure Cognitive symptoms including difficulty remembering n 16 76% and feeling cognitively slowed n 14 67% were the most problematic for individuals in this series more than 3months after exposure with neuropsychologicaltesting iden­ tifying impairments in at least 1cognitive domain in all 6 pa­ tients who completed neuropsychological evaluation to date eTables 2 3 and 4 in the Supplement Cognitive difficulties interfered with these patients' ability to multitask process in­ formation quickly with accurate recall solve problems and per­ form rapid decision making Compared with vestibular and oculomotor impairments cognitive impairments are often the slowest to improve following acquired brain injury which was observed in this series Therefore extended cog­ nitive rehabilitation with emphasis on return to work was used In addition it is not uncommon for patients with neu­ rological injury resulting in cognitive impairment to have mood disturbances such as depression anxiety and or posttrau­ matic stress disorder Mood dysfunction can directly result from acquired brain injury or develop in response to the pre­ cipitating event and novel deficits 3-1 33 The presence of subjective neurological symptoms pre­ senting in a cohesive community has raised concerns for col­ lective delusional disorders including mass psychogenic ill­ ness However neurological examination and cognitive screens did not reveal evidence of malingering and objective testing and behavioral observations during cognitive testing indicated high levels of effort and motivation Several of the objective manifestations consistently found in this cohort such as oculomotor and vestibular testing abnormalities could not have been consciously or unconsciously manipu­ lated Furthermore mass psychogenic illness is often associ­ ated with transient benign symptoms with rapid onset and recovery often beginning with older individuals 34 35 In con­ trast the Havana cohort experienced persisting disability of a significant nature and are broadly distributed in age Rather than seeking time away from the workplace the patients tent neurological impairment and peripheral vestibulopathy with the directional nature of exposure descriptions are not readily apparent No other manifestations of viral illness such as preceding fever were identified It is unlikely a chemical agent could produce these neurological manifestations in the absence of other organ involvement particularly given that some individuals developed symptoms within 24 hours ofar­ riving in Havana There are important considerations in this investigation In particular the anatomic substrates causing the symptoms have not yet been identified This may represent a significant challenge because even the designation of concussion ' is not yet a true diagnosis as no definitions include the underlying cause Nonetheless there is an emerging consensus that con­ cussion or mild traumatic brain injury is a type of brain net­ work disorder based on classic symptoms eg slowed pro­ cessing speed and memory dysfunction as well as changes in the white matter tracts and consecutive connectivity as de­ tected with advanced neuroimaging studies Beyond the absence ofblunt head trauma there were ad­ ditional notable differences between the manifestations ob­ served in the Havana cohort and characteristicacute and per­ sistent symptoms of concussion For example individuals experienced unilateral ear pain and tinnitus after exposure and some were later detected to have a unilateral peripheral ves­ tibulopathy along with central vestibular dysfunction a find­ ing uncommon in concussion Further studies have reported that while most individuals following concussion have a rela­ tively rapid full recovery at least 15% are thought to experi­ ence characteristic persisting symptoms 373 8 In contrast to clas­ sic concussions most patients referred following suspected exposure in Havana exhibited significant impairment that per­ sisted for months with no significant improvement in mul­ tiple cases until rehabilitation was initiated For practicing clinicians if a patient presents reporting a similar potential exposure and symptoms similar to those observed in mild traumatic brain injury in addition to a thor­ ough history objective evaluation should include screening assessments of vestibular oculomotor and cognitive func­ tioning Based on findings of this assessment appropriate referrals to subspecialists should be considered including neurorehabilitation physiatry vestibular physical therapy neuro-optometry neuropsychology and audiology Limitations This study has several limitations First due to the sensitive nature of this publication certain details typically reported in a case series of exposure were omitted including specifics about geography relationships between individuals and individual demographics Second because these patients' first evaluation was elsewhere each patient did not undergo each of the tests described In particular neuropsychological characterization was incomplete at the time of publication Jama com JAMA March 20 2018 Volume 319 Number 11 1131 Research Preliminary Communication Clinical Findings and Outcomes in US Government Personnel Reporting Directional Sensory Phenomena in Cuba Preliminary results were presented given the importance and strong public interest in this case series Third the reha­ bilitative course of this Havana cohort may not be represen­ tative because this represents a referral population There may be additional individuals exposed while in Havana Cuba who have not been identified due to subtler manifes­ tations that either resolved spontaneously or did not prompt presentation for medical treatment Therefore the actual number of individuals exposed is unknown and the relative dose of exposure that causes acute and chronic symptoms remains unclear Conclusions In this preliminary report of a retrospective case series per­ sistent cognitive vestibular and oculomotor dysfunction as well assleep impairment and headaches were observed among US government personnel in Havana Cuba associated with reports of directional audible and or sensory phenomena of unclear origin These individuals appeared to have sustained injury to widespread brain networks without an associated his­ tory of head trauma ARTICLE INFORMATION Accepted for Publication February 8 2018 Published Online February 15 2018 doi 10 1001 jama 2018 1742 Author Affiliations Department of Physical Medicine and Rehabilitation University of Pennsylvania Perelman School of Medicine Philadelphia Swanson Hampton Biester Center for Brain lnJury and Repair University of Pennsylvania Philadelphia Swanson Hampton Green-McKenzie Diaz-Arrastia Grady Verma Biester Duda Wolf Smith Division of Occupational and Environmental Medicine Department of Emergency Medicine Perelman School of Medicine University of Pennsylvania Philadelphia Green-McKenzie Department of Neurology University of Pennsylvania Perelman School of Medicine Philadelphia Diaz-Arrastia Department of Neurosurgery University of Pennsylvania Perelman School of Medicine Philadelphia Grady Smith Department of Radiology University of Pennsylvania Perelman School of Medicine Philadelphia Verma Wolf Penn Therapy Fitness Good Shepherd Penn Partners University of Pennsylvania Philadelphia Duda Author Contributions Drs Smith and Swanson had full access to all ofthe data in the study and take responsibility for the integrity ofthe data and the accuracy ofthe data analysis Concept and design Swanson Hampton Smith Acquisition analysis or interpretation of data All authors Drafting of the manuscript Swanson Hampton Biester Duda Smith Critical revision of the manuscript for important inteffectuaf content All authors Statistical analysis Swanson Hampton Smith Administrative technical or material support All authors Supervision Swanson Smith Conflict of Interest Disclosures All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest Dr Green-McKenzie reported receiving grants from Health Resources and Services Administration and the National Institute for Occupational Safety and Health No other disclosures were reported Disclaimer Support for this article was provided by the US government in the form of background information and referral of patients The findings and conclusions are those of the authors and should not be construed as officially reflecting the views ofthe US Department of State Additional Contributions We are grateful to the following individuals who did not receive compensation for their role in the study Michael Gallaway OD neuro-optometry consultant Department of Optometry Salus University Philadelphia Mary-Fran Madden OTR L CBIS MSCS occupational therapy consultant Penn Therapy Fitness Good Shepherd Penn Partners University of Pennsylvania Philadelphia Darlene Mancini CCC-SLP speech language pathology consultant Penn Therapy Fitness Good Shepherd Penn Partners University of Pennsylvania Philadelphia Danielle Sandsmark MD PhD neurology consultant Department of Neurology University of Pennsylvania Perelman School of Medicine Philadelphia Grant Liu MD neuro-ophthalmology Department of Neurology University of Pennsylvania Perelman School of Medicine Philadelphia Nora Johnson MBA MS PsyD neuropsychology consultant Department of Physical Medicine Rehabilitation University of Pennsylvania Perelman School of Medicine Philadelphia Sherrie Davis AuD audiology consultant Department of Otorhinolaryngology University of Pennsylvania Perelman School of Medicine Philadelphia Michael J Ruckenstein MD otorhinolaryngology consultant Department of Otorhinolaryngology University of Pennsylvania Perelman School of Medicine Philadelphia Charles Bae MD sleep medicine consultant Department of Neurology University of Pennsylvania Perelman School of Medicine Philadelphia David M Raizen MD PhD sleep medicine consultant Department of Neurology University of Pennsylvania Perelman School of Medicine Philadelphia Sharon Schutte-Rodin MD sleep medicine consultant Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia and Douglas J Wiebe PhD epidemiology and biostatistician consultant Department of Biostatistics and Epidemiology University of Pennsylvania Perelman School of Medicine Philadelphia REFERENCES 1 US Senate Committee on Foreign Relations Subcommittee on Western Hemisphere Transnational Crime Civilian Security Democracy Human Rights and Global Women·s Issues Attacks on US diplomats in Cuba https www foreign senate gov hearings attacks-on-us-diplomats-in 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Garzia RP Richman JE Nicholson SB Gaines CS A new visual-verbal saccade test the Development Eye Movement test DEM J Am OptomAssoc 1990 61 2 124-135 29 Mucha A Collins MW Elbin RJ et al A brief Vestibular Ocular Motor Screening VOMS assessment to evaluate concussions preliminary findings Am J Sports Med 2014 42 10 2479-2486 30 Johnson VE Stewart W Smith DH Axonal pathology in traumatic brain injury Exp Neural 2013 246 35-43 31 Alderfer BS Arciniegas DB Silver JM Treatment of depression following traumatic brain injury J Head Trauma Rehabil 2005 20 6 544-562 32 Bryant R Post-traumatic stress disorder vs traumatic brain injury Dialogues Clin Neurosci 2011 13 3 251-262 33 Jorge RE Arciniegas DB Mood disorders after TBI PsychiatrC in North Am 2014 37 1 13-29 34 Jones TF Craig AS Hoy D et al Mass psychogenic illness attributed to toxic exposure at a high school N Engl J Med 2000 342 2 96-100 35 Weir E Mass sociogenic illness CMAJ 2005 172 1 36 36 Shenton ME Hamada HM Schneiderman JS et al A review of magnetic resonance imaging and diffusion tensor imaging findings in mild traumatic brain injury Brain Imaging Behav 2012 6 2 137-192 37 Mcinnes I Friesen CL MacKenzie DE Westwood DA Boe SG Mild traumatic brain injury mTBI and chronic cognitive impairment a scoping review PLoS One 2017 12 4 e0174847 38 Bigler ED Neuropsychology and clinical neuroscience of persistent post-concussive syndrome J Int Neuropsychol Soc 2008 14 1 1-22 Jama com JAMA March 20 2018 Volume 319 Number 11 1133 Attachment 3 UNCLASSIFIED April 11 2018 MEMORANDUM To From Ambassador Peter Bodde Joshua L Dorosin Deputy Legal Adviser Subject B5 UNCLASSIFIED UNCLASSIFIED - 2 - B5 UNCLASSIFIED Attachment 4 C ' - 1 · · · h ' · ' t' ' 1 f 'j ' From SMART Archive Sent 6 6 2017 8 54 08 AM To SMART Core Subject 1 4 0 1 4 G B1 B7 F MRN Oate OTG From Action E O TAGS Captions Subject 17 HAVANA67 Jun 06 2017 0612542 JUN i7 AMEMBASSY HAVANA WASHDC SECSTATE ROUTINE 13526 ASEC NOFORN OS CHANNEL 1 4 0 1 4 G B1 B7 F This document is classified SECRET NOFORN in its entirety b B6 B7 C 1 4 0 1 4 G B1 B7 F 6 POC for this Cable is B6 B7 C Sig nature Classified By Derived From Declassify On Drafted By Approved By Released By Info Dissemination Rukl DELAURENTIS Name ------ OSCG 11 01 j HAVAN Havana Archive Copy 86 B7 C Attachment 5 SYSTEM II 90321 THE WHITE HOUSE WASHINGTON 8215637 June 2 1982 MEMORANDUM FOR THE VICE PRESIDENT THE SECRETARY OF STATE THE SECRETARY OF DEFENSE THE ATTORNEY GENERAL THE SECRETARY OF AGRICULTURE THE SECRETARY OF COMMERCE THE DIRECTOR OFFICE OF MANAGEMENT AND BUDGET THE DIRECTOR OF CENTRAL INTELLIGENCE THE CHAIRMAN JOINT CHIEFS OF STAFF THE ADMINISTRATOR AGENCY FOR INTERNATIONAL DEVELOPMENT THE DIRECTOR INTERNATIONAL COMMUNICATION AGENCY SUBJECT Staffing at Diplomatic Missions The President has approved the attached National Security Decision Directive on Staffing at Diplomatic Missions and Their Constituent Posts FOR THE PRESIDENT signed William P Clark Attachment NSDD 38 Reformatted for reproduction purposes only g mpnsdd combible doc pg 77 #15 SYSTEM II 90321 THE WHITE HOUSE WASHINGTON June 2 1982 National Security Decision Directive Number 38 STAFFING AT DIPLOMATIC MISSIONS AND THEIR CONSTITUENT POSTS This directive supersedes the directive of October 14 1974 and subsequent directives governing the Monitoring Overseas Direct Employment MODE system In accordance with my letter to Chiefs of Mission and the memorandum of September 22 1981 conveying it to heads of Executive Departments and Agencies all agencies with staffs operating under the authority of Chiefs of Mission will ensure that in coordination with the Department of State the Chiefs of Missions' approval is sought on any proposed changes in the size composition or mandate of such staff elements Departments and agencies wishing to initiate changes should transmit their proposals to Chiefs of Missions in consultation with the Department of State In the event the Secretary of State or his designee is unable promptly to resolve to the satisfaction of the parties concerned any disputes which may arise between Chiefs of Mission and Agency Heads or his designee the Secretary of State and the other Agency Head concerned will present the differing views to me for decision through the Assistant to the President for National Security Affairs Formal acknowledgment of changes approved by Chiefs of Mission or determined by me shall be transmitted to diplomatic missions by the Department of State 2 SYSTEM II 90321 Overseas staffing of elements with U S diplomatic missions abroad shall conform to decisions reached in accordance with the above procedures and decisions made through the budgetary process Departments and agencies will keep the Department of State informed as to current and projected overseas staffing authorizations for each diplomatic post differentiating between the number of U S personnel and the number of foreign national personnel authorized for each post The Department of State shall maintain a current record of staffing authorizations for each overseas post Agencies will cooperate with the Department of State in providing data including any data needed to meet special reporting requirements The Department of State in consultation with concerned agencies will develop guidelines by July 1 1982 for my approval to implement this directive signed Ronald Reagan 3 NSDD 38 GUIDELINES COVER LETTER SYSTEM II 90417 THE WHITE HOUSE WASHINGTON 8220142 July 13 1982 MEMORANDUM FOR THE VICE PRESIDENT THE SECRETARY OF STATE THE SECRETARY OF DEFENSE THE ATTORNEY GENERAL THE SECRETARY OF AGRICULTURE THE SECRETARY OF COMMERCE THE DIRECTOR OFFICE OF MANAGEMENT AND BUDGET THE DIRECTOR OF CENTRAL INTELLIGENCE THE CHAIRMAN JOINT CHIEFS OF STAFF THE ADMINISTRATOR AGENCY FOR INTERNATIONAL DEVELOPMENT THE DIRECTOR INTERNATIONAL COMMUNICATION AGENCY SUBJECT Guidelines to Implement NSDD 38 The attached Guidelines to replace all guidelines and other agreements previously in effect under the Monitoring Overseas Direct Employment System are approved FOR THE PRESIDENT signed William P Clark Attachment Guidelines Reformatted for reproduction purposes only g mpnsdd combible doc - pg 80 #16 4 NSDD 38 GUIDELINES 07 13 82 SYSTEM II 90417 GUIDELINES These guidelines are issued pursuant to the Presidential Directive of 2 June 1982 on Staffing at Diplomatic Missions and Constituent Posts These guidelines replace all guidelines and other agreements previously in effect under the Monitoring Overseas Direct Employment MODE system The purpose of the Directive and these guidelines is to allow the flexible systematic and expeditious deployment and management of personnel of all U S Government Agencies operating under the authority of Chiefs of Mission in support of U S foreign policy objectives These guidelines will ensure that the approval of Chiefs of Mission is sought by U S Government Agencies on proposed staffing changes for activities operating under the authority of Chiefs of Mission The Chiefs of Mission will transmit their views on overseas presence to the Department of State as department and agency representatives will communicate with their respective department agency headquarters in this regard These guidelines also provide for the resolution of disagreements should such arise between the Chiefs of Mission and department agency representatives and between the Department of State and department agency heads A Requests for Changes in Staffing 1 Preliminary or exploratory consultation by the requesting agency with the Chief of Mission regarding staffing changes is encouraged Such informal proposals may be initiated in Washington or by agency overseas representatives 2 Formal requests for approval of staffing changes as required by the Directive must be made by the cognizant Agency to the Chief of Mission in consultation with the Department of State Copies of such requests will be provided to the Department of State 3 The Chief of Mission will convey his views on formal requests to the Department of State The point of contact in the Department of State for such matters is the Office of Management Operations M MO Room 5 7427 since changed to the Office of Rightsizing the USG's Overseas Presence MIR SA-I Room H-1301 Washington D C 20522-0113 SYSTEM II 90417 Attention Assistant for Overseas Positions The Chief of Mission's response to the formal request should be addressed to that office for action Copies of requests and responses will be given to the appropriate regional and functional bureaus in the Department of State and the requesting agency B Resolution of Disagreements 1 If there are disagreements over staffing levels between Chiefs of Mission and Agency heads the views of both parties will be forwarded to MIMO MIR for immediate presentation to the Secretary of State for decision within 15 working days of receipt from M MO MIR 2 If the Secretary of State is unable to resolve the issue to the satisfaction of the parties concerned the Secretary and the Agency head concerned will present their respective views to the President for decision through the Assistant to the President for National Security Affairs C Formal acknowledgment of Changes Changes in staffing levels at individual posts reached in accordance with the above procedures will be provided by telegram from the Department of State to the Chief of Mission and the agencies concerned D Staffing Authorization Records The Department of State shall maintain a current record of staffing authorization for each overseas post Staffing authorization is defined as all full-time permanent direct-hire United States Government employees including Foreign Nationals and United States Military Personnel under the authority of a Mission Chief Departments and agencies will provide the current and projected overseas staffing authorization information required by the directive to the Department of State Office of Management Operations M MO Room 7427 since changed to the Office of Rightsizing the USG's Overseas Presence MIR SA-I Room H-1301 Washington D C 20522-0113 Attention Assistant for Overseas Positions That official will solicit additional information from departments and agencies when necessary to meet 6 special reporting requirements as established by statute or as levied by the NSC 0MB or the Congress Reformatted for reproduction purposes only g mpnsdd combible doc - pg 81-82 #16 Attachment 6 SEHSITIV£ BUT UNCLASSl FIED The High Threat High Risk Post Review Process B7 F 8l 3HSITIVE BUT UM'CLA S SIFIED 2 B7 F SENSIIIVEBOI UNCLASSIFIED Attachment 7 B7 A B7 E B3 B7 A B7 E B3 2 UNCLASSIHEO LES B7 E B3 B7 E B3 B7 E B3 B7 E B3 83 B3 B7 E 83 Attachment 8 NO DISCERNIBLE C LASSIFlCAT ON Vinyard Chandali A S ARB From Sent Cc Subject SMART Core Wednesday May 23 2018 4 03 AM Darnour Made C Durkin Luke T Cordell Janis W Harlow Graham B Michaud Matthew P Darnberg-Ott Gaetan W Snyder Nicholas J rsrnai Jerrier S Graham Jeffrey D DeRosa Jason M Lamontagne David M Lumpkin Helga K Brust Frederick E Ou Andrnw H Swaine Kelly M Wuebbels Mark C Blackstone Kevin Thornton Susan A Clark Mark D Helier James R Hathaway James L Handon-Davidson Linda D Brosius Theodore A Evans Peter O Dean Nicholas J Trenkle Timothy P Dupuy Sandra L Kalajian Usa K Hattingh Elizabeth F Cognato Michael H Mirza Sumreen K Cavey Michael L Chiaventone Ana L Schwartz Kevin M Berkana Moulik D Higgins Justin X Degnan Christopher J Levis Brian J Hwang Jason S Norris John J Smith M Hanscom Larson Ingrid D Lo Debra Helliu Lisa K Thompson Sean A Quinzio Sarah R Duvall Ur nea Paik Connie Y Roskamp Philip W McMullen Linda C Walter Jesse C Edwardsen Jessica R Peck Daniel W Borneo Michael Nowinski Richard J Elli$ Donna P Blackburn Douglas B Billard Ian M Tokiwa Leslie M Frye Samuel C Sheives Kevin W Sherman Anne N Tolentino Phillip A · Sola-Rotger Nitza Capeles Ronda M Ma Julia C Wells Joseph Z Kirn Juli S Tarr Katherine Green Tristan N Wang Fashen Vincent Hester Michael R Cheng Nathanael D Slawson Erin R Dietz Jacob Brooke Jake Reynolds Caroi T Beijing EAC Convened Reference Victim of Auditory or Sensory Phenomena Jc11 siti QC Info Office EX PR N EAC NDONES A EAP FAO EX HRU EX PMO REG lMO OFF RSP_SPU cM -coNSULAR FAO AP RSP_ARF FO_STAFF p PRESS J_POL FO_SR_ADVISOR PD_ANP PD_MTS AlTW2 SHULMAN RSP_CT MTS_PR N_2 REQ_TAGS_ 1 PD_PRIN Oate DTG From Act1011 E O TAGS Captions Subject May 23 2018 2308022 MAY 18 AMEMBASSY BEIJING WASHOC SECSTATE ROUT ME 13526 ASEC AMGtAMED CASC KPAO CN NOFORN SENSITIVE Beijing EAC Convened Reference Victim of Auditory or Sensory Phenomena 1 4 0 B1 B5 c B7 A Vinyard Chandal A S ARB 1110 O SCEltNI LE CLASSIFICAT ON l NO DISCERNISL E CLASSIFICATION c 85 j A follow-up SVTC wiH include discussion of these issues 4 t BY-i Next steps wll include finalizing language for the Mission Chlna staff notice town halls at Embassy Beijing and at each consulate withe and communication wfth host nation 87 C Signature BRANSTAD w-wwwwc 'cc' ·c cw ······w n· ··· ··• • ··• •·············································•·w·•····························································································•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·•·· ··· - Classified By Name Office '--- -------- Agency U S Department of State Derived From Declassify On Drafted By Cleared By Approved By Released By Info DSCG 11-01 2043 05 23 BEIJING' Beijing AmEmbassy Beijing Grulich Edward G Beijing John R Beijing Muncl1meyer Kather1ne A Beijing A m l' 0 rr ih •r 11 Beijin Beijlng AmEmbassy Beijing Fritz Jonathan D Beijing BEIJ NG' Beijing CHENGDU AMCONSUL ROUTINE GUANGZHOU AMCONSUL ROUTINE SHANGHAI AMCONSUL Aour1NE SHENYANG AMCONSUL ROUTINE 86 87 C ----- -------------- -««¼xc xc xx ·•·•···•···•••····•···•·····•········••••••·•·····•· cz x x e-x-x-x-xnnnnnnnnn• Action Post Dissemination Rule Vinyard Chand all A S ARB NONE D S_EX_PRIN DIS_EAC_INDONES A D S_EAPJAO D S_EX_HRU DIS_EX_PMO D S_REG_ MO_OFF DlS_RSP_SPU DIS_CM_CONSULAR DlS_FAO_EAP2 DIS RSP ASEAN FORUM DIS FO STAFF DIS P PRESS DIS J POL D S FO_SPEC_ASST D1S_PD_ANP D1S_PD_MTS DIS_A 1W2 DIS_SH UUv1AN D S_RSP_CT D S_MTS_PR N_2 DlS_TAGS_1 DJS_PD_REGIONAL Scnsitiv0 NO O SCERNIBLf CLASSIFICATION 2 Attachment 9 From SMART Archive Sent 4 4 2017 1 07 42 PM To SMART Core Subject Embassy Havana convene emergency action committee meeting MRN Date DTG From Action E O TAGS Captions Subject 17 HAVANA31 Apr 04 2017 041707Z APR 17 AMEMBASSY HAVANA WASHDC SECSTATE ROUTINE 13526 ASEC NOFORN OS CHANNEL Embassy Havana convene emergency action committee meeting 1 4 0 1 On April 3 2017 Post conducted an Emergency Action Committee EAC meeting regarding the subject o-B1 17 Havana 29 NODIS cable B7 C 3 Sf-Nfll 1 4 0 B1 BS Signature DELAURENTIS Classified By Derived From Declassify On Name ------- DSCG 11-01 2042 04 04 B6 B7 C Drafted By Approved By HAVANA HAVANA Havana Havana Released By AMEMBAS S Y H A V A N A j ---- Dissemination Rule Archive Copy SECR ETf 'NOFORM 1 lf -1