An Assessment of Illness in U.S. Government Employees
and Their Families at Overseas Embassies
Standing Committee to Advise the Department of State
on Unexplained Health Effects on U.S. Government
Employees and Their Families at Overseas Embassies
David A. Relman and Julie A. Pavlin, Editors
Health and Medicine Division
Division on Engineering and Physical Sciences
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by Contract 19AQMM19C0090 between the National Academy of Sciences and the Department of State. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-68137-7
International Standard Book Number-10: 0-309-68137-5
Digital Object Identifier: https://doi.org/10.17226/25889
Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
Copyright 2020 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. An assessment of illness in U.S. government employees and their families at overseas embassies. Washington, DC: The National Academies Press. https://doi.org/10.17226/25889
The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.
The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president.
The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.
The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.
Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.
Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.
Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.
For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.
STANDING COMMITTEE TO ADVISE THE DEPARTMENT OF STATE ON UNEXPLAINED HEALTH EFFECTS ON U.S. GOVERNMENT EMPLOYEES AND THEIR FAMILIES AT OVERSEAS EMBASSIES
DAVID A. RELMAN (Chair), Thomas C. and Joan M. Merigan Professor, Department of Medicine, Department of Microbiology & Immunology; Senior Fellow, Freeman Spogli Institute for International Studies, Stanford University; Chief of Infectious Diseases, Veterans Affairs Palo Alto Health Care System
1DORIS-EVA BAMIOU, Professor of Neuroaudiology, Ear Institute, University College of London
LINDA BIRNBAUM, Director (retired), National Institute of Environmental Health Sciences, National Institutes of Health
MICHAEL BONINGER, Professor and Endowed Vice Chair for Research, Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine
RONALD BROOKMEYER, Dean and Distinguished Professor of Biostatistics, University of California, Los Angeles, Fielding School of Public Health
CAROLINE BUCKEE, Associate Professor of Epidemiology, Harvard T.H. Chan School of Public Health
TIMOTHY J. BUCKLEY, Exposure Methods and Measurements Division, National Exposure Research Laboratory, U.S. Environmental Protection Agency
JOSEPH J. FINS, E. William Davis, Jr., M.D. Professor of Medical Ethics; Chief, Division of Medical Ethics; Professor of Medicine, Professor of Medical Ethics in Neurology, Professor of Medical Ethics in Rehabilitation Medicine, Professor of Medicine in Psychiatry, Professor of Health Care Policy and Research, Division of Medical Ethics, Weill Cornell Medical College
JOHN C. GORE, Director and Hertha Ramsey Cress University Professor of Radiology and Radiological Sciences, Biomedical Engineering, Physics and Astronomy, and Molecular Physiology and Biophysics, Institute of Imaging Science, Vanderbilt University
WALTER KOROSHETZ, Director, National Institute of Neurological Disorders and Stroke, National Institutes of Health
PAMELA LEIN, Professor of Neurotoxicology and Department Chair, Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis
SAAFAN MALIK, Director of Research and Acting Deputy Division Chief, Defense & Veterans Brain Injury Center, Research & Development Directorate J-9, Defense Health Agency, Department of Defense
JEFFREY S. PALMER, Group Leader, Human Health and Performance Systems Group, Lincoln Laboratory, Massachusetts Institute of Technology
GREGORY B. SAATHOFF, Professor of Emergency Medicine, Professor of Public Health Sciences, University of Virginia School of Medicine
CLIFFORD B. SAPER, James Jackson Putnam Professor and Department Chair, Department of Neurology, Harvard Medical School
MARK J. SHELHAMER, Professor of Otolaryngology, Johns Hopkins University School of Medicine
JEFFREY P. STAAB, Professor of Psychiatry, Director of the Fellowship in Consultation-Liaison Psychiatry, Department of Psychiatry and Psychology, Mayo Clinic, College of Medicine and Science; Consultant in the Departments of Psychiatry, Psychology and Otorhinolaryngology, Head and Neck Surgery at Mayo Clinic
JONATHAN D. TROBE, Professor, Ophthalmology and Visual Sciences, Department of Neurology; Co-Director, Kellogg Eye Center for International Ophthalmology, University of Michigan
DAVID WHELAN, Professor of the Practice, Electrical Engineering, University of California, San Diego
1 Doris-Eva Bamiou is a member of the Standing Committee, but was unable to participate directly in the authoring of this report.
Health and Medicine Division Project Staff
LIZA HAMILTON, Program Officer
CLAIRE MOERDER, Research Assistant
MARGARET MCFARLAND, Senior Program Assistant
JULIE PAVLIN, Senior Director, Board on Global Health
Department on Engineering and Physical Sciences Staff
ALAN SHAW, Director, Intelligence Community Studies Board
WILLIAM MILLONIG, Director, Board on Army Research and Development
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Ellen Wright Clayton, Center for Biomedical Ethics and Society
Marion Ehrich, Virginia Polytechnic Institute & State University
Michael E. Goldberg, Columbia University College of Physicians and Surgeons
Joshua A. Gordon, National Institute of Mental Health
Suzet McKinney, Illinois Medical District
Aubrey K. Miller, National Institute of Environmental Health Sciences
Xin Qi, Case Western Reserve University
David A. Savitz, Brown University
Susan L. Whitney, University of Pittsburgh
Ross Zafonte, Harvard University
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by Linda A. McCauley, Emory University, and Robert F. Sproull, University of Massachusetts at Amherst. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
SECTION 1 INTRODUCTION AND CHARGE TO THE COMMITTEE
SECTION 4 PLAUSIBLE MECHANISMS
SECTION 5 ACUTE TREATMENT AND REHABILITATION
SECTION 6 LOOKING TO THE FUTURE AND RECOMMENDATIONS
C Additional Comments on Directed Radio Frequency Energy
Acronyms and Abbreviations
|ABIT||Acquired Brain Injury Tool|
|CDC||Centers for Disease Control and Prevention|
|DoD||Department of Defense|
|DOS||Department of State|
|DR2||Disaster Research Response|
|FDA||Food and Drug Administration|
|FSO||Foreign Service Officer|
|GAO||Government Accountability Office|
|GuLF STUDY||Gulf Long-term Follow-up Study|
|HHS||Department of Health and Human Services|
|HIPAA||Health Insurance Portability and Accountability Act|
|IEEE||Institute of Electrical and Electronics Engineers|
|IPM||Integrated Pest Management|
|IRB||Institutional Review Board|
|MED HART||Department of State, Bureau of Medical Services Health Alert Response Team|
|MRI||magnetic resonance imaging|
|mTBI||mild traumatic brain injury|
|NHANES||National Health and Nutrition Examination Survey|
|NIH||National Institutes of Health|
|NTP||National Toxicology Program|
|OCD||obsessive compulsive disorder|
|OGA||Office of Global Affairs|
|PPPD||persistent postural-perceptual dizziness|
|SARS-CoV-2||severe acute respiratory syndrome coronavirus 2|
|TMS||transcranial magnetic stimulation|
|U.S.S.R.||Union of Soviet Socialist Republics|
An individual assigned to the U.S. Embassy in Cuba was awakened one night at home in Havana in 2016 by severe pain and a sensation of intense pressure in the face, a loud piercing sound in one ear with directional features, and acute disequilibrium and nausea. Symptoms of vestibular and cognitive dysfunction ensued. A handful of other cases involving colleagues with similar features began that year, and others in the next. Few people were aware of these cases until spring 2017. In addition, the mechanisms and origins were mysterious, and for these and other reasons, there was a delay in recognizing an important cluster of unexplained illnesses, and an early failure to investigate them in a concerted, coordinated, rigorous, and interdisciplinary manner.
In some ways, the problem presented here is an age-old one; that is, how to detect and recognize important anomalies or signals, in a complicated, “noisy” background. Public health systems have grappled with this problem for centuries. In the 1990s, the Centers for Disease Control and Prevention (CDC) conducted population-based surveillance for “unexplained death and critical illness” in persons less than 50 years of age, with features suggestive of infectious cause, at four sites in the United States, and found a surprisingly high incidence of 0.5 cases per 100,000 per year (Hajjeh et al., 2002). The most common clinical presentation was neurologic; a known infectious cause was discovered for only a minority of them; and no obvious relationships among cases were uncovered (Nikkari et al., 2002). But the landscape that countries face today in which the cases in question arise, is an even more complicated one. Not only must governments consider a wide variety of evolving natural causes in a rapidly changing world, but also an increasing threat of disease of deliberate human origin, both accidental and purposeful.
The cases of the Department of State (DOS) employees in Cuba and China have attracted much attention. Among the reasons and ramifications, the clinical features were unusual; the circumstances have led to rampant speculation about the cause(s); and numerous studies, along with the charged political setting, have had consequences for international relations.
The committee was asked by DOS to review the cases, their clinical features and management, epidemiologic investigations, and scientific evidence in support of possible causes, and advise on approaches for the investigation of potential future cases. The committee faced a variety of challenges in responding to these requests (see Section 2). In particular, much of the detail and many of the investigations performed by others were not available to it, either because they are classified for reasons of national security or restricted for other reasons (e.g., internal department deliberations, protected health information, etc.). Thus, the committee had only limited amounts and kinds of information. Despite these challenges, the committee arrived at a number of observations and recommendations, after carefully reviewing the information that was available.
First, the committee found a constellation of acute clinical signs and symptoms with directional and location-specific features that was distinctive; to its knowledge, this constellation of clinical features is unlike any disorder in the neurological or general medical literature. From a neurologic standpoint, this combination of distinctive, acute, audio-vestibular symptoms and signs suggests localization of a disturbance to the labyrinth or the vestibulocochlear nerve or its brainstem connections. Yet, not all DOS cases shared these distinctive and acute signs and symptoms. In fact, the cases are highly heterogeneous. Some patients described only a set of nonspecific, chronic signs and symptoms indicative of disruption of vestibular processing and/or cognition and diffuse involvement of forebrain structures and function, raising the possibility of multiple causes or mechanisms among different patients, as well as for the same patient.
Second, after considering the information available to it and a set of possible mechanisms, the committee felt that many of the distinctive and acute signs, symptoms, and observations reported by DOS employees are consistent with the effects of directed, pulsed radio frequency (RF) energy. Studies published in the open literature more than a half century ago and over the subsequent decades by Western and Soviet sources provide circumstantial support for this possible mechanism. Other mechanisms may play reinforcing or additive effects, producing some of the nonspecific, chronic signs and symptoms, such as persistent postural-perceptual dizziness, a functional vestibular disorder, and psychological conditions.
The committee is left with a number of concerns. First, even though it was not in a position to assess or comment on how these DOS cases arose, such as a possible source of directed, pulsed RF energy and the exact circumstances of the putative exposures, the mere consideration of such a scenario raises grave concerns about a world with disinhibited malevolent actors and new tools for causing harm to others, as if the U.S. government does not have its hands full already with naturally occurring threats. Because the committee was not able to assess specific scenarios involving malevolent actors, one strong suggestion is that follow-up studies on this topic be undertaken by subject-matter experts with proper clearance, including those who work outside the U.S. government, with full access to all relevant information. Second, the committee was concerned about the possibility of future new cases among DOS or other U.S. government employees working overseas, either similar or dissimilar to these, and the ability of the U.S. government to recognize and respond to these cases in a coordinated and effective manner. The next event may be even more dispersed in time and place, and even more difficult to recognize quickly. Toward this end, the committee offers a number of observations, best practices, and recommendations for clinical management, surveillance, and a systematic response in anticipation of future health events. These observations and recommendations should be reviewed and acted on now. It is imperative that the United States recognize and quickly respond to future cases with a well-coordinated, multi-disciplinary, science-based investigation and effective interventions. Finally, the committee is concerned about how best to manage the continuing care of those already affected, and how to strengthen the nation’s commitment to the health and well-being of those who serve the country overseas. Both of these priorities need and deserve additional attention and resources.
On a personal note, it was an honor and privilege to work with a wonderful committee and staff at the National Academies of Sciences, Engineering, and Medicine. Every person contributed unique and important insights and ideas. Finally, it was humbling to learn of the commitment and sacrifices made by those who work for DOS and the rest of the U.S. government in difficult and challenging circumstances overseas. It would behoove us all to consider how we can provide greater support.
David A. Relman, Chair
Standing Committee to Advise the Department of State on Unexplained Health Effects on U.S. Government Employees and Their Families at Overseas Embassies
Hajjeh, R. A., D. Relman, P. R. Cieslak, A. N. Sofair, D. Passaro, J. Flood, J. Johnson, J. K. Hacker, W-J Shieh, R. M. Hendry, S. Nikkari, S. Ladd-Wilson, J. Hadler, J. Rainbow, J. W. Tappero, C. W. Woods, L. Conn, S. Reagan, S. Zaki, and B. A. Perkins. 2002. Surveillance for unexplained deaths and critical illnesses due to possibly infectious causes, United States, 1995-1998. Emerging Infectious Diseases 8(2):145-153.
Nikkari, S., F. A. Lopez, P. W. Lepp, P. R. Cieslak, S. Ladd-Wilson, D. Passaro, R. Danila, and D. A. Relman. 2002. Broad-range bacterial detection and the analysis of unexplained death and critical illness. Emerging Infectious Diseases 8(2):188-194.