Similar reports of sickness after hearing noises began trickling in from other diplomats in Havana. One of them, a foreign-service officer, told me he was awakened one morning in March by a screeching noise. “It paralyzed me,” he said. “When the sound occurred, I could not move. I couldn’t get up until it stopped.” In the days that followed, he felt extreme fatigue, heard a ringing in his ears, found himself making many mistakes at work and became sensitive to loud sounds and bright light.
That month, DeLaurentis called a meeting of his senior staff to tell them what was going on. He insisted that they tell no one else — not even their families — which had the perverse effect of heightening the staff members’ anxiety rather than calming it. Within days, DeLaurentis felt compelled to call an open meeting of the American staff. More than 60 people crammed into the Embassy’s Sensitive Compartmented Information Facility — an inner sanctum for confidential communications. They were told about the noises and the symptoms and were offered the opportunity to be tested if they had concerns. Nearly all of those present, as well as some family members, soon asked to be evaluated.
“There was a sense of hysteria and concern,” said another government official who worked in Havana at the time. “Perhaps ‘hysteria’ is the wrong word. It really was more concern and fear: ‘Why are you just telling us about this now?’ The ambassador was doing his best to allay any fears, saying: ‘If you want to be tested, we’re going to do that. If you want to send your family home to the U.S., you’re allowed to do that.’ ”
Of the roughly 80 people tested, 12 were found by the otolaryngologist to have symptoms similar to what the first two officials experienced months earlier. But a few did not hear noises, and some who did described other, more subtle sounds, including one that called to mind the experience of vibrating air pressure in a car with a single open window in the back.
In April, DeLaurentis called a meeting with ambassadors from Canada, Britain, France and other U.S. allies. None knew of any similar experiences afflicting their officials in Cuba. But after the Canadian ambassador notified his staff, 27 officials and family members there asked to be tested. Twelve were found to be suffering from a variety of symptoms, similar to those experienced by the Americans.
By August 2017, the number of U.S. diplomatic personnel and family members reporting symptoms totaled at least 16, and some were insisting that their symptoms went beyond what could be treated by the otolaryngologist. The foreign-service worker who spoke with me, for instance, said his symptoms progressed to include vision changes, dizziness and increasing cognitive deficits. The State Department’s medical director arranged for affected individuals to be treated at the University of Pennsylvania’s Center for Brain Injury and Repair. Around the same time, the story finally went public, with news reportsciting an official theory that attributed the symptoms to a sonic attack using some sort of invisible energy force — like something out of “Star Wars,” only real.
“We hold the Cuban authorities responsible for finding out who is carrying out these health attacks,” Rex Tillerson, then the secretary of state, said. Soon Tillerson ordered nearly every American at the Havana Embassy, and all family members, to depart, leaving only a skeleton crew. The United States then expelled 15 Cuban diplomats from their Embassy in Washington, issued a travel warning to American tourists and placed new limits on travel between the two countries.
The claim of an invisible weapon, fantastic as it sounded, gained scientific respectability when, in February 2018, The Journal of the American Medical Association published a study by the doctors at the University of Pennsylvania. “These individuals appeared to have sustained injury to widespread brain networks,” the paper stated. Finding no obvious signs of a viral or chemical cause, the Penn group left unanswered how the injuries might have occurred. They simply assumed that the symptoms were due to an “unknown energy source associated with auditory and sensory phenomena.”
Since then, reports from major news organizations, including NBC and The Times, have focused on the “unknown energy source” theory. Most recently, “60 Minutes” aired a segment on March 17 titled “Targeting Americans.” The correspondent Scott Pelley said the diplomats had “suffered serious brain injuries” and noted that the F.B.I. is “investigating whether these Americans were attacked by a mysterious weapon that leaves no trace.” The attacks, Pelley intoned in his signature rumble, appear to be “a hostile foreign government’s plan to target Americans serving abroad.”
And yet, two and a half years after the first diplomats in Havana said they heard strange sounds and fell ill, and after at least six visits to Cuba by the F.B.I., the study by Penn researchers, another study led by the otolaryngologist at the University of Miami and a continuing investigation by a “health incidents response task force” organized by the State Department, the claims of an attack by an invisible weapon remain not only unproved but also highly contested by prominent physicists and engineers in the United States and abroad.
Dozens of leading neurologists, psychiatrists and psychologists, meanwhile, have offered an alternative narrative: that the diplomats’ symptoms are primarily psychogenic — or “functional” — in nature. If true, it would mean that the symptoms were caused not by a secret high-tech weapon but by the same confluence of psychological and neurological processes — entirely subconscious yet remarkably powerful — underlying hypnosis and the placebo effect. They are disorders, in other words, not of the brain’s hardware but of its software; not of objective injuries to the brain’s structure but of chronic alterations to how the brain functions, typically following exposure to an illness, a physical injury or stress. And the fact that the State Department and doctors the government selected to treat the diplomats have dismissed this explanation out of hand does not surprise these experts. After all, they say, functional neurological disorders are among the most misunderstood, debilitating and denigrated ailments known to medicine.
On Nov. 2, 1881, a 15-year-old French girl broke a pane of glass, resulting in a slight cut to the back of her left hand. The wound healed in four or five days, but by then her fingers had contracted into a cup shape, with the thumb pressed against the index finger. It remained that way, “a veritable clubhand,” for an entire year, as described by the neurologist Jean-Martin Charcot. A founder of modern neurology, Charcot diagnosed the contracture as “hysterical” in nature, not directly caused by the minor injury but also not simply a figment of the girl’s mind.
Charcot applied the term “hysteria” not to episodes that conjure our cartoon images of Victorian matrons swooning or running amok but to cases like the girl who lost the use of her hand: persistent disorders of the nervous system, whether of sensory perception or the control of movements, that appear to lack any physical cause. Charcot devoted much of his career to studying and treating such disabilities, and many of his insights remain relevant today. He was among the first, for instance, to dispel the belief that hysterical disorders occur only in women. “That a strong and vital workman,” he said in an 1887 lecture, “a railway engineer, fully integrated into the society and never prone to emotional instability before, should become hysteric — just as a woman might — this seems to be beyond imagination. And yet, it is a fact — one that we must get used to.”
Having treated many railroad workers who developed paralysis or bizarre movement disorders after seemingly minor injuries, Charcot came to one of his key insights: that these conditions rarely develop out of the blue but are instead often triggered by a slight trauma, as if the person had been frightened into it. By comparison, in cases of a purely physical injury resulting in a chronic disability, he said, “there is not the same disproportion between the triviality of the injury and the intensity of the contracture; and, moreover, it has not the same persistence after the cure of the peripheral irritation.”
News reports cited an official theory that attributed the symptoms to a sonic attack using some sort of invisible energy force — like something out of ‘Star Wars,’ only real.
By the early 20th century, Charcot’s neurological perspective had given way to the psychiatric theories of Sigmund Freud, who regarded the behaviors as being a result of repressed trauma so unacceptable to the conscious mind that it had been converted into physical symptoms. “Conversion disorder” thus became the province not of neurologists but of psychiatrists. But as Freud’s influence dwindled over the course of the 20th century, interest in patients like these declined so markedly that the phenomenon virtually disappeared from medical textbooks.
Then, around the turn of the century, neurologists who specialized in movement disorders began seeing and writing about cases that had been thought to be a relic from a hundred years earlier. One such neurologist was Mark Hallett, who in 1984 joined what is now the National Institute of Neurological Disorders and Stroke (Ninds) as its clinical director and chief of the Human Motor Control Section. Hallett, one of the country’s leading experts in movement disorders, decided to open a clinic where neurologists from around the country could refer patients with the most difficult-to-diagnose ailments. In a 2015 presentation to students, he described how some of those patients turned out to have a disorder that Charcot would have instantly recognized but which few modern doctors then understood.
“This class of patients turned out to be about 30 percent of the patients that were coming into our clinic,” Hallett said. He showed clips of three women who suffer from functional disorders: one who experiences severe tremors, another who repeatedly jerks her arms up as if startled and a third with balance problems that cause her to sway and sometimes fall as she walks. Based on M.R.I. or electroencephalogram (EEG) testing, Hallett told the students, the patients’ movements appear to be voluntary. “But they say it’s not voluntary,” he said. “This isn’t something they’re doing; this is something that happens to them.”
What Charcot did for the 19th-century understanding of “hysteria,” Hallett and a small group of other leading neurologists have done for the 21st century’s understanding of what they now call functional or psychogenic disorders. The name, in fact, is a rare point of contention among them. Some, like Stanley Fahn of Columbia University Medical Center, have argued for “psychogenic” because, among other reasons, it points directly to the mind as the source of the sufferer’s troubles. Others, like Hallett and Jon Stone, a neurologist at the University of Edinburgh in Scotland, dislike “psychogenic” for exactly the same reason: because it makes the condition sound as if it’s purely a psychiatric problem, whereas they see it as having a major neurological component.
“I wince when I hear the word ‘psychogenic,’ ” Stone told me during one of many Skype conversations. “It creates a false impression about what these disorders are. They’re like depression or migraine. They happen in that gray area where the mind and the brain intersect.”
One of the first modern textbooks published on the subject, coedited by Stone, Hallett and Alan Carson of the University of Edinburgh, estimates that about 15 percent of patients seen by neurologists have a functional disorder. The most remarkable kind involve bizarre movement abnormalities that look, to the untrained eye, exactly like epilepsy, Parkinson’s, multiple sclerosis, blindness, coma or paralysis. Other times, they cause the sort of more mundane yet still debilitating symptoms seen in the diplomats.
The emerging understanding of functional disorders has spread widely enough that an editorial accompanying the Penn study in JAMA argued that a functional disorder could also explain many of the symptoms ailing the diplomats. “In particular,” the editorial stated, “persistent postural-perceptual dizziness (P.P.P.D.) is a syndrome characterized primarily by chronic symptoms of dizziness and perceived unsteadiness, often triggered by acute or chronic vestibular disease, neurological or medical illness or psychological distress.”
Months after the JAMA paper was published, Stone co-wrote a letter to the editor, endorsed by 38 prominent neurologists, psychologists and psychiatrists from around the world, which likewise argued for the diplomats’ illness being functional. “In many functional neurological disorders, initial sensory discomfort together with anxiety and heightened attention trigger maladaptive processes that lead to persistent symptoms,” the letter stated. “Although diagnostic caution is warranted, functional neurological disorders are common genuine disorders that can affect anyone, including hardworking diplomatic staff.”
In a Skype conversation, I asked Stone if he had ever treated a patient with P.P.P.D. “I had a lady today with P.P.P.D.,” he said. “This lady walked normally into my office. You wouldn’t think anything was wrong with her. But like most of these patients, they come in absolutely at their wits’ end, and they’re quite concerned you’re not going to believe them. What she was describing was a continuous feeling of movement, that things are swaying, which is just driving her nuts — not literally nuts, but it just wasn’t stopping.”
I asked him if she had an actual medical disorder causing her symptoms. “She does have something medical,” Stone answered, a note of exasperation in his voice. “She’s got a functional disorder.”
But how does an individual case of functional disorder, like the one experienced by Stone’s patient, map onto an outbreak involving dozens of diplomats? In Stone’s view, whether somebody develops a functional illness on his or her own or does so in a group is immaterial. While some call the latter “mass hysteria,” and others use the more modern term, mass psychogenic illness (M.P.I.), Stone finds both terms misleading at best. “The term ‘mass hysteria’ is just ridiculous and insulting,” he told me. And he dislikes M.P.I. because its use of “psychogenic” suggests that affected individuals’ symptoms are “all in their mind.”
“M.P.I. is a subset of functional disorders, not a separate entity,” Stone said. “I agree completely that ideas about illness can transmit from one person to another. This happens all the time with many types of functional disorder. Even just seeing a news item on multiple sclerosis can be the trigger for some individuals to develop similar symptoms.”
If it is hard to understand how a mysterious psychological and neurological process could have sickened a group of previously healthy diplomats, it turns out to be even harder to understand how invisible weapons could have done so.
I asked Douglas Smith, the senior author of the paper in The Journal of the American Medical Association, what kinds of devices might have injured the diplomats. While noting that he is not an expert on such devices, he replied, “The usual suspects are anything from ultrasound, infrasound, microwave — those are things that could potentially affect the brain.”
But physicists and engineers who specialize in the effects on humans of such technology strongly disagree. Ric Tell, a former chief of the Electromagnetics Branch of the Environmental Protection Agency, has spent more than 50 years studying and helping to set international standards on safe exposure limits to electromagnetic radiation, including microwave radiation. “If a guy is standing in front of a high-powered radio antenna — and it’s got to be high, really high — then he could experience his body getting warmer,” Tell told me. “But to cause brain-tissue damage, you would have to impart enough energy to heat it up to the point where it’s cooking. I don’t know how you could do that, especially if you were trying to transmit through a wall. It’s just not plausible.”
The U.S. military has tested beams of powerful microwaves as a crowd-control device, but the process works not by penetrating the brain but by heating people’s skin surface so quickly that they run from it soon after the device switches on.
One theory for how the sounds reported by the diplomats might have been generated was that it involved something called the “Frey effect,” named after Allan H. Frey, an American scientist who found that microwaves aimed at the head can cause a clicking sound. But according to Kenneth Foster, a professor of bioengineering at the University of Pennsylvania and an author of a 1974 study on the effect, the sound would be so soft that near silence would be needed for a person to detect it. “It is just a totally incredible explanation for what happened to these diplomats,” he said. “It’s just not possible. The idea that someone could beam huge amounts of microwave energy at people and not have it be obvious defies credibility. There’s nothing behind it. You might as well say little green men from Mars were throwing darts of energy.”
Ultrasound has also been proposed as a possible cause of the diplomats’ symptoms, based on the observation that at high-enough levels, it can cause an “acoustic bubble” to form in liquids. This has led to speculation that such bubbles could form in the inner ear or brain, causing injury. Timothy Leighton, a professor of ultrasonics and underwater acoustics at the University of Southampton in England, literally wrote the book on acoustic bubbles (called, naturally enough, “The Acoustic Bubble”). As he explained it to me: “If you put an ultrasound transducer next to a liquid, the way we do in ultrasonic cleaning baths, you can cause bubbles to form. But if you send it through the air, you will never get that effect. Acoustic bubbles only happen if you have direct contact. If someone goes for a pregnancy ultrasound, the doctor holds the transducer up against the body. They even have to put a slippery gel on the woman’s abdomen, because if there is even a microscopic air gap, the ultrasound won’t propagate.”
Devices that generate high-pitched noise are sometimes used by businesses to deter young people from congregating around a certain area, because they can perceive it and find it annoying, while many older people’s ears cannot hear it. But while exposure to extremely loud noises can certainly induce hearing loss or tinnitus, noise has never been shown to produce brain damage in humans. “We have no evidence of that at all, and no real theories of how it could possibly do that,” Leighton said. “The idea of some kind of secret ultrasonic death ray going through the air to hit you, it’s nonsensical.”
But then what caused the diplomats’ brain damage? That turns out to be something of a trick question, because many neurologists and psychologists assert that the JAMA paper provided no convincing evidence of any brain damage at all. Certainly they published no images of physically damaged brains (and in any case, no such visibly apparent injury is typically associated with concussions). Instead, the diagnosis was based on the diplomats’ symptoms and their performances on tests of balance, hearing, memory, eye movement and the like. Even most of those test results — almost none of which are strictly objective, critics say — were within the range of normal.
For all their mystery, functional disorders are not diagnosed simply after eliminating every possible “normal” disorder that might be causing a patient’s symptoms. Rather, neurologists look for signs and symptoms that are inconsistent, varying even during the course of an examination, and incongruent with what they expect to see in known, objective disorders caused by a physical injury or illness. One of the most remarkable aspects of the diplomats’ illnesses, for instance, is that even if all of them experienced an actual blow to the head shortly before their symptoms appeared — which none of them did — most should have fully recovered in a matter of days, weeks or months, as is standard following a minor head injury. Instead, many of them experienced symptoms that remained steady or worsened over a period of months, and some continue to suffer chronic, perhaps lifelong symptoms. While usually inconsistent with a concussion, such long-term effects are routinely seen in cases of a psychogenic disorder.
The biological underpinning of how such disorders are kicked into gear remains, as with many other neurological disabilities, only faintly understood. The experience is thought to be brought on, in part, by undue attention, fear and expectation. But these conscious processes are only part of the story; much more happens at the deep, neurological level where all our perceptions, feelings, movements and memories are encoded. For instance, a 2016 study of people with functional disorders, co-written by Hallett, found decreased functional connectivity from a region of the brain involved in self-agency — the perception of having control over your actions. Another study Hallett co-wrote found more gray matter in the left amygdala and other emotion-regulating areas in the brains of people with functional disorders, and less gray matter in the left sensorimotor cortex, where movements and sensations are controlled. Essentially, such findings suggest, functional disorders appear to hijack the normal neurological mechanisms by which we experience our body.
“These disorders challenge our views of what perception really is, and the truth of our perceptions,” Stone told me. “In some instances they are disorders of perception and are giving us a window into how perceptions go wrong.”
To sufferers, of course, the details of how a functional disorder develops matter less than simply getting help to recover. Consider the case of Jason Lindsley. One night in March 2016, Lindsley — then a healthy 21-year-old college student living in Lancaster, Pa. — felt flulike symptoms coming on, with fever and chills. After a couple of hours, he began to feel strangely numb, from head to toe. But by 1 a.m., the numbness had gone, replaced by extreme pain in his lower back.
At that point, Lindsley’s mother, who is a nurse, drove him to the local emergency room. “They decided they wanted to treat me for lower back pain,” Lindsley told me. “I’ve had football injuries from the past. I have a herniated disk. So they gave me pain medication, said try to relax and sent me home.”
That was on a Friday night. By Monday morning, the pain medicine had run out, but the pain persisted. On Tuesday, he saw his family physician, who referred him to a spine specialist. The next morning, Lindsley’s legs felt wobbly. By Thursday, he was having such trouble walking that his parents gave him a bar stool to use as a makeshift walker. By Friday morning, he was unable to stand.
The spine specialist he saw that day offered a tentative diagnosis of Guillain-Barré syndrome, a neurological disorder caused by an immune-system attack on the peripheral nervous system. Taken immediately to the hospital, he was placed in the intensive care unit and given intravenous immunoglobulin as treatment.
But he didn’t recover. After multiple blood tests, spinal taps, M.R.I.s and physical exams, doctors at his local hospital and at the University of Pennsylvania could find nothing physically wrong with him. According to Lindsley, he was told by a senior neurologist at Penn, “I guess we’ll have to figure it out at the autopsy.” The neurologist gave him a diagnosis of conversion disorder, the century-old Freudian term. But three psychologists whom Lindsley subsequently consulted could find no deep, dark psychological torment underpinning his paralysis.
A year later, despite months of physical therapy aimed at strengthening his leg muscles, he remained unable to stand without assistance. Then, as Lindsley was resigning himself to a lifetime of disability, his mother found a video online of Jon Stone talking about functional disorders. She insisted that her son watch it. “With the conversion disorder,” Lindsley recalled, “the doctors were labeling me with a mental problem, like I was doing this to myself, and it was my fault. Dr. Stone said that is absolutely not the case. I thought, maybe this guy is right — that your brain is so powerful it can trick itself into doing whatever it wants.”
Lindsley emailed Stone, who put him in touch with Kathrin LaFaver, a neurologist who trained under Hallett at Ninds and now runs a clinic for functional-movement disorders — one of the few in the United States — at the University of Louisville. Lindsley decided to give her clinic a shot. In March 2017, almost exactly a year after his symptoms began, he entered in a wheelchair. A week later, he walked out on his own power as if nothing had ever been wrong.
The treatment consisted of what LaFaver calls motor retraining, designed to overcome Lindsley’s resistance to normal movements. Physical therapists began by asking him to make minuscule movements of his feet, assuring him, over and over, that he could do what his brain was telling him he couldn’t. He also spent part of each day undergoing cognitive behavioral therapy aimed at learning relaxation strategies and focusing on his own well-being.
LaFaver’s clinic has drawn patients from across the United States. “There’s a huge unmet need,” she told me. “More patients have these disorders than have multiple sclerosis. Everyone has heard of multiple sclerosis. There is an M.S. treatment center in every large city. And yet here we are with these functional disorders, which are more common, yet nobody has heard of it, and there are almost no treatment centers. It’s mind-boggling.”
‘Even just seeing a news item on multiple sclerosis can be the trigger for some individuals to develop similar symptoms.’
To see and hear for myself whatever happened in Cuba, I went to Havana for five days in October. In a meeting there at the headquarters of the Cuban Ministry of Foreign Affairs, Johana Tablada, the ministry’s U.S. deputy general director, complained bitterly of how her country has been accused of having knowledge of the attacks.
“What we know is what did not happen,” she said. “We know there was not a person who came and attacked Americans with a weapon.”
On the street where the first diplomats said they heard strange noises and became sick, I heard nothing but the odd bleating of a goat. A neighbor told me that nobody who lived nearby had heard anything out of the ordinary. “Only them,” the man said.
The State Department has now identified 26 U.S. diplomats and family members as having become sick in Havana, as well as one additional confirmed case that was reported last year in Guangzhou, China.
“I’m not really doing too well,” Catherine Werner, who became ill while working in Guangzhou, told me. “My balance is so impacted that I need certain aids to help me. Now I use a balance vest and a cane. It’s something I’m struggling with because I’m only 32. I went from managing a team of very smart, driven individuals and working on really critical trade policy and promotion issues to not being able to recall very basic words, not being able to process very simple tasks and problems. My whole life has really been derailed.”
The noises she heard were unlike what the initial group of sickened officials in Cuba reported. “I experienced a very low, pulsing sound, mostly during the night,” she said. “It was waking me up. I thought at first it was the air-conditioning system making a funny noise. It sounded mechanical, like a very low but humming, oscillating sound.”
Her initial symptoms, too, included some that other diplomats have not reported. While she experienced tinnitus, nausea and dizziness, as others did, she also developed hives and nosebleeds. “My hair started falling out in clumps,” Werner told me. “Yeah, I was really sick.”
Since the initial Canadian report, more diplomats or family members from that country have been identified with symptoms, bringing the total number to at least 15. When it announced a new case in January, the Canadian government said it would cut its diplomatic staff in Cuba by up to half.
On March 27, Secretary of State Mike Pompeo reiterated the claim that the U.S. diplomats were the victims of “health attacks.” “We have not been able to resolve this yet,” he said. “Some of the best minds, not just in government, but across the global medical system, have not yet been able to identify and connect up so that we can find the cause, so that we can go attack the problem set. It has proven incredibly vexing.”
One promising piece of news is that among the doctors at the National Institutes of Health asked last year to examine the diplomats was Mark Hallett. He was not, however, appointed to the task force established by the State Department. When I requested an interview with Hallett, he replied in an email that he did not think he would be allowed to talk. “The N.I.H. is concerned about us in H.H.S. [Health and Human Services] getting involved with matters of the State Department,” he wrote. (Additionally, the N.I.H. explained Hallett’s silence by saying it would be premature for him to talk about the evaluation of the patients.) He was also denied permission to be listed as a writer of the letter that Stone submitted to JAMA in response to Smith’s paper.
To find out more about why one of the world’s leading experts on functional disorders would be forbidden to express his views on the matter, I submitted a Freedom of Information Act request. I eventually received 79 pages of material, including the email in which the director of Ninds apparently told Hallett that he could not speak with me. The entire text of the email was redacted.
The idea that the diplomats have a functional disorder is firmly rejected not only by State Department officials but also by the diplomats I spoke with and doctors who have treated them, who are convinced that the symptoms were caused by something external, physical, “real.”
“I had everything from brain scans to physical exams to advanced eye exams, the whole nine yards,” said the foreign-service officer who became sick while in Havana. “These tests demonstrated a brain injury. It’s a disservice to those of us who were injured to suggest that we were just making it up in our minds.”
“All the people on my team who have examined these folks believe it’s real,” Smith said. “It’s only people outside who think it’s psychogenic.”
Peter Bodde is a retired ambassador who in 2018 led an Accountability Review Board that examined the State Department’s response to the diplomats’ illnesses. “People will have their opinions,” he said. “But our colleagues were injured, and they were attacked, and that’s real, and you can see it.”
But what if the State Department, the Penn doctors and the diplomats themselves are wrong, and those who see the possibility of an outbreak of functional disorders are right?
“If people have a functional disorder, it’s obviously very damaging to tell them they have a brain injury,” Stone said. “Telling someone they have a traumatic brain injury is not going to help them if they actually have a functional disorder. And it can stop them from getting therapy that might help them.”