Many previous posts have discussed the disagreements between the U.S. and Cuba over what, if anything, happened to U.S. diplomats stationed in Cuba starting in late 2016.  That disagreement continues.
U.S. Medical Report 
The latest report on these issues by the University of Pennsylvania’s Center for Brain Injury and Repair was published in the July 23/30 issue of the medical journal, JAMA. Its abstract of the study said the following:
- “Importance. United States government personnel experienced potential exposures to uncharacterized directional phenomena while serving in Havana, Cuba, from late 2016 through May 2018. The underlying neuroanatomical findings have not been described.”
- “Objective. To examine potential differences in brain tissue volume, microstructure, and functional connectivity in government personnel compared with individuals not exposed to directional phenomena.”
- “Design, Setting, and Participants. Forty government personnel (patients) who were potentially exposed and experienced neurological symptoms underwent evaluation at a US academic medical center from August 21, 2017, to June 8, 2018, including advanced structural and functional magnetic resonance imaging analytics. Findings were compared with imaging findings of 48 demographically similar healthy controls.”
- “Exposures. Potential exposure to uncharacterized directional phenomena of unknown etiology, manifesting as pressure, vibration, or sound.”
- “Main Outcomes and Measures. Potential imaging-based differences between patients and controls with regard to (1) white matter and gray matter total and regional brain volumes, (2) cerebellar tissue microstructure metrics (mean diffusivity), and (3) functional connectivity in the visuospatial, auditory, and executive control subnetworks.”
- “Results. Imaging studies were completed for 40 patients (mean age, 40.4 years; 23 [57.5%] men; imaging performed a median of 188 [range, 4-403] days after initial exposure) and 48 controls (mean age, 37.6 years; 33 [68.8%] men). Mean whole brain white matter volume was significantly smaller in patients compared with controls (patients: 542.22 cm3; controls: 569.61 cm3; difference, −27.39 [95% CI, −37.93 to −16.84] cm3; P < .001), with no significant difference in the whole brain gray matter volume (patients: 698.55 cm3; controls: 691.83 cm3; difference, 6.72 [95% CI, −4.83 to 18.27] cm3; P = .25). Among patients compared with controls, there were significantly greater ventral diencephalon and cerebellar gray matter volumes and significantly smaller frontal, occipital, and parietal lobe white matter volumes; significantly lower mean diffusivity in the inferior vermis of the cerebellum (patients: 7.71 × 10−4 mm2/s; controls: 8.98 × 10−4 mm2/s; difference, −1.27 × 10−4 [95% CI, −1.93 × 10−4 to −6.17 × 10−5] mm2/s; P < .001); and significantly lower mean functional connectivity in the auditory subnetwork (patients: 0.45; controls: 0.61; difference, −0.16 [95% CI, −0.26 to −0.05]; P = .003) and visuospatial subnetwork (patients: 0.30; controls: 0.40; difference, −0.10 [95% CI, −0.16 to −0.04]; P = .002) but not in the executive control subnetwork (patients: 0.24; controls: 0.25; difference: −0.016 [95% CI, −0.04 to 0.01]; P = .23).”
- “Conclusions and Relevance. Among US government personnel in Havana, Cuba, with potential exposure to directional phenomena, compared with healthy controls, advanced brain magnetic resonance imaging revealed significant differences in whole brain white matter volume, regional gray and white matter volumes, cerebellar tissue microstructural integrity, and functional connectivity in the auditory and visuospatial subnetworks but not in the executive control subnetwork. The clinical importance of these differences is uncertain and may require further study.” (Emphases added.)
U.S. Commentary on the JAMA Report
JAMA Editorial  In the same JAMA issue containing the University of Pennsylvania report, two medical doctors published an editorial that cautioned readers that the relevance of the neuroimaging findings was “uncertain” and that the exact nature of the affliction “remains unclear,” adding that more scientific evidence is needed.
Washington Post Editorial  “The authors of the study acknowledge it had limitations: a small sample, a control group that was not ideal, and the methods could not offer any clues about what external event caused the trauma. A fair amount of mystery still shrouds the whole episode. The FBI was brought in to investigate, but its findings are not known. There has been speculation the U.S. diplomats, and some from Canada, were attacked by a weapon or device such as a microwave beam or sonic waves, but there is no confirmation.”
After conceding that the new study reported in JAMA “does not solve” the issues, the Post editorial asserts that study “does require that it be pursued. . . .The [U.S.] must continue to demand accountability for whoever did this, and the first step is to find out who, and why.”
According to the editorial, service in Cuba “clearly was not safe for the diplomats who suffered brain trauma. Cuba has a pervasive security service. Surely it knows what really happened. Instead of urging everyone to look the other way, Cuba’s government should get to the bottom of this and make public the findings. The [U.S.] must demand no less.”
New Yorker Article  Adam Entous, a staff writer for The New Yorker, interviewed Dr. Douglas Smith, the director of the University of Pennsylvania’s Center for Brain Injury and Repair, about its study. Smith said that the study revealed tangible neurological changes that “are not like anything we’ve ever seen before.” But it “is clear that something structural in the brain was affected, but we don’t know what that is and what caused the effects.” Nevertheless, Dr. Smith added, the “mass-hysteria hypothesis is debunked by very obvious neurological findings that you can’t imitate, you can’t mimic.” The study validated “that there are signs of brain damage.”
Dr. Smith also told Entous that the 40 patients also included CIA officers and that the study included imaging data for 36 of the 40 patients; the other four “were unreachable by any mode of communication,” presumably because they were CIA officers who are now operating under new covers in other countries.
According to Entous, although there still is no “hard scientific evidence about what caused the injuries, U.S. intelligence agencies still think the victims were attacked, most likely by Russia, which had ‘the means, motive, and opportunity,’ a second senior U.S. official told me. The official cautioned, however, that it was highly unlikely, at this late stage in the investigation, that U.S. spy agencies would uncover direct evidence, such as intercepted communications of Russian operatives admitting their culpability. The [unnamed] official said, ‘You almost never have it direct from the horse’s mouth, saying, ‘It was us. Great job, comrade!’ ”
Slate Article  After publication of the previously mentioned report, Slate published the following list of the suggested potential causes for the problems of these U.S. diplomats “ranked in highly unscientific order from least likely to most likely:” (1) noise; (2) microwaves; (3) viral infection; (4) previous trauma; (5) crickets or cicadas (partially); and (6) “it’s all in their heads.”
Cuba’s Reactions 
At a July 30, 2019, press conference in Havana, Dr. Mitchell Joseph Valdés-Sosa, General Director of Cuba’s Neurosciences Center, on behalf of the Cuba’s Expert Committee, presented reactions to the University of Pennsylvania’s report.
Dr. Valdés-Sosa said that this report does not allow clear scientific conclusions to be drawn. The medical results are confusing and contradictory, of special concern given the numerous questions already raised by the international scientific community, which have not been satisfactorily answered.
The article does not prove that the diplomats suffered brain damage during their stay in Cuba, contrary to speculation and what was raised in tan August 2018 article in JAMA. More specifically the Cuban expert asserted the following:
“1-The authors themselves acknowledge that the study is inconclusive and that they have no explanation for their findings.
2-The changes described are small, very diverse, inconsistent, and do not indicate a coherent pattern. This is not only the opinion of the Cuban medical group, but of recognized experts in the field of neuroimaging, who have stated that these results are not consistent.
3-It is common that in neuroimaging studies, as in other medical fields, there are effects noted in small samples, which are not replicable. They originate by chance. Some of the changes reflect a slight change toward the abnormal, but others are slightly hyper normal.
4-The degree of to which the two groups’ data overlap is not shown in the article.
5-The differences between diplomats and controls, if any, may be related to how the control group was selected. Any pre-existing illness in a group of diplomats, which is absent in the controls (and vice versa) could give rise to a difference in the images.
6-The measures of functional connectivity networks used are very nonspecific and are altered by the psychological state of the subject, as recognized in the article itself and by the scientific community.
7-There is no discernible relationship between the alterations detected in the neuroimages and the symptoms reported by diplomats.
8-There is no coherence between the findings reported in this article and those from the previous one. For example, in the previous piece, from the same research group at the University of Pennsylvania, alterations of executive functions in neuropsychological tests were described. In this work no functional connectivity alterations are found in the executive subnet.
9-Alterations noted in neuroimages, if any, may have originated before the subject’s stay in Cuba or due to a disease unrelated to the ‘directional’ phenomena of strange sounds and other sensations described by diplomats.
10-Although the article’s title refers to so-called ‘directional phenomena,’ the work does not show any relationship between the findings in the images and these alleged phenomena. This is important, given the scientific community’s widespread skepticism regarding theories of sonic or microwave attacks.”
Therefore, the Cuban experts believe “the only way to clarify the health status of those affected is through transparent scientific discussion and the exchange of open, unbiased information.”
These experts observations were previewed by Cuba Foreign Minister Bruno Rodriguez. He tweeted, “There isn’t the least evidence or scientific explanation supporting deliberate actions against diplomats in [Havana]. The article published by JAMA corroborates that. The [US] government lies are targeted against [Cuba]. The manipulation of this issue should stop.”
It is totally amazing that after nearly three years after the first U.S. diplomats in Cuba reported various medical problems, there still is no definitive public verdict on whether and why some diplomats (and CIA personnel) have suffered medical problems.
 This blog has published many posts about this situation. See the “U.S. Diplomats Medical Problems in Cuba, 2017-18” and “U.S. Diplomats Medical Problems in Cuba, 2019” sections of List of Posts to dwkcommentaries—Topical: CUBA.
 Verma, Swanson, Parker, et al., Neuroimaging Findings in US Government Personnel With Possible Exposure to Directional Phenomena in Havana, Cuba, JAMA (July 23/30, 2019); Lederman, Doctors find differences in brains of U.S. diplomats who alleged mystery attacks in Cuba, NBC News (July 23, 2019); Health incidents in Cuba and China; an explainer, Center Democracy in Americas (Mar. 15, 2019)
 Muth (MD) & Lewis (MD), Editorial: Neurological Symptoms Among US Diplomats in Cuba, JAMA (Mar. 20, 2019).
 Editorial, The U.S. must demand accountability for what happened to diplomats in Cuba, Wash. Post (July 28, 2019).
 Entous, Brain Scans Shed New Light on Mysterious Attacks on U.S. Diplomats and Spies in Cuba, New Yorker (July 29, 2019).
 Paulus, A Comprehensive List of All the Potential Causes of the Cuban “Sonic” Attacks, Slate (July 26, 2019).
 No clear scientific evidence exists on alleged sonic attacks against U.S. diplomats in Cuba, Granma (Aug. 5, 2019); Rodriguez, Tweet (July 24, 2019); Cuba dismisses findings of ‘sonic attack’ study, BBC (July 24, 2019).
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It is still a puzzle…