WASHINGTON — Alone in her bed in a sprawling Chinese metropolis, Catherine Werner was jolted awake one night by a pulsing, humming sound. It seemed to be coming from a specific direction.
Perhaps the A.C. unit in her upscale Guangzhou apartment was malfunctioning, the American diplomat thought. But at the same moment, she also noticed intense pressure in her head.
The sounds and sensations returned, night after night, for months. When Werner's health began declining in late 2017 — vomiting, headaches, loss of balance — she brushed it off at first, thinking China's polluted air and water were getting to her.
It wasn't until months later — after her mother, Laura Hughes, grew alarmed, flew in from the U.S. and then got sick, too — that Werner was medevaced from China back to the States. Doctors at the University of Pennsylvania found a vision disorder, a balance disorder and an "organic brain injury" — diagnoses similar to those of 26 U.S. diplomats and spies in Cuba who started hearing strange sounds and falling ill in late 2016.
The United States faced a troubling question: Had whatever happened to the Americans in Cuba spread?
What follows is the first comprehensive account of the extraordinary chain of events set off by a suspected "health attack," as the U.S. calls the mysterious phenomena, on a U.S. worker abroad.
It draws on interviews with more than a dozen current U.S. officials, a written testimonial from Werner's mother to members of Congress obtained by NBC News, internal State Department documents, recorded conversations and other interviews. NBC News also reviewed hundreds of pages of medical records of U.S. government workers evacuated from both Cuba and China, including those the U.S. has "medically confirmed" were attacked and those it ultimately said were not.
For the past 18 months, more than two dozen U.S. diplomatic staffers once stationed in Cuba and China have endured an ordeal that is equal parts medical mystery, political stand-off and bureaucratic muddle.
Cuba and China deny any role. While the U.S. hasn't named a culprit, it says the "health attacks" caused brain injury and other physical harm. Physicians enlisted by the State Department have identified what they call a "Brain Network Disorder" acquired by U.S. personnel serving abroad, say U.S. officials, that includes structural changes to the brain not found in any previously known disorder.
Yet some diplomats and their doctors now tell NBC News they have growing concerns that the U.S. is trying to downplay whatever happened — at least in China.
Equally unsettling to the diplomatic evacuees: suspected incidents of harassment and break-ins they say have occurred since returning to the States. Four U.S. officials tell NBC that the FBI has investigated.
Laura Hughes awoke one morning at her Pennsylvania farm to find that her husband had booked her a flight to Guangzhou. He'd been watching his daughter Catherine's health decline during regular video chats from halfway around the world and believed the situation had become acute.
"You have to go to China," Hughes recalled him saying. "Something is very wrong."
Hughes arrived in Guangzhou and set about getting Werner new air and water filters and imported food. When mother and daughter noticed signs of home intrusions — lights turned on that had been left off, household items out of place — they adopted two dogs.
Werner, 31, worked with the Commerce Department's Commercial Service and figured the harassment was due to her work on high-profile U.S. trade issues with China. It's not uncommon for U.S. diplomats in hostile countries to suffer harassment or home intrusions intended to remind them they're being watched.
Werner declined to comment for this article. But the facts of her case were confirmed by her attorney, Mark Zaid, who did not object to making Werner's story or elements of her medical records public.
An up-and-comer in the Commercial Service, Werner had grown up partially in China and spoke Mandarin. After studying at Boston's Northeastern University, she had landed jobs at Morgan Stanley and Barclays and worked in Hong Kong before joining the government.
Now she was bumping into furniture, struggling to recall basic words and vomiting for no reason.
"My once beautifully articulate, intelligent and thoughtful daughter had been reduced to a shell of her former self," Hughes would later write to Congress.
Hughes heard the sounds, too — high-pitched and low-pitched — along with pulsing pressure that felt like a wave washing through her body. Soon she, too, developed headaches, nausea and problems concentrating.
She and her daughter became convinced the dogs were being poisoned after they started regurgitating blood, Hughes wrote. On one occasion, they came home to find the dogs' water bowl filled with urine.
Three months after arriving in China, Hughes flew home, feeling she "physically could not tolerate staying any longer." She said she pleaded with Werner to return but couldn't convince her to leave her job.
In late March, Werner reported to the consulate's security office to update the security team on the suspected harassment. But when the officers saw how her health had deteriorated, they referred her to State Department doctors.
A week later, she was given a series of tests called the HABIT, short for the Havana Acquired Brain Injury Tool, which was developed in response to the mysterious illnesses reported by diplomatic staff in Cuba. Twenty-six U.S. staffers had complained of symptoms that included hearing and memory loss and headaches after hearing strange noises and feeling vibrations, usually coming from a specific direction, and always in hotel rooms or their homes. Some Canadian diplomats were affected, too.
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State Department medical staff have been trained to administer the triage tests if diplomats report suspicious sounds or symptoms. The exam includes memory tests like recalling strings of numbers and balance tests like standing on one leg, four U.S. officials told NBC News. Those who fail are sent for more advanced testing at the Penn Center for Brain Injury and Repair at the University of Pennsylvania in Philadelphia.
Werner's HABIT tests, given in Guangzhou, showed multiple deficits similar to the Cuba cohort. So a week later, she was sent to Penn, where dozens of doctors performed tests to identify any other possible cause of her problems. Doctors even administered a spinal tap to rule out known nervous system diseases.
Among Werner's diagnoses was "neuropsychological dysfunction due to organic brain injury."
Records show she tested below the fifth percentile on a developmental eye movement exam. A psychological evaluation found problems with motor functioning and visual perception, with "clear evidence of decreases in functioning from pre-injury likely." An MRI found "scattered supratentorial white matter lesions," mild but "more than typical for age."
At Penn, a computerized map of Werner's brain was constructed using an experimental MRI technique called diffusion tensor imaging, and experts compared her brain map to a composite created from the cohort of patients affected in Cuba.
Werner's findings were similar enough to the Cuba patients that State Department officials felt they had no choice but to warn the public. So 40 days after Werner arrived in Philadelphia, the U.S. issued its health alert.
"The medical indications are very similar, and entirely consistent with, the medical indications that were taking place to Americans working in Cuba," Secretary of State Mike Pompeo told Congress.
U.S. medical teams were dispatched to the embassy and five consulates to test any diplomat or family member with concerns. State Department officials said about 300 were tested, including in Guangzhou, Shanghai and Beijing.
After confirming Werner's medical issues, the State Department agreed to pay for her mother to be tested, too — by the same physician treating Werner and the Cuba patients.
Since returning from China, Laura Hughes had been trying to hide her newfound struggle with recalling words from her husband, but he noticed. She grew particularly alarmed when she discovered she couldn't remember the names of the family pets.
An MRI of Hughes' brain in June found chronic small vessel ischemic changes, "more than expected for age." Additional neuroimaging found "scattered foci of abnormal signal in white matter," and an evaluation listed acquired brain injury on her problem list. A neuropsychologist wrote Hughes "continues to experience persistent cognitive impairments, cognitive weaknesses and variable functions after a number of environmental exposures in China."
And an optometrist — the same one who evaluated the Cuba patients — found similar visual deficits to Werner's, writing that they were "most likely the result of her exposures in China."
The State Department wouldn't say whether Hughes is considered a confirmed case, citing privacy issues.
The medevac flights that whisked Americans out of Cuba and China marked the end of the first chapter in a harrowing ordeal. When they got back to the U.S., new challenges awaited.
The Americans struggled to determine who was paying medical and travel bills as they shuttled to Philadelphia for appointments. There were concerns about whether psychiatric evaluations might jeopardize security clearances, whether their medical records were being given to the FBI without consent. A rift emerged between the Miami physician initially enlisted to screen workers and the Penn doctors.
Meanwhile, in Cuba, a list of names found its way into a television special that aired on state TV, raising concerns that the American staffers — some of whom were intelligence officers under diplomatic cover — had been "outed."
In Washington, editorials and comments by Cuba-friendly lawmakers suggested the Americans could be suffering from mass hysteria. But in a conference call with Cuba patients last month, Deputy Secretary of State John Sullivan ruled out that possibility, arguing there are objective medical findings that can't be faked.
"Any suggestion that this is some sort of mass hysteria is simply counterfactual, and the medical community, every doctor I've spoken to about this is unanimous," Sullivan said on the call, according to a recording obtained by NBC News. "It's real. It happened. And that's the set of facts."
But with hundreds of diplomats reporting strange sounds or symptoms, who determines which are real, "confirmed" cases and which aren't? If the U.S. still doesn't know what's causing the damage, how can it be sure?
Fifteen Americans who failed the HABIT test in China were medevaced to Philadelphia. In some cases, further testing at Penn found similar medical issues to Cuban evacuees, including acquired brain injury, vestibular dysfunction and sleep disorders, medical records reviewed by NBC News show. But State Department officials say 14 of them were determined not to be cases. One was deemed "indeterminate."
In a few cases, patients who'd suffered concussions during childhood but fully recovered were told their current symptoms might have been caused by the earlier concussions, according to State Department correspondence reviewed by NBC News.
The Trump administration has never discussed publicly how the determination process works, leaving those who believe they are legitimate cases but have been told they are not with little recourse to challenge the government's decision.
But U.S. officials involved in the process tell NBC News that Penn doctors perform the evaluations and tests, diagnosing specific conditions like acquired brain injury and balance disorder. Then they deliver their findings to the government. State Department doctors, who have not examined the patients, consider other information including the location of the reported "exposure" and past medical history before deciding whether the full picture matches what was seen in the Cuba patients.
They look for the "classic" presentation of an incident: A worker hears sounds or feels a sensation, usually coming from one direction, and then develops symptoms within minutes or hours.
The process is entirely disconnected from the ongoing federal investigation into the attacks. State Department doctors do not take into account FBI interviews with the patients or other reports from investigators.
"We look at it purely from a medical perspective," Dr. Charles Rosenfarb, the State Department's medical director, told NBC News in an interview.
Physicians treating the Americans wouldn't speak on the record. But one of the doctors recalled telling the State Department that a China patient had the same symptoms and findings as the Cuba patients, only to see that patient be "cleared." He said the Penn doctors are "getting thrown under the bus" by the "doubting voices in the State Department."
Penn wouldn't make any physicians available to answer questions, but gave NBC News a statement from its chair of neurosurgery saying Penn's doctors and researchers are "continuing to work closely with medical colleagues from the Department of State to provide high-quality evaluations and care."
The State Department is covering medical bills for those medevaced from Cuba or China for up to a year, even if they're determined not to be cases. Yet for the diplomats, the determination still matters greatly.
The confirmed Cuba cases were given FBI letters identifying them as "a possible victim of a crime." The letter notes they are "entitled to receive certain services" through the FBI's Victim Assistance Program and grants access to a special system to track their case, according to one letter reviewed by NBC News.
Unlike in Cuba, there's been no diplomatic drawdown in China, leaving some concerned that their colleagues still in China remain in harm's way.
Most of the American diplomatic evacuees have improved enough to resume work, State Department officials said. Some have been granted accommodations, such as shortened work hours, dimmed office lights or special glasses. Meanwhile, the White House National Security Council is preparing legislation to deal with gaps that Workers' Compensation doesn't currently cover, such as care for affected spouses or pay-outs for permanent impairment of the brain.
In internal State Department instructions reviewed by NBC News, workers in Cuba and China were told not to discuss what they knew with the public, with reporters or on social media.
Yet over the last year, patients have extensively shared their records, recollections and medical updates with one another through encrypted messaging apps and in person, as they try to piece together what happened to them overseas.
More recently, they've started to voice concerns among themselves that despite its "medical confirmation" that a worker in China was affected, the Trump administration may be backtracking.
In May, Pompeo called Werner's case "entirely consistent" with the Cuba patients. But now top U.S. diplomats say they're not sure it's the same thing, with one telling the House Foreign Affairs Committee it's "apples and oranges."
And the State Department, in explaining why it's not setting up a review board to assess the response in Cuba, told NBC News that Pompeo didn't believe there was enough information to prove that Werner's injury was "related to a U.S. government mission abroad."
Sullivan, after meeting with the Penn doctors, acknowledged "there may be a suspicion" that the U.S. government is trying to "minimize" what happened in China.
"I can assure you that is not the case. We are pursuing this vigorously," Sullivan said on the conference call with patients. "There's no conspiracy here to cover up or to minimize this or to limit it to Cuba."
In September, the lead Penn doctor was quoted in The New York Times confirming that microwave weapons were suspected. That same month, NBC News reported that U.S. intelligence agencies considered Russia the main suspect.
But despite the collective efforts of the FBI, CIA, NSA, CDC and the U.S. military, the Trump administration still says it doesn't know who or what is responsible for the "health attacks."
Even in the United States, not all evacuated from Cuba and China are convinced they're safe.
At least six of the evacuated Americans have reported suspected harassment or surveillance in the U.S. to the FBI, four U.S. officials and others familiar with the investigation said. They include evacuees from both China and Cuba, including some who have never met.
Some reported suspected break-ins at their homes or temporary housing, after finding items moved or tampered with, or lights and televisions turned on that had been left off. Some handed over potential evidence to the FBI, including surveillance footage and a laptop suspected to have been tampered with.
Others reported being conspicuously followed — including from their doctors' offices in Philadelphia — and suspicious activity on cellphones. At one point, patients whose treatment was transferred from Penn to Washington's MedStar National Rehabilitation Network were told all of their MedStar appointments were canceled indefinitely due to safety concerns, four people familiar with the cancellations said. The situation was ultimately resolved.
It's unclear whether the incidents can be substantiated. There are no indications the investigation has turned up anything suspicious.
The FBI declined to comment. A MedStar spokesman did, too, citing federal patient privacy regulations.
The Cuban and Chinese embassies in Washington did not respond to requests for comment. The Russian embassy referred NBC News back to an earlier statement from the Foreign Ministry denying any Russian involvement.