A failure to communicate


The State Department did a poor job getting out the word of complaints that more than 20 U.S. embassy personnel and their family members in Havana had suffered “medical injuries similar to mild traumatic brain injury or concussion,” the U.S. Government Accountability Office reported.
More effective communication is important, the GAO said, because it can help U.S. officials deal with similar incidents elsewhere, such as in Guangzhou, China, where an American government employee reported “very similar” symptoms as those in Havana.
GAO said the State Department officials took too long to notify the agency’s Office of Management Policy, Rightsizing, and Innovation, or M/PRI.
The M/PRI is responsible for determining if an incident warrants examination before the Accountability Review Board, or ARB. Failure to notify the office puts the State Department “at risk of not meeting statutory time frames for convening an ARB and could result in State being less able to improve security programs and practices at other U.S. diplomatic posts,” the GAO said.
U.S. officials knew about the reported incidents in Cuba in early 2017, but didn’t notify the M/PRI until August 2017.
That was a mistake, said the GAO, stating:

Federal law generally requires the Secretary of State to convene an ARB not later than 60 days after the occurrence of an incident that resulted in serious injury, loss of life, or significant destruction of property at, or related to, a U.S. mission abroad unless the Secretary determines the incident clearly involves only causes unrelated to security.

Then-Secretary of State Rex Tillerson convened an ARB on Jan. 12, 2018 “to review the circumstances surrounding unexplained medical conditions affecting Embassy Havana diplomatic community members.”
A State Department fact sheet about the review stated:

The ARB’s mandate was not to determine the cause of the unexplained health incidents, but to examine the Department of State’s response, including the adequacy of security and other related procedures. The ARB first met February 9, and interviewed more than 116 individuals over the course of four months. On June 7, the ARB submitted a report of its findings and recommendations to Secretary Pompeo. Pursuant to law, the Secretary submitted a report to Congress on August 30, 2018 outlining the ARB’s recommendations and actions taken in response.
The ARB found the Department’s security systems and procedures were overall adequate and properly implemented, though there were significant vacancies in security staffing and some challenges with information sharing and communication. The ARB did not find any U.S. government employee engaged in misconduct or performed unsatisfactorily in a way that contributed to these incidents.
The ARB issued 30 recommendations, and the Department accepted all of them. The ARB’s recommendations fall in six areas: accountability, interagency coordination, medical issues, communication and information sharing, risk/benefit analysis, and diplomatic security.

Accountability: The ARB found the lack of a single designated senior-level Department official with responsibility for responding to the attacks resulted in insufficient communications with employees and impeded coordination within the Department and with other agencies. The ARB recommended elevating the overall responsibility for the Cuba response to the Deputy Secretary of State. In May, the Deputy Secretary – at the Secretary’s request – established the interagency Health Incidents Response Task Force to direct a multi-agency response to the unexplained health incidents that have affected U.S. government personnel and family members stationed overseas. The Department has committed to reviewing – and revising when necessary – procedures for ensuring continued senior-level leadership at all times, as well as validating and strengthening guidance for Chiefs of Mission (including Chargés), emphasizing their responsibility for the safety and security of personnel abroad. The Department is establishing a new position solely responsible for longer-term outreach and assistance to personnel affected by these incidents.

Interagency Coordination: The ARB found that interagency information sharing should be enhanced to improve understanding of the problem and more coordinated initial responses. The ARB noted the Department’s well-established and successful procedures for dealing with crisis situations and highlighted the benefit of reviewing its processes for communication and coordination with interagency partners, as well as reminding leaders of these processes. The Department agrees with these recommendations and will re-issue guidance outlining the various tools and processes Washington and posts abroad have available to prepare for and respond to crisis situations. The Department will reinforce the importance of proper and timely implementation of these procedures, and is committed to working with interagency partners to ensure coordination of efforts on the response to the incidents.

Medical Issues: The ARB found the Department’s Bureau of Medical Services provided competent and professional response to an unprecedented situation, but they had insufficient resources to support the long-term care and follow-up needed for these types of incidents. To address the ARB’s recommendations, the Department, in coordination with other appropriate U.S. government agencies, is identifying and reviewing applicable legal authorities and resources for long-term medical follow-up and treatment for U.S government personnel and families impacted by the incidents in Cuba, and will seek legislative remedies where necessary. The Department is also working closely with the Department of Labor to allow for the proper adjudication of workers’ compensation claims from Department personnel. Additionally, the ARB recommended the Department make pre-departure and post-assignment medical screening a mandatory condition for assignment to, or temporary duty in, Havana. The Department is in the process of developing policy modifications to make such screenings mandatory. The ARB also recommended the Department engage the Centers for Disease Control and Prevention (CDC) to undertake a comprehensive medical and epidemiologic study of the symptoms and clinical findings related to the incidents in Cuba. The Department is working with the CDC to support such an analysis.

Internal Communication and Information Sharing: The ARB made several recommendations to facilitate communication and information sharing in the case of any future incidents. The Department is implementing the ARB’s recommendations, with the goal of: clarifying responsibilities, providing centralized points of contact to coordinate efforts, establishing clear notification protocols, and ensuring as much transparency as possible to those affected, taking into account the privacy of the individuals involved as well as sensitive law enforcement and national security information.

Risk/Benefit Analysis: The ARB made several recommendations to ensure the Department enacts its already established processes to conduct formal risk/benefit analyses and ensure any actions balance Department priorities with risk management. The Department is implementing these recommendations, and taking steps to enhance broader awareness of these processes throughout the Department. For example, the Department has processes to conduct an analysis at least once annually of mitigation measures and residual risks associated with operating at high threat, high risk posts and at those posts on Authorized or Ordered Departure for 90 days or more due to security reasons. The Department will continue to implement this approach.

Diplomatic Security: The ARB found individual offices within the Bureau of Diplomatic Security (DS) responded to the Cuba incidents reports based on their respective areas of expertise, but that the overall response would have benefitted from the formulation and resourcing of a formal DS multi-disciplinary working group. The Department agreed, and DS formed a Health Incidents Response Working Group with members from all relevant DS offices reporting to the DS Assistant Secretary. This working group has increased communication among the various interagency investigative representatives, and ensured action items are addressed quickly and comprehensively. Additionally, to address future potential unexplained health-security incidents, the Department developed standardized formal guidance, leveraging existing crisis response processes, designed to ensure a consistent response from all agencies at post. All posts are reviewing and updating their emergency action plans to incorporate this guidance. The ARB also suggested the Department review its training programs for security personnel. DS is in the process of reviewing its training and briefing programs to ensure security officers have adequate knowledge of these types of incidents prior to going to post.
The Department has already implemented half of the ARB’s 30 recommendations and is actively working to complete the rest. Due to the nature of the recommendations, some may take longer than others to implement. Some recommendations will not be able to be fully closed until such time as the cause behind the incidents has been determined. Others may require seeking legislative remedies. The Department is committed to working with its interagency partners and Congress, as appropriate, on resolving ongoing issues related to the unexplained health incidents in Cuba.

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