Neurological disorders in complex humanitarian emergencies and natural disasters

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    Neurological Disorders in ComplexHumanitarian Emergencies

    and Natural Disasters

    Farrah J. Mateen, MD

    Complex humanitarian emergencies include the relatively acute, severe, and overwhelming health consequences ofarmed conflict, food scarcity, mass displacement, and political strife. Neurological manifestations of complexhumanitarian emergencies are important and underappreciated consequences of emergencies in populationsworldwide. This review critically assesses the existing knowledge of the range of neurological disorders thataccompany complex humanitarian emergencies and natural disasters in both the acute phase of crisis and the longshadow that follows.

    ANN NEUROL 2010;68:282294

    Complex humanitarian emergencies occur when civil-ian populations experience immediate, severe, andoverwhelming health consequences. Armed conflict, mass

    displacement, and food scarcity are major threats to pop-

    ulations worldwide.1 Although rarely considered, neuro-

    logical manifestations are important components of com-

    plex humanitarian emergencies.

    This review explores the neurological manifestations

    of complex humanitarian emergencies, where docu-

    mented, from more than 100 countries around the

    world. Whereas historical perspectives of neurological

    disease and emergencies have focused on combatants,

    modern emergencies are increasingly experienced by

    unarmed civilians. Armed conflict today is more often

    protracted, intrastate, fought by irregular groups, and

    marred by targeted violence toward civilians.2 Civilians

    are now the most likely group to experience both mor-

    bidity and mortality in times of warfare.

    People in low-income and middle-income coun-

    tries are especially at risk for health consequences of

    emergencies. Existing health services may be inadequate

    or absent and a priori health status may be poor. How-

    ever, neurological consequences of emergencies are not

    confined to people in resource-poor regions. Emergen-

    cies and disasters are experienced in all parts of the

    world, leading to a heightened need for neurological

    services and increasing the already-high burden of neu-

    rological disease.

    The aim of this review is to provide a topical

    understanding of neurological manifestations in times of

    armed conflict, mass displacement, natural disasters, fam-

    ine, and torture experienced over the past generation

    (1985 to present). The first goal is to concentrate atten-

    tion on the real experiences of people who suffer neuro-

    logical disorders in crisis settings. The second is to pro-

    vide a useful framework for policymakers, aid workers,

    and relief organizations to include neurological disorders

    in the priority setting arena.

    Because neurological disorders in times of crisis can

    be both acute and chronic, each type of humanitarian

    emergency will be considered in relation to: (1) the more

    immediate manifestations of neurological injury that

    accompany a disaster, relevant to relief workers and res-

    cue agencies; and (2) the chronic neurological disorders

    of survivors; ie, those disorders that persist in the long

    shadow of crisis in the months to years that follow basic

    relief efforts. Although psychiatric disorders have a com-

    plex interplay with the experience of neurological disor-

    ders, this review will focus solely on those disorders tradi-

    tionally considered as neurological.

    View this article online at DOI: 10.1002/ana.22135

    Received Feb 13, 2010, and in revised form May 26, 2010. Accepted for publication Jun 18, 2010.

    Address correspondence to Farrah J. Mateen, Room E8527, 615 N. Wolfe Street, Baltimore, MD. E-mail:

    From the Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD.

    282 VC 2010 American Neurological Association

  • Armed Conflict

    Acute PhaseTraumatic injuries to the brain, spinal cord, plexus, and

    peripheral nerves are well-documented during armed

    conflict (Table 1). Damage may be direct, due to violent

    warfare between combatants or combatants and civilians,

    or indirect, due to exploding ordinances postconflict.

    BRAIN INJURY. Traumatic brain injury is the most

    commonly documented neurological consequence of

    armed conflict and exceeds the rate of other injuries,

    including amputations, in many countries. Between 2003

    and 2007, Military Health Services of the United States

    reported more than 43,000 new diagnoses of traumatic

    brain injury related to Operation Enduring Freedom,

    Operation Iraqi Freedom, and unaffiliated wars. The esti-

    mated cost in 2009 was 100 million $US for direct care

    with an additional 10 million for related prescription

    drug costs.3

    Although nearly all reports of traumatic brain

    injury derive from combatants and veterans, several stud-

    ies from Afghanistan, Bosnia, Croatia, Iran, Iraq, Israel,

    and Lebanon have looked at civilian injuries. In recent

    years, pediatric traumatic brain injury,4,5 self-inflicted

    head injury,6 and secondary neurological consequences of

    traumatic brain injury, including intracranial infection,79

    post-traumatic epilepsy,10,11 and chronic headache,12,13

    have received greater attention. Secondary neurological

    complications may exist in up to 35% of penetrating

    brain injuries.7 Likewise, the consequences of mild trau-

    matic brain injury are increasingly recognized.14

    Survival following traumatic brain injury varies

    widely in recent reports. In Croatia (19911994), the

    mortality rate at a frontline hospital was 46%15 and in

    Bosnia and Herzegovina (19941995) it was 37%,16

    whereas in U.S. Field Hospitals (1991) in Operation De-

    sert Storm, the mortality rate was approximately 5%.17

    The first 2,000 wartime hospital admissions of children

    in Iraq and Afghanistan were reported in 2008.4 Case fa-

    tality rates of head injury far exceeded any other cause of

    admission and accounted for 30% of all deaths among

    admitted children. Prehospital mortality in Afghan chil-

    dren was considered high and may have deflated the real

    pediatric case fatality from war. A lack of standard defini-

    tions for level and type of injury prevents robust compar-

    isons between locations and cohorts.

    In current wars, blast injuries are the most common

    form of head injury and may be due to rocket and mor-

    tar shells, artillery, booby traps, aerial bombs, improvised

    explosive devices, landmines, or rocket-propelled gre-

    nades.18 Antipersonnel landmines have received concen-

    trated attention in recent years with the aim to ban their

    TABLE 1: Reported Neurological Manifestations by

    Category of Emergency (19852009)



    or Event

    Neurological Manifestations

    Documented in Association

    with the Emergency

    Natural disasters Seizures


    Head and spinal cord injury

    Peripheral nerve and brachial plexus injury

    Ischemic and hemorrhagic stroke

    Worsened symptoms of dementia


    Delayed vaccination leading to

    polio outbreaks

    Meningitis from contaminated

    anesthetic storage

    War/conflict Head and spinal cord injury

    Post-traumatic CNS infection

    Neuropathic pain

    Epilepsy, post-traumatic

    Headaches, chronic, post-traumatic

    Peripheral nerve injury and neuromas

    Multiple sclerosis exacerbations

    Memory loss

    Meningococcal meningitis outbreaks

    Japanese encephalitis outbreaks

    Tuberculous meningitis outbreaks

    Polio outbreaks

    Measles outbreaks

    Cerebral malaria

    Long-term: brain tumors

    Food scarcity Epilepsy

    Toxicity from antiepileptic drugs


    Peripheral neuropathy

    Optic neuropathy

    Sensorineural deafness

    Wernickes encephalopathy

    Seasonal ataxic syndrome

    Strachans syndrome

    (B-complex vitamin deficiency)

    CNS central nervous system.

    Mateen: Neurology in Humanitarian Emergencies and Disasters

    September, 2010 283

  • use worldwide. Landmines can be found in more than

    70 countries with a predominant effect on civilian youth

    in low-income and middle-income countries.19 In 2009,

    20 people were maimed or killed by antipersonnel land-

    mines on a daily basis.20 Although a significant fraction

    of landmine-related injuries are fatal (5055%),21 acute

    head and spinal cord injury has been reported.22,23 In Sri

    Lanka, where injuries were recorded by body part, 16%

    of landmine injuries occurred above the neck.24 Children

    are likely to be more affected by head injury than adults

    because they are more likely to pick up landmines than

    adults and have their vital organs closer to the point of


    SPINAL CORD INJURY. Spinal cord injury is a major

    cause of severe disability during armed conflict.27 In

    some recent conflicts, civilian mortality rates from spinal

    cord injury and its complications show only modest dec-

    rements from the nearly 80% mortality reported by Har-

    vey Cushing in 1927.28 In recent years, spinal cord

    injury has been reported from Afghanistan, Senegal, Bos-

    nia, Croatia, Iraq, Israel, and Lebanon. A study in an

    evacuation hospital in Croatia revealed injuries due to

    projectiles from automatic rifles


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