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, sniper fire, and frag-

    ments of explosive devices. The average age was 39 years

    old in civilian causalities but 28 years old in military cas-

    ualties.29 Permanent paralysis or death was found in

    nearly half of spinal cord injury patients in 2 Croatian

    referral hospitals.29,30 Six years postconflict, there was no

    significant change in the number of rehabilitation beds,

    facilities, or professionals in Croatia.31 A referral hospital

    for Afghan victims of war in Pakistan saw more than

    1,700 patients for spinal cord injury between 1983 and

    1996.32 In Afghanistan in 2003, a study of 311 residents

    of Kabul and Herat found acute care for spinal cord

    injury survivors was practically nonexistent, with a high

    prevalence of pressure sores and recurrent urinary tract

    infections among spinal cord injury survivors. In Kabul,

    63% of all spinal cord injuries in an International Com-

    mittee of the Red Cross spinal cord injury program were

    attributed to war.32 In Africa, reports on spinal cord

    injury during armed conflicts are limited. A referral hos-

    pital in Senegal found that less than half of patients with

    spinal cord injury experienced partial or complete recov-

    ery, citing a special need for immediate and multidiscipli-

    nary management of spinal cord injury patients.33

    PERIPHERAL NERVE INJURY. Peripheral nerve injuries

    are often more common than traumatic brain and spinal

    cord injuries during conflict34 but are comparatively

    understudied. Peripheral nerve and plexus injury can

    result from direct trauma, chemical warfare, and long-

    term damage from unhealed fractures. The Belgrade

    Military Medical Academy managed 3,091 missile-

    induced peripheral nerve injuries from 1991 to 1995.35

    A total of 713 patients (99% male) were reported with

    peripheral nerve injuries due to war in Croatia and Bos-

    nia and Herzegovina. The majority had single-nerve

    lesions with the peroneal (21%) and ulnar (20%) being

    the most common.36 In U.S. Army casualties of the Per-

    sian Gulf Conflict, the most common nerves affected in

    one report were median (18%), peroneal (16%), ulnar

    (12%), and radial (11%)34; however, when considering

    10-year outcomes, there was no significant difference in

    the rate of peripheral neuropathy between deployed and

    nondeployed Gulf War veterans.37

    Peripheral nerve injuries have a long-term relation-

    ship to pain among survivors of armed conflict. High-ve-

    locity missile injuries comprised more than 75% of

    reported cases in a meta-analysis of causalagia in

    2003.38,39 In Serbia, 15% of peripheral nerve injuries

    caused by missile were considered painful.35 Multimodal-

    ity treatment including early nerve repair40 and regional

    anesthesia41 have been studied more thoroughly as a result.

    Chronic PhaseIn times of conflict, health systems fall into disrepair and

    persons with chronic diseases cannot access health serv-

    ices. Chronic diseases are often not priorities in resource-

    poor regions, even before an armed conflict arises. In

    Nicaragua, prolonged conflict between 1983 and 1987

    led to rampant inflation of service fees, targeted killings

    of health care professionals, and weakening of basic

    health services.42 In Iraq, doctors left Baghdad due to

    threats, kidnappings, violent events, and violent deaths,

    leading to a peak loss of 22% of specialists in 2007.43 In

    Sierra Leone, the 1 neurologist in practice during the

    civil war moved out of the country.44

    In Kosovo in 1999, high numbers of deaths were

    reported to be due to renal disease, ischemic heart dis-

    ease, and diabetes,45 but the neurological causes of death

    were not specifically reported. A similar situation likely

    occurred in Chechnya and Ingushetia,46 demonstrating

    the need to emphasize chronic disease care when human-

    itarian emergencies occur in developed regions. A combi-

    nation of targeted political civilian violence, declining

    access to health care, lack of fuel, and mistrust of existing

    health services can lead to a predominance of untreated

    chronic conditions. In contrast, malnutrition and infec-

    tious diseases are the usual causes of death seen during

    emergencies in developing countries.47

    The theory that stress may increase the rate of mul-

    tiple sclerosis (MS) exacerbations has been posited. War

    stress would therefore be a special concern among

    ANNALS of Neurology

    284 Volume 68, No. 3

  • people with diagnosed MS. A study of 156 patients with

    relapsing-remitting MS patients in Israel48 found a 3- to

    18-fold increase in relapse rate during a 33-day period of

    war as compared to the rate a year earlier when no war

    occurred. Patients who reported high levels of distress

    due to rocket attacks, perceived death threats, or home

    evacuation were more likely to have an attack. A similar

    study in Lebanon49 found patients with clinically-definite

    MS have both increased rates of relapse during war and a

    higher number of gadolinium-enhancing lesions on mag-

    netic resonance imaging of the brain.

    United States veterans of World War II have been

    noted to have increased rates of MS compared to the av-

    erage U.S. population, with a marked excess seen in all

    age-sex groups.50 Long-term prisoners-of-war from the

    Far East, however, were not noted to have an excess of

    MS or any other neurodegenerative disease after 46 years

    of follow-up.51

    Survivors of landmine injury may experience mem-

    ory loss,52 painful neuromas of the amputated stump,53

    postamputation pain,54 phantom limb phenomena,55

    and significant locomotor disability.56 Rehabilitation

    services for landmine survivors reach less than 5% of

    people with disability in developing countries.57

    Long-term follow up for neurological mortality was

    studied among 621,902 Persian Gulf Veterans (1991

    1992) and 746,248 nonveterans.58 No neurological mor-

    tality was associated with Gulf War service, including

    death due to motor neuron disease, Parkinsons disease,

    multiple sclerosis, or brain tumors; however, veterans

    potentially exposed to nerve agents at Khamisiyah, Iraq,

    and to smoke from oil-well fires had a higher risk of fatal

    brain cancer.

    Neurological Disorders in Refugees andInternally Displaced Persons

    The Unit...


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