the official magazine of the brain injury association of california


War ravages lives across borders and cultures and within military ranks. The physical casualties [of war] are front and center, but the less talked about and equally debilitating occurrences of traumatic brain injury (TBI) are the silent wounds effecting millions globally — wounds which often goes untreated. In a conflict setting, TBI is commonly caused by blasts and leaves service members and civilians alike to grapple with life-altering cognitive difficulties, sometimes without adequate medical care to support recovery. Though the problem is more prevalent than the help, there are many agencies and organizations dedicated to assisting these victims of war. The Office of the UN High Commissioner for Human Rights (OHCHR), the UN Assistance Mission (UNAMA), the United Nations Children’s Fund (UNICEF), and others, are dedicated to shedding light on the problem and providing solutions. SERVICE MEMBERS AND TBI According to the Joint Theater Trauma Registry, compiled by the U.S. Army Institute of Surgical Research, 22 percent of soldiers wounded in the U.S. war in Afghanistan had injuries

to the head, face or neck. This percentage can serve as a rough estimate of the fraction who have TBI, according to Deborah L. Warden, a neurologist and psychiatrist at Walter Reed Army Medical Center who is the national director of the Defense and Veterans Brain Injury Center (DVBIC). Warden said the true proportion is probably higher, since some cases of closed brain injury are not diagnosed promptly. In the Vietnam War, by contrast, 12 to 14 percent of all combat casualties had a brain injury, and an additional 2 to 4 percent had a brain injury plus a lethal wound to the chest or abdomen, according to Ronald Bellamy, former editor of the Textbooks of Military Medicine, published by the Office of the Surgeon General of the U.S. Army. Bellamy said that because mortality from brain injuries among U.S. combatants in Vietnam was 75 percent or greater, soldiers with brain injuries made up only a small fraction of the casualties treated in hospitals. Kevlar body armor and helmets are one reason for the high proportion of TBIs among soldiers wounded in more current conflicts. They work by shielding the wearer from bullets and shrapnel and have improved overall survival rates. Kevlar

helmets have reduced the frequency of penetrating head injuries. However, the helmets cannot completely protect the face, head and neck — nor do they prevent the kind of closed brain injuries often produced by blasts. Most brain injuries in war zones are caused by improvised explosive devices (IEDs), and closed brain injuries outnumber penetrating ones among patients seen at Walter Reed, where thousands of patients with TBI are treated. All admitted patients who have been exposed to a blast are routinely evaluated for brain injury — 59 percent of them have been given a diagnosis of TBI, according to Warden. Of these injuries, 56 percent are considered moderate or severe, and 44 percent are mild. A blast creates a sudden increase in air pressure by heating and accelerating air molecules and, immediately thereafter, a sudden decrease in pressure that produces intense wind. These rapid pressure shifts can injure the brain directly, producing concussion or contusion. Air emboli — a blockage of blood supply caused by air bubbles — can also travel to the brain, causing the death of brain tissue. When service members have serious brain injuries, they receive immediate care on the battlefield and are then transported to military combat support hospitals, where they undergo brain imaging and are treated by neurosurgeons. Treatment may include the removal of foreign bodies, control of bleeding or craniectomy — which relieves pressure from swelling. Soldiers with TBI often have symptoms affecting several areas of brain function. Headaches, sleep disturbances and sensitivity to light and noise are common. Cognitive changes, diagnosed on mental-status examination or through neuropsychological testing, may include disturbances in attention, memory or language, as well as delayed reaction time during problem solving. Often, the most troubling symptoms are behavioral ones — mood changes, depression, anxiety, impulsiveness, emotional outbursts or inappropriate laughter. Some symptoms of TBI overlap with those of post-traumatic stress disorder, and many effected in the military sector have both conditions. The good news is service men and women are young and healthy, and as such are in a good position to recover. CIVILIANS INJURED IN CONFLICTS The U.S. wars in Iraq, Afghanistan, Yemen, Syria and Pakistan, military operations in Somalia as well as the more recent conflict in Ukraine have taken a tremendous human

toll on those countries. Hundreds of thousands of civilians have been injured as a result of these conflicts and many of these injuries have resulted in TBI. For example, according to the Watson Institute for International and Public Affairs, blast-induced TBI has been referred to as the signature injury of the conflicts in Iraq and Afghanistan. People living in these war zones have been attacked in their homes, in markets and on roadways. They have been subjected to bombs, bullets, fire and IEDs. Civilians are victimized at checkpoints, as they are run off the road by military vehicles, when they step on mines or cluster bombs, as they collect wood or tend to their fields and when they are kidnapped and executed for purposes of revenge or intimidation. A new book, published by world-renowned UCSF neuroradiologist Dr. Alisa Gean, tackles the complexity of TBI, how it is sustained and how it affects both civilians and combatants alike. The text includes information and research gathered from nearly three decades of studying civilian TBI, as well as five intensive years of studying TBI sustained from combat, terrorism and natural disasters. “Aproximately 85% of injured World War II soldiers suffered from gunshot wounds. Today’s enemy is using a new weapon to kill, defeat and demoralize — the improvised explosive device.” says Dr. Gean. The U.S. war in Afghanistan lasted for 22 years and resulted in an enormous footprint of civilian casualties. In their Afghanistan Protection of Civilians in Armed Conflict Annual Report, the Office of the UN High Commissioner for Human Rights (OHCHR) and the UN Assistance Mission (UNAMA) documented some 8,820 civilian casualties (3,035 deaths and 5,785 injuries) in 2020. These civilians paid a terrible price for the failure of peace negotiations and the country remains amongst the “deadliest places in the world to be a civilian”, according to Michelle Bachelet, UN High Commissioner for Human Rights. “I am particularly appalled by the high numbers of human rights defenders, journalists and media workers killed since peace negotiations began”, she says. According to the report, the overall drop in civilian casualties in 2020 was due to fewer casualties from suicide attacks by anti-government elements in populated areas, as well as a drop in casualties attributed to international military forces. There was, however, a “worrying rise” in targeted killings by such elements — up about 45 per cent since 2019. The use of IEDs by the Taliban, air strikes by the Afghan Air

Force and ground engagements also resulted in increased casualties, according to the report. Anti-government elements bore responsibility for about 62 percent of civilian casualties, while pro-government forces were responsible for about 25 pe cent of the casualties. About 13 percent of casualties were attributed to crossfire and other incidents. The report went on to note that the years-long conflict in Afghanistan “continues to wreak a shocking and detrimental toll” on women and children, who accounted for 43 percent of all civilian casualties — 30 percent children and 13 percent women. “This report shows the acute and lasting needs of victims of the armed conflict and demonstrates how much remains to be done to meet those needs in a meaningful way”, High Commissioner Bachelet said. “The violence that has brought so much pain and suffering to the Afghan population for decades must stop and steps towards reaching a lasting peace must continue.”

CHILDREN OF WAR June 3rd marked the 100th day of the war in Ukraine — a war that has shattered the lives of millions of children. Only days before, on June 1st, the International Day for Protection of Children [in Ukraine and across the region] was marked. “June 1 is the International Day for Protection of Children,” said UNICEF Executive Director Catherine Russell. “Instead of celebrating the occasion, we are solemnly approaching the 100th day of the war. Without an urgent ceasefire and negotiated peace, children will continue to suffer — and fallout from the war will continue to impact vulnerable children around the world.” The scale and speed of the emergency in Ukraine have not been seen since World War II, the United Nations said in a statement, which estimated that 5.2 million children in the region need humanitarian assistance; three million inside the country and more than 2.2 million in refugee-hosting countries. As intense artillery exchanges continue between

Russian and Ukrainian forces in eastern Donetsk region and amid reports that Russian troops are continuing their campaign, UNICEF said that almost two in three children in Ukraine have been displaced by fighting. “Civilian infrastructure on which children depend continues to be damaged or destroyed,” the agency explained. “This so far includes at least 256 health facilities and one in six UNICEF-supported ‘Safe Schools’ in the country’s east. Hundreds of other schools across the country have also been damaged. Conditions for children in eastern and southern Ukraine where fighting had been quite intense are increasingly desperate.” In addition to the trauma of fleeing their homes, UNICEF states that children fleeing violence faced a significant risk of family separation, abuse, sexual exploitation and trafficking. The UN agency also reiterated its call for “full humanitarian access” so that teams can “safely and quickly reach children in need wherever they may be”. Inside Ukraine, UNICEF and partners have already distributed life-saving health and medical supplies for nearly 2.1 million people in war-affected areas. Equally important, critical safe water access has also been secured for more than 2.1 million people living in areas where networks have been damaged or destroyed. The long-lasting mental health toll of the war on children has also contributed to an acute child protection crisis, made worse by the fact that many displaced families are out of work and unable to meet their children’s basic needs. “These children urgently need safety, stability, child protection

services and psychosocial support — especially those who are unaccompanied or have been separated from their families. More than anything, they need peace,” UNICEF insisted. Over 610,000 children and caregivers have also received mental health and psychosocial support, while nearly 290,000 children have been given learning supplies. In addition, almost 300,000 vulnerable families have registered for a humanitarian cash assistance program run by UNICEF and the Ukrainian Ministry of Social Policy. In countries hosting Ukrainian refugees, the UN agency continues to look out for the most vulnerable of children by providing anti-trafficking training for border guards and encouraging local authorities to integrate refugee children into schools. Providing vaccines and medical supplies for displaced Ukrainians is a key component of UNICEF’s response, and so too is establishing play and learning hubs to provide young children with a much-needed sense of normalcy and respite. In total, 25 UNICEF-UNHCR “Blue Dots” — one-stop safe havens that provide support and services for families on the move, have been established along major transit routes in Moldova, Romania, Poland, Italy, Bulgaria and Slovakia, the agency said. In Moldova, more than 52,000 refugees, mostly in female-headed households, have been reached through a UNICEF-UNHCR multi-purpose cash assistance program. Highlighting the devastating and lasting consequences of the war on millions of the country’s youngest citizens, UN Children’s Fund UNICEF maintains that most of the victims were from “attacks using explosive weapons in populated areas”, a claim



supported by the UN human rights office, OHCHR. With the use of explosive weapons, it is inevitable that many of these children will be effected by TBI. According to the Save the Children Blast Injury Report, the use of explosive weapons, traditionally meant for the open battlefield, in densely populated towns and cities continues to cause devastation to children. Time after time, these weapons result in death, life-changing injuries and the destruction of vital facilities, such as schools and hospitals. From Syria, to Yemen, to Afghanistan, the families of the injured are left to manage TBI among other devastating injuries with health systems often at the point of collapse. And children are particularly vulnerable to blasts with their bodies being lighter, and thus easily thrown farther than an adult’s body. There are good reasons why the killing and maiming of children in conflict is defined as a grave violation by the United Nations. If children survive explosive weapons, they often find themselves dealing not only with physical trauma and disability, but with the loss of family members, the destruction of their homes and the disruption of their education — and with it their future prospects. To say nothing of the acute stress already caused by growing up in a war zone. Though children can be quite resilient, they cannot be expected to recover without sustained and specialist support. Left untreated, the long-term effects of blast injuries will leave children facing a lifetime of suffering, and will ultimately create an entire generation at risk of exclusion. The Pediatric Blast Injury Partnership (PBIP), led by Imperial College London with Save the Children, is a practical response to the unique medical challenges faced by children with blast injuries. One of the PBIP’s most valuable resources to date is the Pediatric Blast Injury Field Manual, which gives medical staff in conflict settings, who often have to operate with little or no previous experience or training, the knowledge and technical guidance needed to treat children from the point of injury onwards. It also offers advice on how to provide long-term rehabilitation care and mental health support.

Smart initiatives like these will make a real difference to injured children, and medical institutions and humanitarian agencies like Save the Children will undoubtedly continue to build on this work to ensure children have the best chance of recovery. But in order to truly protect children in conflict, governments need to take an active role to advocate for children. This is why PBIP is calling on all warring parties to Stop the War on Children by taking steps to uphold international laws and norms, ensuring accountability for crimes against children and investing in the support necessary to help children recover from the physical and psychological trauma caused by conflict. PBIP found that 80% of pediatric blast patients experienced penetrating injuries to the head. By comparison, just 31% of adult blast patients experienced the same injury. Within this, younger children are more affected. Children under seven are almost twice as likely to present with head injuries as older children. In one study, 90% of children who died from blast injuries had skull fractures. When children survive a blast, they are almost always left with life-limiting brain injury. Take 12-year-old Mahmoud who lives in Gaza. In 2014 when he was playing in the street, he was hit by an explosive weapon. “I heard an explosion and I felt something go into my eye. I touched my eye and felt blood pouring out. I ran for help and was taken to the hospital. I woke up missing one of my eyes.” Mahmoud’s family says byond his physical injuries, he was not himself after the accident. Mahmoud ikely suffered an undiagnosed TBI. Helle Thorning-Schmidt, CEO of Save the Children International and former Prime Minister of Denmark is uncompromising in her assessment: “International law makes clear that everyone has a responsibility to make sure children are protected in war. Yet explosive weapons continue to kill, maim and terrorize thousands of children every year. Every warring party — from armed groups to governments — must do more to protect children and abide by this important moral principle.”