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Article The World We Want In partnership with the UNDP

Mind your brain: Traumatic brain injury as a public health problem (An Indian perspective)

Introduction

The World Health Organisation (WHO) addresses neurotrauma or Traumatic Brain Injury (TBI) as ‘a critical public health problem that deserves the attention of the world’s health community.’ In a manner of speaking, every disease, every condition that affects us, should ideally be addressed as a public health problem requiring multidimensional approaches to solve it. But there is a broad difference in our outlook when we look at isolated medical conditions that affect a select few as compared to when we look at a problem that affects a significant percentage of the population. When we begin to look at a problem as a threat looming large over the populace in general, we tend to put in more resources to solve it; we tend to apply different approaches to address the problem. This paradigm shift is not easy. But it is absolutely imperative that we undergo this transformation in how we look at the problem of TBI. In this article, we will try and undertake this journey by looking at the problem of TBI, how it affects us, and how we might be able to approach it by transforming the way we look at it and the difficulties faced in the process of doing so.

The textbook definitions of TBI go along the lines of ‘acquired open or closed head injury, caused by external physical force and resulting in structural changes in the brain and partial or total functional disability.’ But they don’t do justice to the dramatic nature and the impact of TBI. A blow to the head usually lasts for a few milliseconds. The effects last a lifetime. The blows seldom come with warning signs. You are fit at one moment, struggling for your life the next. At times, death appears to be the better choice for the patient. The recent example of Michael Schumacher’s accident while skiing perhaps illustrates the point better than any other. Michael Schumacher was a seven-times Formula One racing champion. He had a career spanning for over seventeen years. For seven years, he was the fastest human being on land, cruising across difficult race-tracks at speeds of up to three hundred kilometres per hour. Last year, he went skiing with his son in the French Alps. While trying to cross an unsecured off-piste area, he fell and his head hit a rock. He was wearing a skiing helmet, which probably saved his life, but the injury was severe. Several months later, he is still mostly unconscious, and is still struggling for his life at a hospital. The doctors have tried all the latest modalities of therapy on him but the prognosis seems to be grim, to put it mildly. In the rare event that he survives, he’ll probably have to live as a severely disabled person. From the fastest human being on the planet to being locked in a vegetative state of coma, traumatic brain injuries have their way of altering the course of our lives, in ways most unexpected.

Historical Overview of TBI

Having evolved in a world full of different kinds of motion, trauma has always been a problem that bugs living creatures. It precedes the evolution of brains but ever since animals evolved brains, traumatic injury to it has been an especially threatening situation. We, humans, have been dealing with it since our beginning. Fractured skulls by blow to the head by an instrument, falls from height, to the modern high-impact road traffic accidents, our encounters with trauma have always been multi-faceted and the relationship has evolved over time. The nature of the injuries has changed rapidly as the causes of trauma have evolved and so have our ways of dealing with it.

The oldest manual of surgery that uses rational and scientific methods to deal with diseases rather than invoking magical thinking and supernatural powers is the Edwin Smith Papyrus dating back to the Egyptian civilisation some 3500 years ago. It makes the distinction between three kinds of illnesses, “A medical condition I can treat”, “A medical condition I can contend with”, and “A medical condition I cannot treat.” It is somewhat reassuring to see that the ancient Egyptian physicians weren’t put off by the complicated nature of head injuries in most cases and deemed most of them to be in one of the first two categories. With their limited resources and very poor understanding of how the human brain works, they devised immature methods to cope with traumatic brain injuries. Most importantly, they realised the importance of a sequential aspect of therapy in such cases and laid particular stress on thorough clinical assessment and (primitive) diagnostic procedures to determine the course of treatment.

Our medical system has evolved a lot in the intervening three and a half thousand years but the basic nature and structure of therapy still bears the rigour promoted by the ancient physicians. And at times, it may seem like we are often as helpless as the ancient physicians when it comes to more severe forms of injury. Apart from falls in the elderly, the most important cause of head injury in our modern world is road traffic accident. As has been suggested by the famous webcomic artist Randall Munroe in his comic xkcd, road traffic signs should read, “You’re in a box on wheels hurtling along several times faster than evolution could possibly have prepared you to go.” We have engineered vehicles that allow us to move around in speeds that weren’t possible throughout our evolutionary history. Harnessing this kinetic energy has come with its own risks. Our skulls, despite their resilience, cannot cope with impacts higher than what they evolved to resist and they give in resulting in damage to what is arguably the most important organ in the human body, the brain.

The Global Situation

On an average, more than two million people in the United States suffer from some sort of head injury. The number is close to a million in the United Kingdom. In a third-world country like India, the number ranges around two million. The worldwide figures are equally alarming; an estimated ten million people suffer from different varieties of traumatic brain injury every year. To understand the burden of the disease, we have to look at the demographic that is primarily affected by this and we have to contextualise the data with respect to the socioeconomic background of the victims in different countries.

The leading cause of traumatic brain injuries in most developed countries is primarily due to fall in the elderly. As the population ages, this is a problem that is going to be even more menacing in the future. The second leading cause in these countries is road-traffic accident. In the developing world, in countries of Sub-Saharan Africa, Latin America, the Indian subcontinent, and so on, road traffic accidents are the leading cause. This leads to a unique impact of the affliction on the socioeconomic state of a nation.

The primary age-group that is affected by road traffic accidents throughout the world lies between the ages of sixteen and thirty years. In the developing world, the sex-ration is heavily skewed against the males, with as many as five times more males being affected by it than females. In the developing world, this implies a greater economic impact of the condition as it affects a significantly productive age group, the economically advantageous sex (unfortunately), and the young victims have to deal with the disability that might result from it for more years. The problem is compounded further due to the lack of proper infrastructure to rehabilitate the victims in poorer countries. In a rough estimate, the National Institute of Mental Health and Neurosciences in India puts the burden of traumatic brain injury amounting to a loss of about 3% of the entire Indian GDP every year.

Looking at TBI as a public health crisis

This section will aim at describing the efforts being taken to address TBI as a public health problem, the difficulties in implementing that in different countries, a comparative analysis of this problem across different nations (with focus on India, a third world nation) and so on.

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