EDITORIAL
Traumatic Brain Injury: A Silent Epidemic It is a startling revelation to note that mortality from traumatic brain injury (TBI) over the past 12 years has exceeded the cumulative number of American battle deaths in all wars since the founding of our country. The enormity of the problem, often referred to as the silent epidemic, becomes even clearer when we realize that the total number of head injuries is conservatively estimated at over 2 million each year, with 500,000 serious enough to require hospital admission. The outlook for many survivors is poor. Approximately 70,000 to 90,000 each year face a life-long debilitating loss of function, 5,000 will develop epilepsy, and 2,000 will live in a persistent vegetative state. The fear, anguish and despair experienced by the families of victims can scarcely be described. Family members become frustrated by trying to deal with the medical, legal, and social systems that are often not equipped to handle the consequences of TBI. The overall economic cost to society approaches $25 billion each year. Recognition of the seriousness of TBI to our society led the congressional appropriations committees to encourage the Department of Health and Human Services to establish an Interagency Head Injury Task Force. The Task Force, which included representatives of 13 federal agencies, had public hearings and reviewed existing federal programs related to TBI. Its formal report was made availablein June (Washington, DC: US Government Printing Office, 1989-6 17-022/06034). The report sets forth a national strategy to deal with TBI. A key element is the establishment of a national research network consisting of fifteen regional head injury research centers to conduct basic neuroscience research, clinical neurological and behavioral research, and rehabilitation research. The research centers would be associated with regional clinical “hubs” for specialized care, education, and training and would be linked to a network of community care and services to share knowledge and expand access to treatment. Responding to congressional concerns that gaps exist in the country’s ability to manage head injury problems, the report addresses treating and preventing TBI and reducing its economic and psychological impact on survivors and their families. The report also discusses more than 40 implementation issues that should be addressed in carrying out the national strategy, including: 1. Improving emergency services by training emergency personnel and further development of rapid medical transport systems-an effort crucial to prevent additional brain damage after head injury; 2. Increased research, including use of models that mimic the full range of pathology found in human
TBI, to define molecular and cellular characteristics of brain injury, develop better methods of preventing deterioration of the brain just after injury, evaluate and improve therapeutic interventions, and restore function in patients with disability; Development of prevention strategies that reduce the frequency and severity of head injury, including changing behaviors and emphasizing prevention technologies (e.g., the improvement and use of protective helmets and auto air bags); Epidemiological investigations to determine incidence and prevalence of TBI and to identify highrisk populations and risk factors. The major focus for biomedical research in the neurosciences rests with the National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health. The NINDS stimulates and sponsors both basic and clinical investigations and also supports the training of the next generation of scientists who can carry the work forward. NINDS primary research program goals related to TBI are to: (1) understand changes that take place in and around the damaged area of the brain immediately after injury; (2) find ways of preventing further damage by preventing, impeding, or reversing the progression of ischemic and other destructive biochemical and metabolic changes; (3) understand the mechanisms of brain repair or compensation as a step toward the restitution of function; and (4) restore function to victims of head injury. It is hoped that the efforts of the Task Force will stimulate innovative research grant proposals to the NINDS that address these goals. The NINDS individual research fellowship, institutional research training grant, and clinical investigator career development award programs all provide instruments for support during periods of research training. The Interagency Task Force recommendations for a national strategy and the related implementation issues that are set forth in the report go beyond the mission of NINDS as they embrace clinical care, community services, and research responsibilities of other organizations. However, the broad framework proposed by the Task Force provides the basic and clinical neuroscience community with a template to give greater research attention to this major national problem.
Murray Goldstein, DO, MPH, Chairman Interagency Head I n j q Task Force National Institute of Neurological Disorders and Stroke, Betbesdz, M D 327
Traumatic Brain Injury: A Silent Epidemic It is a startling revelation to note that mortality from traumatic brain injury (TBI) over the past 12 years has exceeded the cumulative number of American battle deaths in all wars since the founding of our country. The enormity of the problem, often referred to as the silent epidemic, becomes even clearer when we realize that the total number of head injuries is conservatively estimated at over 2 million each year, with 500,000 serious enough to require hospital admission. The outlook for many survivors is poor. Approximately 70,000 to 90,000 each year face a life-long debilitating loss of function, 5,000 will develop epilepsy, and 2,000 will live in a persistent vegetative state. The fear, anguish and despair experienced by the families of victims can scarcely be described. Family members become frustrated by trying to deal with the medical, legal, and social systems that are often not equipped to handle the consequences of TBI. The overall economic cost to society approaches $25 billion each year. Recognition of the seriousness of TBI to our society led the congressional appropriations committees to encourage the Department of Health and Human Services to establish an Interagency Head Injury Task Force. The Task Force, which included representatives of 13 federal agencies, had public hearings and reviewed existing federal programs related to TBI. Its formal report was made availablein June (Washington, DC: US Government Printing Office, 1989-6 17-022/06034). The report sets forth a national strategy to deal with TBI. A key element is the establishment of a national research network consisting of fifteen regional head injury research centers to conduct basic neuroscience research, clinical neurological and behavioral research, and rehabilitation research. The research centers would be associated with regional clinical “hubs” for specialized care, education, and training and would be linked to a network of community care and services to share knowledge and expand access to treatment. Responding to congressional concerns that gaps exist in the country’s ability to manage head injury problems, the report addresses treating and preventing TBI and reducing its economic and psychological impact on survivors and their families. The report also discusses more than 40 implementation issues that should be addressed in carrying out the national strategy, including: 1. Improving emergency services by training emergency personnel and further development of rapid medical transport systems-an effort crucial to prevent additional brain damage after head injury; 2. Increased research, including use of models that mimic the full range of pathology found in human
TBI, to define molecular and cellular characteristics of brain injury, develop better methods of preventing deterioration of the brain just after injury, evaluate and improve therapeutic interventions, and restore function in patients with disability; Development of prevention strategies that reduce the frequency and severity of head injury, including changing behaviors and emphasizing prevention technologies (e.g., the improvement and use of protective helmets and auto air bags); Epidemiological investigations to determine incidence and prevalence of TBI and to identify highrisk populations and risk factors. The major focus for biomedical research in the neurosciences rests with the National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health. The NINDS stimulates and sponsors both basic and clinical investigations and also supports the training of the next generation of scientists who can carry the work forward. NINDS primary research program goals related to TBI are to: (1) understand changes that take place in and around the damaged area of the brain immediately after injury; (2) find ways of preventing further damage by preventing, impeding, or reversing the progression of ischemic and other destructive biochemical and metabolic changes; (3) understand the mechanisms of brain repair or compensation as a step toward the restitution of function; and (4) restore function to victims of head injury. It is hoped that the efforts of the Task Force will stimulate innovative research grant proposals to the NINDS that address these goals. The NINDS individual research fellowship, institutional research training grant, and clinical investigator career development award programs all provide instruments for support during periods of research training. The Interagency Task Force recommendations for a national strategy and the related implementation issues that are set forth in the report go beyond the mission of NINDS as they embrace clinical care, community services, and research responsibilities of other organizations. However, the broad framework proposed by the Task Force provides the basic and clinical neuroscience community with a template to give greater research attention to this major national problem.
Murray Goldstein, DO, MPH, Chairman Interagency Head I n j q Task Force National Institute of Neurological Disorders and Stroke, Betbesdz, M D 327
