Book: Confronting Traumatic Brain Injury
Authors: Christian Murray-Leslie
Journal: BMJ (2000)

William J Winslade


Yale University Press, £10.50, pp 236 




ISBN 0 300 07942 7

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Rating: ★★★

There is a pressing need to effectively address the issues of prevention of traumatic brain injury and the rehabilitation and care of those affected. Despite the often tragic circumstances and nature of major head injury, the subject evokes little public or political interest and makes many people feel uneasy. The difficulty people have in relating to others with brain injury, as opposed to those with purely “physical” disablement, is well illustrated in this book by the story of press secretary James Brady, hit by a bullet intended for President Reagan. This is one of several instructive case histories that are all too familiar to those of us who try daily to help people adjust to and cope with the consequences of head trauma.

Although head injury is the commonest cause of death in young people and children, reaching epidemic proportions in the United States, and produces some of the most awful impairments for survivors, it has such a low public profile that it has been called “the silent epidemic.” Confronting Traumatic Brain Injury is a serious attempt to raise public awareness, tackle public attitudes, and discuss moral and ethical issues. It makes many practical suggestions for addressing prevention and equitable healthcare provision. It analyses in considerable and fascinating detail the paradox of US attitudes to such commonsense preventive measures as wearing a crash helmet or a seat belt and to the provision of rehabilitation for all those affected by catastrophic injury. Although this is an American book aimed at a broad US public, there is much to be learnt by international readers from the description of successful and failed US initiatives.

Despite many unsatisfactory aspects, not least the gross inequity of rehabilitation provision and the widespread exploitation of those insured by the “for profit” private rehabilitation sector, along with the failure to restrict firearms, more progress seems to have been achieved in the United States than in Britain. Winslade draws attention to the impact of the Americans with Disabilities Act, which is much more effective than the British Disability Discrimination Act. President Bush declared the 1990s the decade of the brain, and substantial sums of federal money have been channelled not only into basic research on head injury but into research on rehabilitation methods and outcomes. Several large rehabilitation centres for brain injury have been set up. A proportion of the money has been channelled through the Department of Education, reflecting the relearning and long term needs of those recovering from head injury.

Unfortunately, attempts to expand Medicare to provide insurance for catastrophic injury for all met with only transient success and foundered on the refusal of the many to share the burden of the few. The British reader will probably be fascinated by the parallels between the Republican years of the Reagan and Bush administration described in the book and the Thatcher years in Britain, where, under the guise of greater individual freedom, selfishness and greed made liberal reforms more difficult.

The moral and ethical dilemmas of managing the persistent vegetative state are particularly well covered. Winslade provides suggestions for raising revenue to support adequate state funded rehabilitation for those who are not insured—at least 40% of the US population.