With a traumatic brain injury, you feel yourself slipping away. You can’t remember things that used to come easily, things like how to find the grocery store — acts and details that live, mocking, at the edges of your thoughts, just outside your grasp.
You know there’s something wrong, but you have a sense that it’s all your fault. Rage bubbles and pops to the surface, the only emotion that seems to escape the thick stew of depression that dulls your days.
You make lists and lists, trying to get your life under control. But two days later, you stare at pieces of paper, trying to remember what the scribble meant, which thing it is that you were supposed to do next.
Chronic pain is there all the time, and you try to plan and wait and be patient and stick with a process, but then you find yourself sitting, head in hands, unable to remember what’s next. All you know is that something’s wrong. And the rage squirms and writhes, trying to bubble up again.
The behavioral changes and impaired functioning caused by post-traumatic brain injury aren’t poignant science fiction. They’re real.
Traumatic brain injury, especially from repeated concussions, has become a pivotal topic in sport, particularly in the National Football League. Watching a game on TV, it used to be easy to scoff at the concept, as you watched players collide a million times and heard the dull thud of plastic against muscle, bone against bone. You’ve seen players get up and walk it off. How could it be life-damaging? And even if it is, didn’t they kind of ask for it?
Watching these young men with lightning fast reflexes and rippling dunes of muscles – symbols, really, of human perfection – it may be hard to believe that they could have anything in common with the guy elbow-deep in the trashcan on your sidewalk. But when it comes to brain injury, its consequences and our reactions to it, the homeless and NFL players may have more in common than you might think.
CNN reports that, probably as a result of brain injury, former San Francisco 49ers lineman George Visger “has lived by scrawling the minutiae of his daily life on hundreds of small yellow notebooks, reminding himself when he left the house, when he got coffee. His is one of several cases of ex-NFL athletes struggling with memory loss, depression and sudden, frightening bouts of rage.”
That description may be sounding uncomfortably like the homeless person in your neighborhood, and for similar reasons. Mild to moderate concussions can result in depression, loss of what are known as “executive functions” (such as long-term planning, delayed gratification, impulse control, and concentration), dementia, and behavioral problems. Concussions are also associated with higher rates of substance abuse and chronic pain.
A survey of retired NFL players found that more than 60 percent had suffered at least one concussion in their career, and 26 percent had had three or more. Among the homeless, a well-done study found that 58 percent of homeless men had had an episode of serious head injury, with one in five having experienced five or more episodes. These injuries led to neurologic changes that are not trivial: a significantly increased likelihood of seizures, mental health problems, drug problems and poor physical health.
Most alarmingly, 70 percent of the homeless reported their first episode of serious head injury before becoming homeless, suggesting, the authors noted, that “in some cases, traumatic brain injury may be a causal factor that contributes to the onset of homelessness, possibly though cognitive or behavioral sequelae of traumatic brain injury.” What’s more, a study like this may actually have under-represented the degree of injury and impairment associated with head trauma among the homeless, since only those people competent enough to seek services at a soup kitchen or shelter were surveyed.
With so much at stake – the loss of human potential, the damage to our society, the costs of care for these kinds of impairments – you might think that society would take very seriously the prevention of head trauma among the homeless. There is, however, a sense that people on the streets may have brought it on themselves.
Assaults resulting in head trauma are a daily occurrence in life on the streets. A head slammed into a dumpster, a dislocating punch to the jaw, a head laceration that’s been stapled closed: these are so common as to be considered “normal” for the homeless.
Among patients presenting to San Francisco General Hospital with assault-related trauma, more than 40 percent were homeless, even though less than one percent of San Francisco residents are homeless. (That high proportion may also be an undercount, since researchers excluded any person whose head injury was so serious that he could not consent to the study. Victims of sexual violence also were excluded.)
Background red color represents the proportion of homeless people by supervisory district in San Francisco. Individual dots represent reported assaults to SFPD during three weeks, April to May, 2011.
You can document the overlap of assaults and homelessness for most urban areas by checking your police department’s violence-reporting maps against your own knowledge of where homeless people can be found. Note that many police departments, including San Francisco, don’t track whether a victim is homeless. Protecting a homeless person from a repeat act of violence is complicated, since the victim can’t easily get away from his perpetrator. He has no door to lock, and he’s likely to run into that violent person at a soup kitchen or shelter.
We’ve come full circle with NFL players and head trauma – from disbelief, to anger, to bargaining, and now to realizing the enormous costs of doing nothing.
We know now that early injuries (even as a teen) and repeat injuries can lead to lost human potential and lost lives. To reach the point of understanding and action, we had to get past the belief that somehow the NFL players deserved what was happening to them, that head trauma is a “normal” part of that life.
We need to do the same for the homeless. For them as well, and for society, the cost of doing nothing is extraordinarily high.
Disclaimer: Identifiable patients mentioned in this post were not served by R. Jan Gurley in her capacity as a physician at the San Francisco Department of Public Health, nor were they encountered through her position there. The views and opinions expressed by R. Jan Gurley are her own and do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.
Photo credit: dbking via Flickr