‘The world has forgotten about us. Not just me; the little boy who used to bring me a piece of bread every morning too. We were on opposite sides of the battles, yet completely alone in this world.’
For the past three years, I’ve been dedicating my life to brain injuries, neuroimaging, and computational neuroscience, all passions of mine. In a few months, I will be submitting my Ph.D. dissertation, but as detailed and extensive as it might be, I know it will never do justice to everything I have to say beyond the science.
I work in a center where every researcher is committed to the understanding of blast and its effect on humans. Within the neuroscience group, I’m the one studying in-vivo brains (i.e., whole, living humans). I recruit soldiers and scan them in an MRI machine, assess their cognition and behavior, and get access to their clinical files.
During my Ph.D., I’ve been investigating the effect blast (the overpressure wave) has on the brain. This is what we call primary injury.
Following the blast phase, subsequent injuries are similar to brain trauma typically seen outside of combat: penetrating wound caused by displaced debris (secondary), traumatic impact against solid surfaces (tertiary), chemical and thermic (quaternary). One or all of the mechanisms can co-occur and have heterogenous consequences.
Brain injuries resulting from blasts have become common and recognized. They are now known as “the signature injury of modern-day conflict”.
We study soldiers because we have access to them. They’re taken in charge by the government, and the recruitment and studies are funded for this purpose. In the Department of Veterans Affairs (VA), for example, traumatic brain injury (TBI) has become a significant focus.
But war affects millions of people worldwide. Victims are increasingly civilians and decreasingly armed personnel. According to The New Your Times, at least 108 million people were killed by conflict in the 20th century. Many more have been exposed to bombs and violence before being displaced, and it’s impossible to track numbers. My parents and grandparents grew up under the bombs and in shelters. They lived through the war for years.
The difficulties experienced following a brain injury include a range of symptoms of which physical, emotional, cognitive, and behavioral. They can appear immediately or can develop in the months or years following exposure to an explosion.
Three years in, and there is yet so much to learn. I’ve reached a few conclusions while working with some of the survivors.
Here is a preliminary non-scientific list of what is critical to know and take into consideration when dealing with TBI in war combatants and survivors.
Conclusion 1: It’s not all structural
On battlefields, during deployment, it’s challenging to diagnose a brain injury, especially when there are no clinical signs (loss of consciousness, post-traumatic amnesia, nausea, intense headache, disorientation, etc…) accompanying exposure to the blast. It’s therefore complicated to tell who might have sustained what, especially when there is no access to scanners and medical equipment. Even when a brain is protected, injury subsequent to blast waves can occur, due to the kinetic energy and head motion¹.
Being taken out of the battlefield as soon as a brain injury is suspected is critical. Repeated exposure in a short timeframe might be increasing the risk and severity of injuries².
Although our patients might not be showing any visible structural damage to their scans, (meaning the physical aspect of the brain preserved), it doesn’t necessarily mean there is no injury. Diffusion-weighted magnetic resonance imaging³ can sometimes uncover subtle damage unseen on routine clinical imaging. This type of analysis reveals microdamage to the white-matter tracts of the brain, which usually carry nerve impulses between neurons.
Conclusion 2: Injuries are personal and very variable
Isolated blast injuries rarely occur. A secondary or tertiary injury most often follows exposure to a blast. Some of the victims might be standing in open fields, and others might be in rooms or vehicles. Some victims might have their head protected, others not, which makes the spectrum of injuries extremely heterogeneous.
However, even when two random cases are similar, bodies respond very differently to trauma. After exposure to an insult, a cascade of biological and neurological reactions can occur⁴. Initial diagnosis and management in conflict zones might also vary.
Given all the range of conditions, we don’t have a baseline when assessing blast-related TBI. Cases and symptoms depend very much on the experience.
Conclusion 3: An understanding community is key
Why do some people seem more susceptible to long-term consequences than others?
A question I asked an American colonel at one of the international conferences where I had the honor of being a speaker.
I came up with this observation after realizing that, although many of the adults around me were close to bombs for 20 years, have lost friends and family in the conflicts, and have survived horrible trauma, the long-term psychological symptoms seem lesser than those sustained by returning veterans.
His answer to my question was brilliant.
According to him, civilians go through what he called “group trauma.” They all lived the same horrible events at the same time. They understand and support each other. They share a history of pain and damage, and their path to recovery is intertwined.
With more conservative views, we can say the same about the soldiers of earlier wars. The long-term psychological outcome seemed to have a better prognosis than it does today. During the American civil war (1861–1865) and the 1st Wold War (1914–1918), for example, troops used to live through very long journeys together. They traveled for months, and even after returning home, they had groups of fellow soldiers with whom they met and reminisced about their days on the battlefields. Of course, weapons back then weren’t as developed and impactful.
However, the common denominator in the two examples stated above seems to be a collective trauma or at least an empathetic community.
Today, persisting struggles are becoming increasingly common. 1/3 of military spouses report mental health disorders in their partner returning from war⁵.
A study of the UK armed force suggests a 6% rate of probable PTSD among current and ex-serving military personnel in 2014–16, as opposed to a 4% rate in 2004–06, while the rate of diagnosed PTSD in a civilian population is around 4%. They also reported a rate in ex-veterans to be higher than in veterans still in service at the time of study⁶.
Conclusion 4: Believing invisible ailments is a step towards recovery
When you’re hurt, and no one is listening, it feels like you’re screaming into the void. Many times, soldiers have a universal struggle: even though they’re hurt, everyone else says they’re fine.
Invisible ailments are tricky and very fast to be dismissed. When nothing is clinically wrong, it’s easy to underestimate whatever the patient is going through.
I’m not saying every struggle has a neurological cause. Sometimes, in-depth neurological and cognitive/behavioral analysis won’t reveal much. Other times, symptoms can be developed with no history of trauma. A predisposed vulnerability has the same effect as an in-war trauma for the long-term development of mental health decline⁷.
What I found helped our patients most is trying to explain how we’re looking at everything we know and taking the time to describe all the different tests, techniques, most novel approaches we’re using.
Conclusion 5: There can be an upward road
Sustaining a brain injury is scary. It might impair the patient to the point where they won’t recognize themselves. People around them might not recognize them. It can change personalities in ways we wouldn’t imagine. It might strip them from their abilities and skills. Sometimes even might destroy one’s will to live⁹. Survivors and their families are likely to face an uncertain future.
But there is often a way back from this traumatic phase. Groups, communities, charities, supports, therapy, etc., the secret is to WANT to get better, to fight, and to go after a new life.
Families and friends, be patient, be understanding, and supportive. You make a difference in the recovery.
You can find such inspiring stories of life after brain injury on the Headway website.
No matter how many stories are recounted to me by my family or by the soldiers I meet, I will never get used to the violence and brutality of humans. I deal with a whole lot of things, I am amazed at how easy it is to adapt to situations, but the violence of humans is something I will never be able to comprehend fully.
The effects of war resonate far beyond the initial blast wave, and the deepest scars are often invisible to the eye.
Be more understanding and supportive in a world strained by cruelty.