By Clarissa Donnelly-DeRoven

North Carolinians die of traumatic brain injuries at a rate higher than the national average, according to a recent analysis by the Centers for Disease Control and Prevention. 

The study, published in the CDC’s weekly morbidity and mortality report in October, analyzed death statistics collected between 2016 and 2019. It found that Southern states and states where a high proportion of residents live in rural areas see higher death rates from TBIs than other parts of the country. 

The national TBI death rate is about 17 per 100,000, while in North Carolina the rate is about 19 per 100,000, a number that translates to about 2,000 deaths per year

While the CDC analysis is new, the data aren’t. For years, the North Carolina Department of Health and Human Services has documented higher death rates from TBIs in rural areas than urban ones.

a map describing the death rate from TBIs in 2012 by county
A map created by NCDHHS using 2012 data shows that rural counties have long suffered higher rates of death from TBIs than urban areas. Credit: Courtesy of North Carolina Department of Health and Human Services

Catie Armstrong, a spokesperson at NCDHHS, did not directly answer the question of what the department is doing to address the disparity but said it is working on general TBI prevention. Staff within NCDHHS’s Division of Mental Health, Developmental Disabilities and Substance Abuse Services participate in a coalition called NC Falls Prevention, which studies the occurrence and impacts of falls — the second-leading cause of TBI death in the state — and develops prevention strategies

The advocacy group Disability Rights issued a scathing report in September, describing the dearth of services DHHS makes available statewide to TBI survivors. 

“The State of North Carolina lacks adequate services and systems to support people with Traumatic Brain Injury,” the report stated, “It lacks even basic data about the location and needs of TBI survivors. The state’s own publications support these conclusions.”

Few trauma centers in rural areas

There’s a range of reasons why the disparity might exist — one explanation the authors of the CDC analysis posit is lack of access to Level I Trauma Centers for rural residents. Patients arriving at Level I centers have immediate access to specially trained trauma surgeons and nurses, neurosurgeons, critical care units and other services that increase survival by as much as 25 percent

 In North Carolina, there are 17 such trauma centers (Level I-III), but only one of those is in a rural county: Atrium Health in Cleveland County. 

a map of all the trauma centers in North Carolina
A map created by the North Carolina Department of Health and Human Services shows where each trauma center in the state is located. There are 17, with just one located in a rural county. Credit: Courtesy of North Carolina Department of Health and Human Services

The only trauma center in the entire western part of the state is Mission Hospital in Asheville, a Level II Trauma Center.

The Medical Director of Mission’s ER, Chris Flanders, said though the hospital’s ER is the only trauma center in the west, all of the hospital’s regional facilities can assess head injuries, and people should seek out care at the nearest facility as soon as they can. 

“All Mission Health Emergency Departments are staffed by the same group of physicians with most of them rotating at both Mission Hospital’s Trauma Center in Asheville and our regional hospitals,” Flanders said in a statement. “This ensures consistent physician care throughout the region at all Mission Health ERs.”

Intentional deaths

While many TBI deaths nationwide and in North Carolina are accidental, nearly half are caused by suicide and homicide. 

The CDC’s analysis found that over the three-year period, 181,227 people died from TBIs nationwide, and about 40 percent of those deaths were from homicide or suicide. An earlier study found that guns caused nearly every TBI-related death, usually self-inflicted.

a graph showing the leading causes of TBI deahts in north carolina
Though more TBI-deaths are caused by accidents, like falls and car accidents, the single biggest source of TBI-deaths are self-inflicted gunshots. Credit: Courtesy of North Carolina Division of Public Health – Injury and Violence Prevention Branch

In North Carolina, 54 percent of the TBI-related deaths were accidents, caused primarily through car crashes or falls, while the remaining TBI-related deaths — 44 percent — were intentional.

Of the intentional deaths, the vast majority — 76 percent — were people who died by suicide. A 2019 report by North Carolina’s DHHS also documented that while a higher proportion of TBI deaths in the state are accidents, the leading single cause of TBI-related death in the state is self-inflicted, via firearm.

The state’s list of TBI prevention strategies, though, does not discuss increasing access to mental health care. They include projects designed to help elderly people from falling, another that educates young athletes about concussions, and a final one that teaches parents how to help their teenagers drive safer. Armstrong said this specific list of prevention strategies is created by the CDC and not editable by state health departments. 

“We do often emphasize falls and motor vehicle/traffic prevention strategies because these are the leading causes of non-fatal TBI, impacting folks that more often live and therefore need services, as well as being among the leading causes of fatal TBI,” Armstrong said in a statement.

The authors of the CDC report encourage states that have high rates of TBI deaths from suicide to increase their prevention strategies. Armstrong said the department has already begun the process. 

Intervention programs

In September 2020, NCDHHS’s Injury and Violence Prevention Branch received a five-year grant from the CDC, which provides $870,000 a year, to work on suicide prevention with “priority populations,” namely veterans, men — particularly older men — and rural residents. 

“Suicides among each of these populations involve a higher proportion of firearms, the most lethal means of suicide,” Armstrong said. 

As part of that work, NCDHHS awarded grants to six agencies to implement community-specific suicide prevention programs, including counseling and safe gun storage. 

The American Foundation for Suicide Prevention received one of the grants. Over the next three years, the organization will implement prevention projects in Pasquotank, Iredell and Watauga counties.

“The reasons [those counties] were chosen were because of their suicide rates — they are high in those areas — as well as some existing relationships we already have,” explained Catherine English, the North Carolina area director at the foundation. 

“Suicide is a serious public health problem,” English said.  “From 1999 to 2019, suicide rates have increased 33 percent in the United States. In 2019, there were 1,358 suicides in North Carolina. The burden of suicide is disproportional for males, veterans and in rural counties. Use of firearms is the leading method of suicide across these groups and is used in 59.3 percent of all suicides in N.C.”

Pasquotank, Iredell and Watauga counties are home to rural residents,  veterans and firearm owners — all target populations for the interventions. The group’s main strategy is to reduce the access to firearms for people contemplating suicide. They do this through teaching people about safe gun storage and training caregivers, friends and other community members to recognize some of the warning signs of suicide. 

Addressing suicides within these populations can pose particular challenges, English said. 

“Men [hear] you’re supposed to be strong, you’re supposed to be the man of the house or something like that, you’re not supposed to have feelings, you’re supposed to take care of everybody else, be the protector, right?” she said. 

The first intervention step, she said, is starting the conversation, “that mental health is as important as physical health, and that you need to take care of your own mental health.”

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (800-273-TALK).

If you would like mental health support, referrals, or information, dial the NAMI NC HelpLine at 1 (800) 950-6264 (1-800-950-NAMI) between 10 a.m.- 6 p.m. EST, Monday through Friday.

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Clarissa Donnelly-DeRoven covers rural health and Medicaid. She previously worked at the Asheville Citizen Times where she reported on the police, courts, and other aspects of the criminal justice system....