Signature injury : an ethnographic study of mild traumatic brain injury in the post-9/11 VA health care system

Zogas, Anna. Signature injury : an ethnographic study of mild traumatic brain injury in the post-9/11 VA health care system. Diss. U of Washington. 2018.

This dissertation is an ethnography of a politically symbolic injury: mild traumatic brain injury. It explores the dynamics of institutional mandates, clinical uncertainty, and the ideology of rehabilitative fantasies as they intersect in encounters between military veterans and clinicians in the Department of Veterans Affairs (VA) Health Care System. Since the beginning of the wars in Afghanistan (OEF) and Iraq (OIF), combat-related traumatic brain injuries have come to signify a convergence of historically-specific wounding technologies, armoring technologies, and medical technologies. For this reason, these physiological injuries to the brain, with their cognitive and emotional consequences, are among the “signature injuries” of the post-9/11 wars. Some traumatic brain injuries are “mild” enough that they do not cause a loss of consciousness, and therefore service members who sustained them were able to continue to function at the time of injury. These “mild” injuries (also called concussions) cannot be diagnosed with imaging technology, so diagnostic evidence of the injury is reconstructed in a verbal, clinical evaluation. Since 2005, the VA has been collecting information about veterans’ past head injuries through its Polytrauma System of Care, a nationwide network of twenty-five clinics specializing in traumatic brain injury (TBI) rehabilitation. In this dissertation, I show that institutionalized techniques for collecting data about veterans’ head injuries produce more than data: screening procedures provoke veterans’ movement into and around the medical center, diagnostic procedures produce anxieties about permanent impairments, and clinicians ground their therapeutic interventions in the medical uncertainty that characterizes the relationship between veterans’ combat-related injuries and their present cognitive symptoms. My central argument is that the TBI Clinic is characterized by intersections of multiple kinds of attention: veterans’ concerns about their inability to pay attention and remember everyday things, doctors’ clinical attention directed at individual patients, and institutional attention directed at the population of OEF/OIF veterans. These forms of attention correspond to multiple regimes of power (governance, control, and targeting) which operate inside the VA and in the broader social context in which the VA is located. I show how convergences of these forms of power over individuals and populations produce paradoxes of attention in the TBI Clinic. My conclusions are based on ethnographic data collected over eighteen months of fieldwork in the pseudonymous Western VA Medical Center, between November 2012 and March 2015. I observed the everyday operations of the TBI Clinic and interviewed veterans and VA clinicians. I contextualize my findings about clinical encounters in the TBI Clinic by drawing on ethnographies of institutions, critical trauma theory, disability studies, and theories of governmentality. From this theoretical perspective, I situate the VA’s efforts to produce knowledge about combat-related mild TBI as part of a set of fantasies of war without American casualties—a fantasy whose endurance depends on veterans’ physical, psychological, and vocational rehabilitation. The dissertation is at once an ethnographic depiction of clinical encounters in the post-9/11 VA, and a theoretical reflection on what it means for veterans to be at once individual patients and part of a population of people for whom the federal government has a specific responsibility.

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