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More on Football and Brain Injury – posted 12/23/2013

December 24, 2013 10 comments

Another football season is winding down and I have to say it has been remarkably entertaining. With so much parity in the NFL, it is impossible to know which team will win out in the end.

There have been so many good story lines. Can the Pats win it all without Gronk? Can Peyton Manning come back with the Broncos and lead them to the Super Bowl? As a Philadelphia Eagles fan, I am excited about the team’s future with Coach Chip Kelly as well as the emergence of quarterback Nick Foles.

At the same time, remaining in the background, are the gnawing, unanswered questions about football and brain injuries. Except for the occasional stories about the increasing number of players whose lives have been destroyed, the football/brain injuries story has receded.

Possibly the settlement of the federal court lawsuit between the players and the NFL at the start of the football season had something to do with this. The deal was generally applauded although a cynic might say the NFL was essentially making a large payoff to make the lawsuit go away.

It remains to be seen how well the NFL has provided for the long-term health needs of its players. When I wrote about this for the Concord Monitor in September, I struck a skeptical tone. I had pointed to the NFL’s long history of denying the link between concussions suffered playing football and long-term brain damage. I compared the NFL’s denial around brain injury to the tobacco companies’ denial of the link between smoking and lung cancer.

I think the parallel is instructive. The matter of football and brain injury is at a very early stage of awareness. Concussion science is young. Careful students of the NFL will note the league has refrained from making any admissions about the health risks of football. The lawsuit settlement has given it some breathing room.

The NFL’s earlier position of absolute denial is no longer tenable because of all the player disclosures of death and disability. The NFL’s public stance has now morphed into more subtle forms of denial. I would describe the NFL’s new posture as “debating the science”.

This is a well-worn strategy frequently employed by a variety of industries. When accused of bad actions which expose the public to a significant public health risk, the industry seeks to generate doubt about the probability and magnitude of the risk.

The goal is to create a controversy and a debate about the science. If the science is inconclusive, there is no need for immediate action. An epidemiologist, David Michaels, has written about the manufacture of doubt. He has described doubt as the best means of competing with the body of fact that exists in the mind of the general public.

In the world of occupational health and safety, examples immediately come to mind. I think of miners and silicosis, construction workers and asbestos, workers exposed to lead and hazardous chemicals, among others. Owners in these industries denied hazards as long as they could until government regulation forced minimum standards to protect workers.

In a different context, I also see a parallel to climate change. Even though there is overwhelming scientific proof of climate change and consensus among the great majority of scientists, deniers, with economic and political motives, use doubt as justification for inaction.

I do not believe the public yet appreciates how bad the NFL’s actions have been. The players’ lawsuit accused the NFL of intentional misconduct, concealment, and fraud in misrepresenting the long-term effects of concussions. The NFL failed to properly treat concussed players and actively worked to conceal the causal link between football and brain injury. In effect, the owners’ profits were placed ahead of everything.

It is a mistake to gloss over the history. Going back almost 20 years when the NFL set up its Mild Traumatic Brain Injury Committee, it placed a rheumatologist in charge. The rheumatologist, who had no background in brain science, had been then-Commissioner Paul Tagliabue’s personal physician.

In the eyes of that Committee, the NFL did not have much of a concussion problem. The NFL’s PR department argued that when concussions occurred, 92% of players returned to the field in less than 7 days. Rather than pointing to a health concern, the NFL saw the players’ quick return as evidence the problem was minimal. Until very recently, the NFL’s position was that concussions were minor events that went away quickly with few long-term effects. The examples of Mike Webster, Andre Waters, Dave Duerson and Junior Seau, rather than anything the NFL did, have demolished the NFL’s former position.

Let me raise some of the questions which I see as ongoing and unresolved. Are efforts to alter rules and improve playing equipment sufficient? Do teams need independent trainers and physicians? Are team doctors compromised by a conflict of interest since their loyalty is to who pays them? Isn’t it true they are not medical advocates for the players but their role has been to get the player back on the field as soon as possible?

What about the health needs of players who were not part of the lawsuit, including those who played 10, 20, 30 or 40 years ago? What consideration, if any, do these players get? Or how about those retired players who are on the borderline. They may have some symptoms like memory loss, severe headaches, and insomnia but no clear diagnosis. A difficulty in assessing chronic traumatic encephalopathy, the football-related brain injury, is that it is a post-mortem diagnosis. I am not aware of any test that can determine if it exists in a living player.

Outside the NFL, one large question is: should children play football? At what age is it safe? When is it safe for a child to return to a game after experiencing a concussion? How many concussion events are too many? This is a game played by millions of children and adolescents. We know developing brains are at a higher risk of concussion incidence.

One generalization I would make: in the NFL, players with concussions get cleared to return to play too soon. Bennet Omalu, a brain pathologist who has been a key researcher of football-related brain injuries, has written that recovery from a single concussion episode might require three months – not days.

Maybe in the future, players will have to wear the following statement on their uniform: “Playing football carries increased risk of brain injury that may have long-term effects and helmets do not prevent that”. Or maybe they will have to sign a waiver to that effect. As with cigarettes, we might get to that place.

These issues are not going away and neither is football. It is safe to say there are more questions than answers.