The NFL is Not Big Tobacco: Overdiagnosis and Chronic Traumatic Encephalopathy (CTE)

Screen Shot 2016-03-18 at 3.48.30 PMAs a general rule, if you keep clobbering a body part it may, in the long run, get damaged. This is hardly rocket science. Soldiers marching long distances can get a stress fracture known as “March fracture.” The brain is no exception. Boxers can get “dementia pugilistica.” This is why we frown upon people who bang their heads against brick walls.

Footballers are at risk of brain damage, specifically a neurodegenerative disease known as chronic traumatic encephalopathy (CTE). CTE was described in a football player by forensic pathologist, Bennet Omalu, who performed an autopsy on Michael Webster, a former Pittsburgh Steeler. Webster died of a heart attack but had a rapid and mysterious cognitive decline.  Webster’s brain appeared normal at first. When Omalu used a special technique, he found a protein, known as tau, in the brain.

Omalu’s discovery inspired the movie Concussion in which Will Smith plays the pathologist. The Fresh Prince plays convincingly a god-fearing, soft-spoken but brilliant physician, who is up against incredulous colleagues and the National Football League (NFL). The NFL clearly has a lot to lose from Omalu’s discovery. However, the director’s attempt to emulate The Insider, where big tobacco tailgates the scientist, fails at many levels.

This is not just because the NFL is not really Big Tobacco. The NFL is adept at playing to the gallery. Recently, it carried a pink logo to increase awareness of breast cancer. The NFL could have chosen prostate cancer. But solidarity with sisters is better PR than showing solidarity with brothers.

The reason why Concussion fails to ignite memories of Big Tobacco is that there is still a lot we don’t know about CTE, or the precise risks of banging one’s head. Some who play contact sports develop CTE, but many are unaffected. CTE has also been reported in people who haven’t had concussive injuries.

Omalu’s discovery has predictably touched our inner sanctum of social justice. Some want college football to be banned. Pitchforks have been raised full mast against the NFL. A narrative has developed in which the rich, greedy and unethical NFL conscripts young, hapless, unsuspecting men from poor families to inevitable brain damage. Righteous indignation is especially delicious when backed by science.

But the science is unsettled, and public policy is even more complicated. For many young men from poor backgrounds, football is their entry to higher education. I suspect such kids would prefer to keep this route open, rather than be fodder for the liberal conscience of the more affluent.

After watching Concussion I tried conjuring images of greedy capitalists polluting local water supplies, but just couldn’t because while the NFL is mega-rich, its players aren’t exactly paupers.

If football is banned I, for one, shall not shed a tear. It is a hideous sport, better suited to the arena of Emperor Commodus. It is strategically barren but packed with jargon giving a pretense of strategy. I’d rather watch cows grazing, than the Super Bowl.

But banning sports on health grounds is a thin end of a very steep wedge. All sports are risky. Tennis players can damage their knees and shoulders. Skiers can mangle their ankles. I’ve seen a fractured nose in a table tennis player (he lost the game, incidentally). Even cricket, the only civilized game on this planet, has recorded the odd fatality.

The riskiest activity, though, is lack of activity. America’s public health problem is obesity, not concussion. Kids need more reasons to get on the field, not excuses to stay off it.

The calls for moderation, so that football is less gratuitously brutal, are reasonable. I doubt asking players to be nicer to their opponents will work. Specific acts should be fouls. I still can’t understand why football – a game where the feet only occasionally touches the ball – is called football. But, correct me if I’m wrong, the head is not an instrument in this game, just an innocent bystander.

There’s a risk of CTE in other sports, too. In soccer, I mean the real football, players often head the ball – hurtling it by some distance. I doubt heading the ball will ever be illegal in professional soccer, or youth soccer outside the US. The Europeans and South Americans are less risk-averse than their frontier cousins. And the game can’t be played with the feet alone. If Diego Maradona had been forbidden from using his head, as well as his hands, he would have credited the Argentinian victory over England to the “Head of God.”

There’s a lot of money in social justice. The push for more safety is someone’s entrepreneurial opportunity. There are helmets that measure the impact of head collisions in football. These helmets may, one day, become mandatory, making their manufacturers very rich. One day analysts will use information from these force-recording helmets to derive minute by minute precise, but unverifiable, risk of brain damage. Player stats will include height, weight, home runs – or is that baseball? I can’t recall – and an index of brain damage.

As awareness of risk of concussions increases, some might blame a whole host of symptoms, and behavioral issues, on bumping their head. There is an entity known as post-concussive syndrome (PCS), characterized by headaches, irritability and difficulty concentrating. These symptoms are so vague that anyone can have them on a bad day. I’m irritable (and irritating) most days, but especially after a holiday.

Bennet Omalu is ready to bet his medical license that OJ Simpson has CTE, raising suspicion that OJ’s alleged homicide of his alleged ex-wife was because of alleged CTE. Incidentally, OJ has written a book about a hypothetical murder he did not commit. If he has CTE, it clearly permits a high level of mental functioning. Perhaps I need to bang my head a few times in order to finish the book that I have been procrastinating over interminably.

With concussions we could enter extremely dodgy territories. Violence, to give one example, perpetrated by sports personalities could be blamed on brain damage from concussion which, too subtle to be seen on computed tomography and magnetic resonance imaging, will need more sophisticated imaging, whose validity is far from proven.

More troubling than overdiagnosis – i.e. giving someone a disease when none exists – is misattribution. Many veterans have concussions. Veterans also suffer from Post-Traumatic Stress Disorder (PTSD). The symptoms of PTSD and PCS are similar. Falsely ascribing symptoms of PTSD to PCS can deprive veterans of proper psychiatric care.

This is not to say that CTE isn’t real. It clearly is. Nevertheless, there’s a lot we don’t know about CTE. It’ll take time to accrue the corpus of knowledge. Till then we must keep our righteous indignation, and angst against the NFL, at bay. Alternatively, just watch cricket.

Saurabh Jha is a radiologist based in Philadelphia. 

This post first appeared in 3quarksdaily.com

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5 replies »

  1. I’m a physician myself, so kudos to Dr. Omalu. The argument that poor ghetto youth and farm boys need the NCAAF is specious.
    1. The vast majority won’t get a college scholarship
    2. “scholar” athletes these days are often “General Studies Majors” who have questionable literacy and learn zilch
    in school. It’s not solely their fault…they have been encouraged to study only the playbook.
    3. Even at the high school level, football players get severe orthopedic injuries (which means they cannot be
    “industrial athletes” (cops, construction workersfirefighters, or soldiers-probably can’t even dance with “The
    Village People.” And, they also get CTE-the risk is estimated to be 20-30%.

    Like Eve tempting Adam with the Apple, Men go into footballin part-
    to get girls. We need to pass a law that cheerleaders bang only nerds-The engineers, lawyers, and physicians of the future. There can be NO football without sex!

    and, as to the argument of the risks of a sedentary lifestyle-there are safer sports than football. Baseball and Basketball come to mind. If “heading” the ball is a risk-perhaps soccer players can wear helmets. Unlike in American Football-I think they could prevent concussions. Baseball, basketball and tennis players are in general healthier than couch potatoes, and I’m sure this is also true of runners and swimmers. It is NOT true of players in the NFL, particularly in recent years. They tend to live only into their fifties to seventies, and many have lost their minds years before their demise.

  2. Noted journalist (and NFL fan) Gregg Easterbrook recently observed that while there are a couple hundred yearly concussion events in the NFL, there are about 300,000 at the high school level, and the first wave of liability litigation judgments are arriving. School districts may well be unable to afford liability insurance going forward, and this, more than anything, may serve to scuttle the HS –> NCAA –> NFL pipeline.

    Easterbrook advocates rule changes like eliminating both kickoffs and the 3-point stance (most head injuries come on kickoff returns, and the 3-pt stance lines players up for helmet-to-helmet contact right at the snap). My grandson, who just finished his NCAA full-ride football career, noted that doing away with “special teams” plays will scuttle the hopes of many lesser players, who always want to impress the coaches with brazen kamikaze aggression. They are the HS players most likely to get severely injured.

    We’re just glad and relieved that Keenan didn’t get hurt. He graduates in May and is done with football.

  3. I really can’t get upset seeing grossly over paid athletes getting a health condition which is a direct result of doing their job properly – that is, trying to end the career of the other guy. At least now they can’t say they didn’t know – which will hurt the lawyers.

    To say this research will slow blacks from pursuing an NFL career and going instead into law or medicine or business is naive, given the college graduation rates of blacks on athletic scholarships. I’ve yet only seen white guys give up football due to CTS fears. The drug of football is too addictive when supplied by the NFL cartel.

    I do agree with getting this information into the hands of responsible parents who will see that their child is steered toward something less athletically dangerous – if not as potentially lucrative. But too many times the family’s athlete is their only financial hope.

    Organized sports is very valuable (even flag football and no head butt soccer) in developing good social lessons and fitness attitudes, but this can be had in many sports which don’t turn participation into a tribal religion.

    Somewhere I read that if just 10% of mothers steer their boys away from football the NFL will have a recruitment problem – we can only hope.

  4. I am intrigued by your statement “solidarity with sisters is better PR than showing solidarity with brothers.” Indeed, everyone is up to take up the breast cancer campaign, but you rarely see awareness or support for prostate cancer. Great writeup!

  5. Excellent. But please admit that your arguments would lead one to say that tobacco is not Big Tobacco 🙂