As GOP lawmakers grapple with the “replace” aspect of Obamacare and seek to overhaul the subject “nobody knew could be so complicated,” we must remember that one of the best ways to reduce spiraling healthcare costs is to improve health through preventive measures.
For instance, increased participation in youth sports would help control rising obesity and sedentary rates which are responsible for 21% of annual medical spending – a staggering $190.2 billion a year. Inactivity among youth spiked from 20% in 2014 to 37.1% in 2015. But while the NIH identifies preventing weight gain in childhood as critical to warding off lifelong obesity outcomes and playing sports as one of the strongest weapons against teen obesity, participation rates have declined nearly 10% since 2009. A number of factors have been attributed to this trend, but with the biggest losses in contact sports like football and wrestling, it’s impossible to ignore the long-standing elephant in the stadium – concussions.
Current polls show 94% of U.S. adults believe sport concussions constitute a public health concern and a full 100% of parents are affected by them. But do the risks of playing contact sports really outweigh their myriad physical, mental, and social benefits? After decades of research, why do we still not know what to do about concussions?
Eric Lindros, who retired from the NHL after suffering 6 concussions and donated millions to the cause, hit the nail on the head in lamenting the lack of tangible results and guidance from concussion research: “It seems like there are so many groups trying to do the right thing, but our voice would be stronger through consolidation. Are we sharing all the information? Let’s get people working together.”
Lindros’ frustrations are best illustrated by disagreement about what a concussion even is. Google defines it as “temporary unconsciousness caused by a blow to the head.” But only a small minority of medical “consensus statements” (of which there are more than 42) even require a loss of consciousness and most sources say indirect impacts are also sufficient to cause concussion. These differences aren’t just academic – accounting for sport concussions that did not involve loss of consciousness made the prevailing incidence rate jump from 300,000 to 1.8 – 3.6 million annually. Failure to agree on how to define the problem has created a snowball effect, contributing to inconsistent diagnostic standards and unreliable incidence and prevalence data that cannot be aggregated or compared.
Even more troubling is that concussion, typically understood as a mild impairment lasting 7-10 days, has become a blanket term for a host of more severe effects. The 2015 film “Concussion” is entirely about chronic traumatic encephalopathy (CTE), a long-term neurodegenerative disease associated with explosive rage, depression, cognitive decline, and high rates of suicide. Players missing months of the football season in the “concussion protocol” typically have post-concussion syndrome (PCS); and high school athletes suddenly dying on the field after initial concussion have second impact syndrome (SIS). This colloquial misattribution of concussion in the media and by some “concussion” advocates further obfuscates what the public should fear and how we should address it.
To properly educate the public on health and safety issues, threats and dangers must be clear and precise. Journalists and policymakers have been waiting on the medical community for such answers, but medical experts have yet to properly itemize and communicate the true risks of concussion from a public health perspective. This has resulted in unfocused fear and societal costs from reduced participation in sports – while sedentary activities in the form of screen addiction and “eSports” are on the rise. This is why it is essential for policymakers to stop viewing sport concussion as a medical issue and start treating it like a regulatory one.
So how should policymakers address an issue when the science is unsettled but constituents are demanding answers? The closest analogous challenge may be that of environmental policy. Though scientific consensus regarding climate change appears to have solidified, earlier years were full of debate about its existence, definition, and significance. In that environment, the 1992 Rio Declaration memorialized the “precautionary principle,” emphasizing that lack of full scientific certainty shall not be used to postpone cost-effective measures to forestall harm where there are threats of serious or irreversible damage.
A 1998 consensus statement described four central components of a precautionary approach:
1) Taking preventive action in the face of uncertainty;
2) Shifting the burden of proof to the proponents of an activity;
3) Exploring a wide range of alternatives to possibly harmful actions; and
4) Increasing public participation in decision making.
Existing evidence of serious, irreversible concussion-related effects supports application of the precautionary principle to contact sports. Theoretically, this could entail (1) measures as severe as banning contact sports altogether; (2) forcing organizations such as the NFL, NHL, and NCAA to prove that their sports are safe; (3) considering changes to rules, equipment, protocols, and educational efforts; and 4) engaging the public to assess risk tolerance and preferences regarding policy options.
However, the precautionary principle is much simpler on paper than in practice, largely because efforts to curb controllable threats tend to run up against very powerful counter-interests – like multinational corporations and the politicians they lobby. For example, despite the prompt international call for a precautionary approach to climate change, political and economic forces favored “business as usual,” leading to decades of mercurial environmental policy. Now, even settled science seems insufficient to overcome a laissez-faire approach to CO2 emissions.
Employing the precautionary approach in the context of concussions will be no simpler – as history can attest. For example, while the discovery of CTE in football players may be relatively new, the “concussion crisis” is not. Calls to modify or ban football due to long-term concussive consequences began in the late 1800s, and Harvard’s medical team came out unequivocally against the sport in 1905, followed soon after by the American Medical Association . Yet, policymakers failed to respond in any substantive way. Indeed, “[f]ootball survived its [first] concussion crisis not because of lack of evidence but because its promoters worked to make football’s perceived contribution to social values greater than its risks. ”
Because the government dropped the ball in failing to take a precautionary approach when the health threats posed by contact sport first came to light, it now owes the public proof of the true risks posed by sport concussions and their related effects. Until such time, harm threatens to result both from playing sports and from not playing sports.
So what should we do until the science catches up? A measured approach incorporating elements of the precautionary approach as it relates to minimizing risk while acknowledging insufficient data should be taken. This means:
1) avoiding undue fear-mongering in the public until greater clarity of risks is achieved;
2) instituting robust rules and policy that mitigate harm based on existing knowledge (e.g. reducing head impacts via contact practice rules and mandatory management protocols); and
3) consolidating research efforts to determine the true risks of head-impact related trauma in sports for various sub-populations. This requires consistency as it relates to terminology, process, goals and aims – before we get into replicable multicenter, longitudinal studies.
Football and other contact sports are ingrained in the social fabric of America, and their physical risks were overlooked for generations in favor of social cohesion. Overcoming this attitude, if warranted, requires solid science and firm facts. Until such science exists, we must properly educate the public without alarm but take firm preventive action through rules and policy until we know more. To echo Lindros, to protect against concussions responsibly, we must get people working together.