The Concussion Crisis

by Linda Carroll

  Eventually, with the help of two hulking male nurses, Eleanor was able get Ralph on a plane and back to Maryland, where he was admitted to a hospital with a dementia unit. Eleanor started to look for an assisted-living facility since she’d realized she wasn’t going to be able to take care of him at home anymore. It wasn’t easy. Many facilities told her they weren’t set up to care for a patient like Ralph. They were used to getting dementia patients who were much older—and frail. Though Ralph had declined mentally, he was still in fairly good health. The facilities didn’t want to deal with a big, and potentially dangerous, patient.

  Once Eleanor did find a place for Ralph, she dug out the names of the crusader and the reporter. She’d decided she needed to find a way to let the world know about the wreckage football could create. When she connected with Nowinski and Schwarz, they suggested that the best way to tell Ralph’s story might be to go to his new home and describe for the world what concussions had wrought. Eleanor wasn’t sure whether it would be fair to expose Ralph to this kind of publicity. And she wasn’t sure she’d even be able to get him to comprehend what was being asked of him. But when she explained to Ralph that it might help everyone understand the dangers of football, it seemed that the door had once again opened, if only for a few brief moments. “Yes,” he said. “It’s for the kids.”

  Eleanor and Sylvia discussed the issue and agreed that they would bring their husbands together for stories that would run on the front page of The New York Times and on an HBO special report spotlighting football’s connection with dementia. Those stories were just the beginning. Both women continued their fight to make football safer, though they chose very different strategies.

  Sylvia worked from the inside to advocate for health benefits for retired players. She had a close relationship with Goodell, watching the 2009 Super Bowl with him in the commissioner’s box. She was happy with the fruits of her quiet diplomacy and proud that her husband’s bittersweet legacy—the 88 Plan—was already providing nearly a hundred former players with benefits. “I feel I get more with sugar than with vinegar,” she said, explaining the difference between her and Eleanor. “But we need Eleanor’s personality on our side. When you’re fighting a fight, or you’re trying to win fair benefits or recognition, you need different types of people on different roads going for the same thing.”

  Eleanor took on the NFL establishment head-on as an outsider who never liked football, and she didn’t care if the commissioner himself was mad at her. When Goodell organized an NFL meeting to examine the later-life care of retirees, Eleanor showed up, insisting that she needed to be there to speak for Ralph and all the others who could not speak for themselves. As she tried to enter the room, Goodell barred the door and told her that the meeting was for players only. Eleanor publicly criticized her exclusion and continued to ratchet up her activism, testifying before Congress and filing a worker’s compensation claim. She described herself as “one very pushy broad” advocating for her husband both as a caregiver and as a crusader.

  It would take just that kind of pushiness on the part of all the reformers if anything was ever going to change.

  Chapter 11

  Seeds of Change

  For years, the entire sports world had been flicking off the periodic warnings from scientists as if their dire-sounding concussion studies were just pesky flies. The spate of retirements due to post-concussion syndrome was dismissed as casually as the bumps on the head that caused them. Not even the deaths from second-impact syndrome could change the reckless way we played our games—that tragic specter could be rationalized away as too rare to worry about. But dementia was something else entirely.

  Although no one knew how common it was, the very idea that playing sports could result in early-onset dementia gave everyone pause. Some tried to suggest that it was just as rare as second-impact syndrome. But ultimately, no one could guarantee that it wasn’t a time bomb ticking away in every player’s brain. The more cases that turned up, the more worried everyone got. Everyone, it seemed, except for the National Football League.

  • • •

  In the spring of 2007, the NFL convened a summit meeting that would bring the opposing sides of the concussion controversy face to face. The league summoned team physicians and trainers from its thirty-two franchises to what figured to be a heated debate: the NFL’s doctors stubbornly defending their dangerous concussion policies against brain injury experts relentlessly criticizing such a head-in-the-sand approach. For months, the two sides had been on a collision course, exchanging harsh words and harsher critiques of each other’s opinions on both the short-term and the long-term effects of concussions. Now, finally, the opposing voices would clash jaw to jaw at the daylong summit behind the closed doors of a conference room in a hotel near Chicago’s O’Hare Airport.

  The NFL’s doctors came armed with the fourteen studies conducted by its Mild Traumatic Brain Injury Committee and published over the previous four years. Those studies, which affirmed NFL medical practices that returned fully half of concussed players to the same game in which they were injured, suggested that concussions were benign and concluded that multiple concussions did not lead to long-term consequences. The outside experts, dismissing the NFL’s studies as “industry-funded research,” came armed with a raft of independent studies as evidence to the contrary.

  Dr. Julian Bailes, a former team neurosurgeon for the Pittsburgh Steelers, stood up at the lectern and presented findings that debunked the NFL’s position and policy on concussion management. He talked about a survey of 2,552 retired NFL players that correlated concussions with increasingly higher incidences of depression and dementia, and about two resulting journal articles he’d co-authored with that study’s principal investigator, University of North Carolina concussion expert Kevin Guskiewicz. One showed that retirees with at least three concussions were three times more likely to be diagnosed with depression than those with no history of head injury; the other showed that retirees with at least three concussions were three times more likely to suffer significant memory problems and five times more likely to be diagnosed with the pre-Alzheimer’s condition called mild cognitive impairment. Though the NFL had dismissed those survey findings as “virtually worthless,” Bailes could turn to harder scientific evidence.

  His PowerPoint presentation was loaded with slides from the brains in which Dr. Bennet Omalu had recently found chronic traumatic encephalopathy. Up came the slides from Mike Webster and Terry Long and Justin Strzelczyk, three Steelers Bailes had gotten to know personally as a team physician, as well as the slides from Andre Waters. The slides from all four middle-aged brains showed splotches the color of a football—clear evidence of the CTE that had manifested in depression and dementia shortly after the players retired from the NFL. As soon as Bailes concluded his presentation, the league’s doctors went on the offensive. Suddenly Bailes found himself trading barbs with the NFL’s new concussion czar, Dr. Ira Casson.

  Casson had replaced Dr. Elliot Pellman as chairman of the NFL’s Mild Traumatic Brain Injury Committee just four months earlier. The league had hoped that Casson would be less of a lightning rod than Pellman, a rheumatologist whose lack of concussion knowledge had infuriated brain injury experts. Casson, at least, was a neurologist, and the experts hoped his background would lead to a more enlightened discussion about the long-term impact of concussions. It quickly became apparent, however, that Casson was going to pick up right where Pellman left off as a pugnacious protector of the status quo. Just like Pellman, Casson attacked the brain injury experts whose research contradicted the league’s position, downplayed the accumulating evidence on the risks of concussions, and defended NFL policies that critics said set a dangerous precedent for millions of kids playing football.

  In an HBO interview shortly after replacing Pellman, Casson had fielded pointed questions about the mounting evidence on the dangers of concussions. He parried them all without missing a beat.

  “Is there any evidence, as
far as you’re concerned, that links multiple head injuries among pro football players with depression?”

  “No.”

  “. . . with dementia?”

  “No.”

  “. . . with early onset of Alzheimer’s?”

  “No.”

  “Is there any evidence, as of today, that links multiple head injuries with any long-term problem like that?”

  “In NFL players? No.”

  “So you don’t think they’re rolling the dice, really?”

  “As far as chronic brain damage is concerned? No, I don’t.”

  In a word, Casson had neatly summed up the NFL’s position going into the summit. So when Bailes finished presenting the CTE slides there, it wasn’t surprising that Casson immediately argued that there was no evidence that any of the four former players sustained brain damage from football. “The only scientifically valid evidence of chronic encephalopathy in athletes is in boxers and in some steeplechase jockeys,” said Casson, who two decades earlier had conducted seminal scanning studies that showed CTE in active and retired boxers. “It’s never been scientifically, validly documented in any other athletes.” Bailes countered that the slides spoke for themselves. “We can’t be sure, but football is by far at the top of the list for me,” he said, “and I don’t see many other clear candidates for how that damage got there.” And so it went.

  The summit may not have settled any scientific arguments, but its mere existence signaled the willingness of the NFL’s rookie commissioner, Roger Goodell, to at least listen to the critics beseeching him to tear down the Berlin Wall of concussion denial. Goodell, who had learned about leadership growing up the son of a principled U.S. senator respected for denouncing the Vietnam War in the late ’60s as a liberal Republican, had barely settled into the commissioner’s office the previous fall when he found himself confronted with a heap of inherited crises. Naturally assuming that the NFL’s most urgent problem was the spate of headline-grabbing scandals involving players’ off-the-field misconduct, he may have underestimated the silent concussion epidemic that his predecessor had allowed to fester untreated for years. It was a growing abscess that would explode into his most consuming problem, what The Washington Post proclaimed “the biggest crisis the sport has ever faced.” To tackle it, Goodell would need to first play catch-up on the fast-evolving scientific research, then admit there was indeed a serious problem, and then finally figure out a way to fix it.

  As if to show he wasn’t just paying lip service to reform, Goodell announced new NFL standards for concussion management on the same day he called for the summit conference. He mandated neuropsychological baseline testing for all players before each season, adopting an objective tool that had been required by the National Hockey League for a decade already. He stipulated that players knocked unconscious could no longer be returned to action the same day. He announced that return-to-play decisions had to be based on health rather than competitive considerations and had to be made solely by team medical personnel without pressure from players, coaches, or executives. To help ensure that, he instituted a “whistleblower” hotline enabling anyone to anonymously report an incident in which a concussed player was pressed back into action before the injury could heal.

  The whistleblower edict resulted from a recent allegation by retired linebacker Ted Johnson that he had been pressured to return too soon after a concussion. The story Johnson revealed to reporters was a warning about the danger not only of concussions but also of the culture that fostered them.

  Back in 2002, Johnson had been knocked out of a preseason game by a concussion sustained in a head-on collision. Four days later, at the New England Patriots’ next full-contact practice, the head trainer issued him a red jersey as a signal to teammates that the linebacker was not supposed to be hit. Johnson told reporters that, just before a high-impact running drill, an assistant trainer raced over with a standard blue jersey to replace the red one. Johnson was sure that the order to change jerseys came from head coach Bill Belichick. Worried about losing his roster spot along with his nonguaranteed contract, Johnson pulled on the blue jersey and lined up for the drill. On the first play, he collided with a running back and instantly felt dazed and disoriented. He continued on in a fog, not mentioning his symptoms to anyone. It wasn’t until after practice that he angrily strode up to the head trainer and growled, “Just so you know, I got another concussion.” The trainer paled and sent Johnson to the hospital, where a neurologist confirmed that the player had sustained another concussion and sidelined him for the next two weeks. Upon his return to practice, Johnson confronted Belichick about pressuring him back too soon after the first concussion. “You played God with my health,” Johnson told the coach. “You knew I shouldn’t have been cleared to play, and you gave me that blue jersey anyway.” Belichick would later tell reporters, “If Ted felt so strongly that he didn’t feel he was ready to practice with us, he should have told me.”

  Johnson played through that season and the next two without reporting symptoms from at least half a dozen concussions, fearing he’d be branded as an injury-prone player. But with his symptoms of fatigue, depression, and cognitive impairment taking on a frightening permanence, he shocked fans by retiring at age thirty-two in 2005, mere months after winning his third Super Bowl ring in four years. When he went public with his cautionary tale two years later, it made front-page news not because of what it said about Belichick, the acerbic coaching genius who denied pressuring Johnson, but because of what it revealed about football’s concussion culture.

  In 2009, Johnson returned to the Super Bowl, this time to publicize his story as part of a growing crusade lobbying the NFL to change its culture of concussions. In the two years since the concussion summit, even as the mounting scientific evidence continued to pour in, the safety reforms had slowed to a drip. As a sign of its continuing denial, the NFL was still distributing an informational pamphlet to all players and their families that minimized the consequences of multiple concussions: “Current research with professional athletes has not shown that having more than one or two concussions leads to permanent problems if each injury is managed properly.”

  Throughout the week leading up to the 2009 Super Bowl in Tampa, the concussion crusaders, led by Chris Nowinski, raised the pressure on the NFL by taking the fight to its biggest stage, exploiting the event’s attendant media circus. Five days before Super Sunday, Nowinski’s Center for the Study of Traumatic Encephalopathy held a press conference at a Tampa hotel to announce the sixth autopsy-confirmed case of CTE in a former NFL player between the ages of thirty-six and fifty. The center’s neuropathologist, Ann McKee, presented findings that showed the condition in a forty-five-year-old former lineman for the hometown Tampa Bay Bucaneers, Tom McHale. More shockingly, she presented the youngest known case of CTE: an eighteen-year-old boy who had sustained multiple concussions playing high school football. Pointing at a slide that showed brown specks of abnormal tau, she declared, “This is something you never should see in an eighteen-year-old brain. This is something that’s highly alarming.”

  To McKee, it was more than that—it was downright “chilling.” When she first saw the brown specks on the eighteen-year-old’s slide, she froze and thought, “That could just as easily be my son.” Her son was also eighteen and an athlete, a goalie on his high school soccer team. The concussion crisis that she had coolly and clinically played a key role in uncovering suddenly hit home in a way that any other soccer mom could empathize with.

  The revelation of CTE in an eighteen-year-old—expanding the issue of long-term brain damage to youth sports—should have fueled the urgency of dealing with this burgeoning public health crisis. Instead, the Tampa press conference drew fewer than two dozen reporters from among the thousands in town for the Super Bowl. It was clear that changing the culture would not be easy.

  That left the crusaders with no choice but to try to beat the NFL at its own masterful PR game. Taking to the airwaves on everything from
National Public Radio to Nightline and 60 Minutes, they kept the pressure on the league like linebackers blitzing a quarterback. Nowinski may have been the most visible provocateur, slamming the NFL goliath with his slingshot every chance he got, but he was hardly alone: brain-injured ex-players advocated for changing the just-rub-dirt-on-it culture; wives begged for help on behalf of retirees too demented to do so themselves; parents of children maimed or killed by second-impact syndrome pleaded for safety reform; and, all the while, New York Times reporter Alan Schwarz kept the unfolding story on the front burner and the front page with a series of muckraking exposés. In the end, the most effective argument would come from the scientists.

  In the spring of 2009, barely three months after McKee had crashed the Super Bowl party with her scary slides, the NFL invited her and other leading researchers to New York City to meet with its Mild Traumatic Brain Injury Committee at the league’s plush Park Avenue headquarters. As she stepped into the huge mahogany boardroom plastered with posters of Vince Lombardi exhorting the Green Bay Packers dynasty she’d grown up rooting for, McKee couldn’t help feeling that she was entering the lion’s den. It didn’t help that she was the only woman in a room designed to celebrate the most testosterone-fueled team sport. She took a deep breath and calmly presented her CTE findings to all the male doctors arrayed around the large conference table. The reaction of the NFL doctors, predictably, was skepticism. One of them, she later told reporters, actually accused her of making up the disease.