by Bennet Omalu
She laughed at me. “If you want to marry me, I will marry you,” she replied.
I grinned. “Yes, let us get married. We will fall in love as we live together in our old age.” At the time, I did not know or understand what love is. I do now. Asking Prema to marry me is the best decision I have made in my life. She is a gift from God.
In December 2005, three years after we first met, Prema and I flew to Enugu, Nigeria, where we were married with our families in attendance. I stood in amazement as she walked down the aisle with her younger brother, Tom, to me standing at the altar next to Father Carmen D’Amico, who officiated our wedding. Prema looked like the angel that she is. With each step she took, I prayed in my heart that the good Lord would give me the strength, courage, and wisdom to love and cherish her, stand by her, uplift her, and support her to become the woman she was born to be, to be the wind beneath her wings that will make her soar as high as she can to be herself, fulfill her dreams and aspirations, and reach for the heavens in our lives together. I vowed to God and myself that I would always be there for her and remain an angel of God to her, until death do us part. As my father advised me, I chose that day to love her and share my life with her for the rest of my life. Every day I reaffirm that decision in my heart.
Prema is such an important part of this story, and not just because she became my wife. The wedding reception where we first met occurred a couple months before I met Mike Webster. As I began to research Mike’s condition and as that research expanded beyond what I ever imagined possible, Prema stood beside me. I soon found myself up against those who tried to discount my research from the start, but she was an opposite voice, encouraging me to believe in myself and to trust my research. Without her, the story ends here. Thankfully, our story—together—is still being written to this day.
Chapter Thirteen
A Game-Changing Diagnosis
One Friday afternoon in 2003, several months after Mike Webster’s autopsy, I finally got around to taking a look at the slides of his brain. I was tired from a long day of work, where I was so busy I didn’t even have time to eat lunch. The clock read 5:00 when I got back to my cubicle of an office. I was munching on a red apple when I glanced up and noticed a box of slides on one of my shelves. About a month earlier, I’d pulled the slides out of my box at the hospital, not because I planned on working on them right away, but because my box was full. That day, I tossed them on my shelf and told myself I would get around to them eventually. Eventually came this day—this late Friday afternoon when my stomach was empty and my body was tired, but I needed to stick around the office to get some work done.
I pulled the set of slides off the shelf, took one out, and placed it on the tray of my office microscope. This microscope, like everything else in my cubicle office, was anything but state of the art. Honestly, it should have been in a high school classroom, not in a medical examiner’s office, but it was what I had been given to work with. The computer I used was just as outdated, but I made do with what I had. Such is the nature of working in a government office where the manager does not like you and you are at the bottom of the seniority scale.
Even with the inferior quality of my office microscope, it was clear something was not right with the cells on these slides. Under normal circumstances, brain cells are a work of art under a microscope. A healthy brain cell resembles a bright, full moon rising above the horizon on a cool, clear October night. Its beauty is nearly indescribable.
I did not see a thing of beauty on the first slide I examined. In fact, I pulled the box of slides back down from the shelf and double-checked to make sure I had the right brain. Yes, the box of slides was labeled Case A02–5214, Mike Webster.
These slides did not appear like they should belong to a fifty-year-old man. Each slide contained numerous brain cells, yet many had died and disappeared, and many appeared like ghost cells. A large number of the remaining cells appeared shriveled, as if in the midst of the throes of death. I observed spaces—spongiosis—in the substance of the brain, with shriveled brain skeleton and skeins of brain scars, like a partially demolished building stripped of its windows and its aesthetics gone, leaving behind just the main frames, pillars, and broken-down walls.
In the midst of this broken-down building, I observed ugly threads and fibrils of brownish proteins inside and outside the brain cells. I recognized them as tau proteins. Tau protein in a healthy brain is part of the skeleton of the brain cells and fibers. They provide both support and transport nutrients up and down the brain cells and fiber. When a person sustains a blow to the head and sustains either a concussion or subconcussion, the skeleton of the cells and fibers fracture. Because the brain cannot heal like the skeleton of the body, the proteins begin to form abnormal “strangle proteins” that eventually kill the brain cells. For most people, the loss of a few brain cells is not a problem, since we have billions. However, when the strangle proteins spread throughout the brain, the damage results in symptoms like Mike Webster demonstrated. The patterns and distributions of these abnormal proteins I found in his brain were also surprising because they looked different from the patterns and distributions we see in patients suffering from other types of dementia, including Alzheimer’s disease. I did not expect to see any of these in the brain of a fifty-year-old former athlete. With this first look through the microscope, I could not yet know the extent of the damage, nor did I see everything I just described during this initial observation. These discoveries unfolded over the course of months.
After my initial observation, I took the slides home to study them with my own equipment, which was significantly better than the microscope in my cubicle. Believe it or not, I did not immediately jump on the slides. When I returned home late that Friday night, I went out to relax. (Prema and I had not yet started dating.) By the time I got home, I had more pressing matters than slides connected to a six-month-old autopsy case. I placed the slides on top of my desk and basically forgot about them.
Looking back, I realize I didn’t just forget about the slides. I knew they were there, but I was hesitant to study them further. Here is why: A short time after I moved to Pittsburgh, one of the autopsy technicians who had worked in the medical examiner’s office invited me to a get-together at his home on a Sunday afternoon. Joe is a big, gregarious Italian guy who loves to cook and entertain. I gladly accepted his invitation, although I got there a little late on the day of the party. When I walked in, Joe handed me a beer and began introducing me to the thirty or so people who were there. Some I knew from work. It was a nice mix of people, with everyone from neurosurgeons to blue-collar types. Everyone seemed to be enjoying themselves, while the wonderful smell of the food was nearly intoxicating. I was glad to be there.
I found a place to sit. The television was on, and most of the other guests were glued to it. I glanced over, wondering if some news story had broken. Instead I saw a game was on. Sports wasn’t much of an interest of mine at the time. When I was a boy in Nigeria, I used to keep up with soccer, but only casually. I also ran track in my early teenage years, but that was the extent of my personal involvement in sports. Nothing changed after I moved to the States. I worked so many hours during my residency and fellowships that there wasn’t much time left over for such pursuits.
The people at the party, however, grew more and more passionate about the game on the television. They yelled and screamed and moaned and cheered with every play. They weren’t just watching the game. As I settled into my seat and started watching the people around me, I noticed an intense debate going on in the room. I listened closely, but the subject made no sense to me. This argument was also odd because most of the people in the room agreed with one another, but that only seemed to make them get louder and more animated in their discussion. It seemed that they were all quite upset with the quarterback of the Pittsburgh Steelers. I had no idea what a quarterback was, and my only exposure to the Pittsburgh Steelers was seeing the name on shirts, hats, and jackets everywhere I went in
the city. At least half of the people in the room on this day had on some sort of Steelers attire.
The game on television, it seemed, was not going well, which only made the debate about the quarterback grow even more intense. From what I could gather, the Steelers quarterback was a young African-American man, and most in the room doubted he was ever going to be any good. The majority seemed to think he needed to be replaced. As the game wore on, the feeling that he should be replaced grew stronger and louder. Of course, the alcohol being consumed by the party guests may have also had something to do with that sentiment. The debate continued when the food was served—and all the way through to the end of the game.
That’s when I left. I thanked Joe for having me over and told him I had a wonderful time. However, as I left his house, I had this feeling that I had just witnessed some sort of an odd religious sect or a cult, like an anthropologist who stumbles upon a ritual ceremony in a clearing in the middle of a rain forest under a starry sky. The emotions and passion in the room surpassed those I observed at any ordinary church service. As Cyril Wecht told me later, when I was neck-deep in my fight with the National Football League, football truly owns a day of the week—the same day the church used to own. God no longer has any claim to Sundays, at least not in Pittsburgh, between Labor Day and Valentine’s Day. Sundays belong to football.
Why would that matter to a scientist in search of truth? Deep in my spirit, I had a feeling that if I pulled out those slides and dug deeper into Mike Webster’s brain, whatever I might discover was going to put me in direct conflict with the passion for football that consumes Pittsburgh and most of America. Conflict never comes at a good time, and this was the worst possible time for me to put myself at odds with my colleagues and my community. My career as a pathologist was really just getting started. I had completed a second fellowship in neuropathology less than one year earlier and was already thinking of working toward a master’s degree in public health. Dr. Wecht had a law degree and had encouraged me to think about going to law school. Law school would be a giant step for my career, a step that would take me even closer to fully realizing the American Dream that attracted me to this wonderful country in the first place.
That is why I let the Mike Webster slides collect dust on my desk. If I pulled them out and examined them thoroughly, the future about which I dreamed, the future that was well within my grasp, might well be at risk. Knowing that, I did not know if I had the courage to go through with what I knew I needed to do.
And yet I had made a promise to Mike Webster, and his spirit would not let me forget it.
• • • •
One evening, I came home late and happened to look over at my desk. There sat the box of slides. I summoned the courage to take another look. The ghost cells and strangling tau proteins popped out at me. Why are they there, and how widespread are they? I wondered. Over the next few months, I either stayed up late at night or got up early each morning and went through slide after slide, observing damaged cell after damaged cell. I stared at those cells so many times that I could close my eyes and still see them and every detail about them. My mind became consumed with understanding what I was observing. Sometimes I woke up in the middle of the night and went straight to my microscope. The search for the truth became my life.
I had more slides prepared from other parts of Mike’s brain. All showed the same fibrils and threads of tau proteins branching out like a sickly tree, entangling and essentially strangling the brain cells. Interestingly, as I examined more slides, I began to notice another type of abnormal protein that should not have been there—the diffuse amyloid protein plaques that were scattered in different regions of his brain and doing the same thing tau proteins did, creating a toxic environment for brain cells. I got totally confused. I did not understand or know what I was looking at. My puzzlement only became agitated. I could not rest until I found the answer.
As I wrote earlier, a healthy brain cell is a thing of beauty, but that beauty had been lost in Mike Webster. The tau and amyloid proteins left many of the remaining brain cells little more than mummified remains of their former selves. It wasn’t just the presence of these proteins that I found alarming, but how uniquely distributed they were in the brain. I had not watched much football, but I knew that very large men collide headfirst multiple times throughout a game. Even though they wear helmets, their brains are not protected. A helmet keeps someone from lacerating their scalp, breaking their skull open, or suffering some type of bleeding inside the skull. It does not cushion the brain as it impacts the inside of the skull in a headfirst collision of bodies. Nothing can protect the brain in such an impact.
The images I observed under my microscope stirred my curiosity. I believe America is the most intelligent country in the world, so surely some American must have already described what I was seeing in great detail. After all, football is the most popular sport in America, and the NFL is its most popular and richest league. I started searching all the published literature I could find regarding brain trauma and dementia. For months, I went to the medical library at the University of Pittsburgh and checked out one medical journal after another. In those days, most journals did not have electronic versions. I read the physical copies. Many times the library did not have the journal I needed. I then turned in an order form for the paper I needed, and someone photocopied the pages I requested and brought them to the circulation desk.
One day, I received a phone call from one of the librarians. “Are you Bennet Omalu?” he asked.
“Yes.”
“Then you are a real person?”
I laughed. “I believe so,” I said.
“May I ask you a question?” He sounded rather hesitant.
“Of course.”
“You have ordered a very large number of journals and research papers through the library. May I ask why?”
“I am a neuropathologist working in the Allegheny County coroner’s office. I am currently doing research for one of the cases on which I am working,” I said.
The librarian let out a little sigh. “Thank you. I am sorry I had to call and ask, but with the unusual volume of requests you have turned in, we needed to verify that you were, in fact, a real person with a genuine need for these papers.”
“I can assure you I am real. I very much appreciate all of your staff at the library. You have all been invaluable to my research,” I said. The librarian did not call back, even though I continued ordering a large number of papers from the medical library.
The more I searched for answers, the more amazed I became that no one had ever reported the phenomenon I had observed in Mike Webster. The tau tangles and amyloid plaques resembled Alzheimer’s disease but did not look exactly like Alzheimer’s disease. As I have already written, Mike was far too young to have Alzheimer’s disease. Also, the patterns, while similar, were distinct from each other. I also researched dementia pugilistica, or punch-drunk syndrome, in boxers. The discovery of that syndrome proved to be quite controversial when papers describing it were first published in the late 1800s and early 1900s. Back then, boxing was one of the most popular sports in America, but the discovery of dementia pugilistica threatened its popularity. However, I knew I had found something different, because the punch-drunk brain frequently shows some physical damage that can be observed with the naked eye. Mike’s brain did not. Whatever I had observed in Mike Webster’s brain was unique.
All we know and have known about blunt force trauma to the head makes it clear that single, episodic, and repetitive blows to the head have the potential to cause permanent brain damage. It makes no difference whether the blows come in sports venues or outside of them. Boxing, obviously, involves blows to the head. Yet, from what I could find, nothing had been reported in any other contact sport regarding brain disease—not in football or rugby or ice hockey or martial arts. I found this hard to believe. How could I, an immigrant doctor working in a coroner’s office in the middle of Pennsylvania, be the first to discover wha
t appeared to be a new disease? This just did not seem possible. Yet all of my research led me to one conclusion: this was indeed something new—a new disease that attacks the brain.
Now I had to answer a second question: What caused it? I could not say just football had done this to Mike Webster. As a scientist, I had to have proof to establish such a connection. Therefore, I began to study the game and what happens physically to those who play it.
When we look at football from a scientific posture, we find a game where large amounts of kinetic energy are transferred to the bodies of players in what is called biomechanical loading. When two players collide, or when one player collides with the ground, this is called impact biomechanical loading. The brain is most vulnerable during this kind of impact, because the brain itself essentially floats inside the skull. When the body abruptly stops, the brain continues to move until it slams against the inside of the skull. When the Jell-O–like soft brain that is 60 to 80 percent water hits against the inside of the skull, the microscopic support structures of the brain fracture slightly. Even more damaging is a hit that is off-center, which causes the brain to experience rotational acceleration where the brain essentially spins within the skull, resulting in sheering damage.
Now, this sort of impact can happen to anyone, and it does. When you get up in the middle of the night and bang your head against the wall while trying to find the bathroom, you have experienced an impact biomechanical loading. That does not lead to strangling tau proteins across your brain, nor does it normally lead to memory loss, violent mood changes, and the other behavior changes exhibited in Mike Webster, changes that began even before his football career ended.
Here’s what made Mike Webster’s experience unique, and what led me to believe that football was at the root of this new disease: a football player can undergo impacts at a velocity between 17 and 25 miles per hour. This results in rapid changes in head and brain velocity that can reach 20.1 miles per hour. The brain then experiences a peak acceleration-deceleration that can reach 138 gravitation (g) force and last up to 15 milliseconds. That’s like getting hit in the head by a 10-pound cannonball traveling 30 miles per hour.1 Another way to think of it is like being in a car wreck. That’s what Mike Webster called it. When asked if he had ever been in a car wreck, he said, “Oh, probably about 25,000 times or so.”2