Truth Doesn't Have a Side

by Bennet Omalu

  I did not set out to be a modern-day Telemachus when I started writing my first CTE paper. I had not taken up the cause of telling the world, or at least America, the inherent dangers of football. At the time, the paper was nothing more than the final step to fulfill the promise I had made to Mike Webster, not a crusade.

  This was not my first academic journal article. Around the time I started working on the CTE paper, another paper I had written came out in the Brain Pathology journal titled “Fatal Fulminant Pan-Meningo-Polioencephalitis Due to West Nile Virus.”2 The paper developed out of an autopsy I had performed on an eighty-seven-year-old gardener who died suddenly after three days of flu-like symptoms. As it turned out, his was one of the first reported cases of West Nile virus infection in a human being that originated in Pennsylvania. I was the lead author of a team of five. Four years later, I along with several others authored a second paper that studied six additional cases of West Nile virus.3 Academic papers are an important part of the scientific process. As a physician, I have to self-finance and publish scientific papers, if and when I can, to do my own little part to advance medicine and improve our lives. I also authored four papers that explored a possible link between bariatric surgery and suicide. Writing the two West Nile virus papers did not mean I had taken up the study of the disease as a life’s cause, any more than exploring the link between bariatric surgery and suicide meant I hoped to become the expert in that field. The CTE paper was more of the same.

  As I wrote in the last chapter, the hardest part of writing the paper was getting started. Until I came up with a name, words refused to come. Once I settled on CTE, the words seemed to fly out. I completed the first draft of the paper in a little over a month. While I made multiple revisions based on editorial input from my coauthors and the editors at the journal that published it, the bulk of the paper is the same as that original draft. I truly believe my writing was guided by God Himself. Right around the time the movie Concussion was released, I went back and reread the CTE paper for the first time since its publication. To be honest, I nearly fell over when I read it. This came out of me? I thought in amazement. This paper is too good to have been written by me! I was floored by its audacious scientific originality, creativity, and innovation.

  The Bennet Omalu of today could not write such a beautiful piece. At that time, I was still filled with youthful idealism and hope. When I wrote that paper, I believed it would truly make a difference, that it would spark a genuine dialogue within the football community that would result in a game that protects its players. I boldly spoke my mind and made the type of strong assertions Dr. Wecht had taught me to make whenever I spoke as an expert in a court case. My boldness was based on truth. I had no reason to be anything but forthright. I did not take a side in the paper. Truth does not have a side. Truth is truth. It is up to us to conform to truth; truth does not conform to us.

  The paper focused on one case—that of Mike Webster. My coauthors and I included photos of the slides of his brain that showed the tau proteins. While the paper focused on Mike, I included information I discovered regarding the frequency of concussions in football and other contact sports. The paper acknowledged the research that had been done up to that point while calling for further study of the long-term, chronic symptoms of brain injury in retired players. I wrapped up the paper with this conclusion:

  This case study by itself cannot confirm a causal link between professional football and CTE. However, it indicates the need for comprehensive cognitive and autopsy-based research on long-term postneurotraumatic sequelae of professional American football. Empirical, cognitive, and postmortem data on CTE are currently unavailable in the population cohort of professional NFL players. Our report therefore constitutes a forensic epidemiological sentinel case that draws attention to a possibly more prevalent yet unrecognized disease because of the rarity of CNS-targeted autopsies in the cohort of retired NFL players.4

  In laymen’s terms, the above says that Mike Webster is probably not an isolated case, that many more former football players probably suffer from CTE. However, because there had not yet been a concerted effort to look for the presence of CTE in the brains of former football players, we have no way to know how widespread this disease might be. I assumed many of those connected with football would be anxious to know more, since I also assumed they surely had the players’ best interests at heart. Yes, I was young and very naive.

  After completing the first draft, I set the paper aside for a short time and then went back and made revisions. I sent copies to Drs. DeKosky and Hamilton, along with Dr. Wecht. I also sent a copy to Ryan Minster and Ilyas Kamboh, both of whom were in the Department of Human Genetics at the University of Pittsburgh. These men were my coauthors on the paper. Each of them suggested changes. Some I accepted, while some I did not. I sent the final draft back to them all. We went back and forth until we had a manuscript we were all proud of.

  Now the question was where to submit the finished paper for publication. I believed there was only one logical choice: Neurosurgery, the same publication in which the NFL concussion committee presented its research. The journal’s editor at the time, Michael Apuzzo, was a professor of neurosurgery at the University of Southern California. Under his direction, the journal had added a sports section that featured articles on sports and the brain. Since Neurosurgery had already published NFL papers focusing on football and concussions, it seemed the logical place to submit my paper.

  I printed out several copies of my paper and mailed them to Dr. Apuzzo in August 2004. The journal required several copies, since every submitted paper goes through a process of peer review. Typically, the paper goes to two reviewers. If they agree a paper is publishable and meets the ethical and generally accepted medical standards, the paper is published. If the two disagree with one another, a third reviewer is brought in to break the tie. Many times the reviewers will make recommendations for revisions or clarifications, which the author must make. All of this is done under the supervision of the journal and section editors. The whole process is a rigorous intellectual back-and-forth that can take months to complete. In the end, however, it should make the paper even stronger.

  From what I observed in the review process, I believe my paper went through many reviewers—possibly up to eighteen—not two or three. Why so many? I do not know. All of them sent comments to me. While many were positive and asked legitimate scientific questions that I needed to clarify, others had a decidedly negative tone. Many of them did not want to see my paper published, but the reasons they gave were not scientifically valid. Some of the negative comments questioned my credentials. They insinuated that I was a no-name and a quack. Who is Omalu? they essentially asked, and why should we take seriously the research conducted by nothing more than a government employee doing autopsies in Pittsburgh?

  The attitude expressed by these reviewers speaks to one of the fallacies of accepted scientific research. Today, the scientific community yields to established, experienced professors in university settings to guide research, review research papers, and determine whose research is funded. The result is a complete lack of innovative approaches to old problems. Instead, we are stuck with conformational intelligence, where the same approach is used over and over. We need a new model of funding research that targets young researchers with out-of-the-box, nonconformational thinking hypotheses and concepts that may not belong or want to be within the four walls of a university, especially in this era of emerging virtual research. If I had done my research in a university setting, I believe I would have been told to stop.

  Looking back, I wonder if my story might have a different ending if I had approached a different journal with my CTE paper. I did not know it at the time, but it seemed that Neurosurgery was becoming the official voice of the NFL regarding brain injuries. One of the first NFL’s MTBI papers published in Neurosurgery was accompanied by a guest editorial by the then NFL commissioner Paul Tagliabue. Tagliabue is a lawyer who was paid millions of d
ollars each year by the NFL owners to maximize profits for the league. Michael Apuzzo also penned an editorial announcing the NFL’s series of papers. In it, he compared professional football to the Roman gladiator contests, with all of their splendor and pageantry. Apuzzo had a front-row seat to that pageantry, since he had worked as a consultant to the New York Giants and was with them when they played in the 2001 Super Bowl against the Baltimore Ravens.

  The seemingly endless process of back-and-forth with the many reviewers left me very frustrated. I suspected that none to several of those reviewing my paper were trauma neuropathologists. Many of their comments made it clear they may not have been adequately educated on the pathology of neurotrauma. The process of answering their questions and objections took three to four times the amount of time it took to write the paper itself. My responses were more than five times the length of the paper. Yet no matter how much I wrote, more questions came.

  My patience began to wear thin. Gradually, without my knowing it, a simmering anger arose within me. I could not believe this was happening in America. In all fairness, some of the reviewers were good to me and commended me for my work. A minority remained vehement that the paper should never be published and that Omalu should not be trusted because his assertions are dangerous.

  However, to the credit of Dr. Apuzzo, Neurosurgery ultimately decided to publish my paper. They included some of the comments from reviewers, but most of those included were positive. One in particular stood out. Dr. Donald Marion, a neurosurgeon from Boston, gave some very constructive comments. Given what happened next, he was an angel from God to me, encouraging me when I could have easily drowned in a sea of doubt.

  Finally, I received a copy of the volume 57, number 1, July 2005, issue of Neurosurgery. I opened to page 128 and just stared at the article. I did not reread it. I had read it enough times during the editorial process. Instead my thoughts turned to Mike Webster and his family. You’ve been vindicated, Mike, I thought. After reading this, people will know you did not want the life into which you descended. Football did that to you. I hope this gives you rest.

  And then I closed the journal and set it on a shelf. I never could have imagined that this was going to be deemed one of the most influential case reports in sports medicine. When I closed the cover of Neurosurgery, I did not imagine that paper would come to define so much of my life and my life’s work. In my mind, it was very much like the other papers I wrote both before and after Mike. I had discovered something in the brain of Mike Webster and now I had reported it. That afternoon I went back to work and completed another autopsy then filed my reports on it, just as I did every day. The Mike Webster paper was just another day at the office, not a life-defining moment.

  Then the NFL stepped in.

  One morning several weeks after the publication of “Chronic Traumatic Encephalopathy in a National Football League Player,” my phone rang. Dr. Wecht’s secretary was on the phone. She only called when there was a problem or when Dr. Wecht needed me. As expected, she said, “Cyril needs to reach you. May he call you at this number?” she asked.

  “Of course,” I said.

  A few minutes later, the phone rang again. “Bennet,” Dr. Wecht said in an anxious tone of voice. He was usually very loquacious, but not this morning. “I just got off the phone with an editor from Neurosurgery.”

  “Is everything alright?” I asked.

  “No. The NFL sent them a letter demanding that your paper be retracted. They want you to say you made the whole thing up.”

  I sat there stunned for a moment. “What did the editor say to them?” I asked.

  “Dr. Apuzzo has set up a review committee to address their concerns and determine if it should be retracted.”

  I wondered if this had been the original plan all along—if they had only agreed to publish my paper to embarrass me. Now it made sense. By holding me up to professional ridicule, they would send a message to other doctors across the world that you don’t mess with the National Football League. If my paper was retracted and all my science debunked, then my career was as good as done. No one would ever touch me or the question of CTE ever again. Panic started to set in—panic and anger. But then I remembered the words of Saint Paul:

  We know that all things work for good for those who love God, who are called according to his purpose . . . If God is for us, who can be against us? . . . What will separate us from the love of Christ? Will anguish, or distress, or persecution, or famine, or nakedness, or peril, or the sword? . . . No, in all these things we conquer overwhelmingly through him who loved us. For I am convinced that neither death, nor life, nor angels, nor principalities, nor present things, nor future things, nor powers, nor height, nor depth, nor any other creature will be able to separate us from the love of God in Christ Jesus our Lord.5

  Once I calmed down, I realized I had the least to lose from this battle. My coauthors were far more established than me. I was only three months out of my training as a neuropathologist when I conducted the Mike Webster autopsy. I was a neophyte. But Drs. Wecht, DeKosky, Hamilton, and Kamboh had their names and reputations on the line. I wondered if they regretted becoming associated with this no-name Nigerian doctor.

  “So what should we do, Cyril?” I asked.

  Dr. Wecht laughed. “Don’t worry about these idiots,” he said. He actually used a much more colorful term, which is Dr. Wecht for you. “Don’t let them intimidate you or silence you. Dr. Marion is going to call you later. Listen to him, and do whatever he asks you to do.”

  “I will,” I said. I hung up the phone and whispered to myself, What have I done? Tears rolled down my face. I knew I had done nothing wrong against anyone. Everything I had done that led up to this moment, from ordering the fixing of Mike Webster’s brain to the extensive study of the slides of his brain to all of my research into brain disease and ultimately in publishing this paper—all of it was driven by my desire to have justice for Mike and restore his humanity. And now I was under attack. My career and the careers of those who had stood with me were all at stake. I knew what I had to do. I had to stand firm on the truth. Truth will not be moved or intimidated by those who seek to silence it.

  I had never set out to become a modern-day Telemachus. My goal was never to be the voice of an outsider who points out what no one else was able to see because their eyes were clouded by conformational intelligence. If the NFL had simply ignored my first paper, I may never have become the one running out into the football arena and crying out, “In the name of Christ, stop!” But once they demanded a retraction, that was exactly who I became. I had no choice. I had to be the voice for those who could no longer speak for themselves. And the next voice that needed to be heard came to me very quickly.

  Chapter Seventeen

  The Baton Is Passed

  Terry Long joined the Pittsburgh Steelers in 1984 when he was drafted in the fourth round out of East Carolina University. In Pittsburgh, players are not just drafted by the team; most are adopted by the city, at least while they are with the team. Terry played for the Steelers for eight seasons. By his second season, he was the starting right guard, where he lined up right next to Mike Webster. The two played together through the 1988 season. Mike finished out his career in Kansas City, where he played two seasons. Terry remained in Pittsburgh, a fixture on the offensive line until injuries finally ended his career after the 1991 season. When his playing career came to a close, he stayed in Pittsburgh. It had become home.

  On June 7, 2005, several weeks before my paper appeared in Neurosurgery, Terry Long was found unresponsive in his home. Apparently, he drank a large amount of antifreeze and took his own life. He was forty-five. I was not on duty when his body came to the coroner’s office. Dr. Abdulrezak Shakir conducted the autopsy. When he removed Terry’s brain from the skull, he did not see any abnormalities. He did not cut the brain; rather, he paused. “I wonder if Bennet will want to examine this?” he asked the others in the room. The consensus was to fix the brain and save i
t for me. When I came into work the next Monday, I walked into the autopsy room, and everyone yelled, “Dr. Omalu, we have another brain for you—another NFL player!”

  That is how I met Terry Long.

  After the brain became fixed in formalin, I took possession of it and examined it by myself at the medical examiner’s office. I took slices from different regions of his brain and packaged them so that slides could be made from them. After my Mike Webster experience, I knew exactly what to look for across his brain. Unlike with Mike, I did not wait weeks and months before examining the slides for evidence of CTE. Between the time of Terry’s death and the preparation of the slides, I received the letter from the NFL demanding that I retract my first paper. When Terry’s brain cells showed the signature CTE patterns of tau proteins and other changes, I knew that not only was I not going to retract my first paper; I was looking through the microscope at my second.