League of Denial

by Mark Fainaru-Wada

  As editor in chief, Apuzzo set out to remake Neurosurgery in his own image: worldly, eclectic, erudite. He wanted to expand the journal’s readership and impact by moving it beyond the narrow world of neurosurgery into what he called “an ‘avant-garde’ progressive position and internationality.” It was the brain science equivalent of Tina Brown’s makeover of the New Yorker. Apuzzo’s avant-garde approach to Neurosurgery included transforming some of the journal’s covers into abstract art and expanding its sports coverage. He decided to establish a sports section to solicit and publish articles on sports and the brain. Bob Cantu was Apuzzo’s pick to edit the section.

  Cantu was a logical choice. One researcher called him the “King of Concussions.” Cantu had been looking into the relationship between sports and head injuries for perhaps as long as anyone alive. When Apuzzo brought him in, Cantu was in his early fifties, a trim man with short red hair that he combed from left to right. Cantu had grown up in Santa Rosa, California, about an hour north of San Francisco, where his father owned a building supplies company. After pitching for two years at Cal, he blew out his arm, and so he decided to accelerate his entry into medical school at the University of California, San Francisco. Cantu moved to Boston in 1964 to do his residency at Massachusetts General Hospital and never left.

  By the mid-1980s, Cantu was chief of neurosurgery service and chairman of the department of surgery at Emerson Hospital in Concord, Massachusetts; for fun, he worked the sidelines at high school football games. At the time, contact sports, especially football, were experiencing a wave of hysteria over something called second impact syndrome. The idea was that a first blow to the head might seem benign, but it primed the brain for the second blow, which killed you. The actual number of cases of second impact syndrome was, in fact, low, but the lack of understanding and the sinister nature of the injury led to a lot of media coverage. Cantu, who was watching teenagers collide every week, decided to start looking into the true nature of those collisions. He didn’t want to miss the concussion that preceded the concussion that wound up killing a kid.

  Cantu quickly realized there were no guidelines for how long a player should sit out after a concussion, and so he decided to come up with some himself. There wasn’t a lot of research to draw on; Cantu admitted the exercise was a bit of a stab in the dark. One of his sources of inspiration was an experiment in which UCLA researchers had bashed rats in the head and then checked their glucose levels, glucose being the chemical that powers the brain. The levels stayed depressed for an average of 5 days but sometimes as long as 10, a possible indication of how long it might take to recover from a concussion. Later, the study’s author, David Hovda, ran into Cantu at a meeting and asked him how he had come up with his recommendation that athletes sit out a week after suffering a concussion. Cantu pulled out Hovda’s study. “You’re making recommendations from rat data?” Hovda asked, grinning.

  By the time Apuzzo tapped him as Neurosurgery’s sports section editor, Cantu had written dozens of papers on concussions and the criteria for returning to play. He had been named president of the American College of Sports Medicine. He was exactly the type of expert Lovell had expected to see on the NFL’s committee. Cantu’s concussion guidelines were still somewhat arbitrary, but they gave coaches, trainers, and team doctors something to go on when assessing whether a player should be allowed back on the field. Cantu believed the NFL’s research was a perfect candidate for the sports section of Neurosurgery; it could help advance the science of an issue that had long been important to him. His doubts about Elliot Pellman notwithstanding, he was curious to see what the NFL, with all its resources, came up with. “I knew the work had been done; I thought the work was important and suggested they submit the first paper to Neurosurgery,” Cantu said.

  The first NFL paper was accepted on May 27, 2003. It was published in the October 2003 issue under the title “Concussion in Professional Football: Reconstruction of Game Impacts and Injuries.”

  To launch the unprecedented initiative, Tagliabue contributed a bland guest editorial titled “Tackling Concussions in Sports.” He wrote that the NFL’s research already had “contributed to advancing our understanding of the science of concussions, which is a concern for everyone involved in competitive sports and recreational activities. The accompanying article confirms the groundbreaking character of this research.”

  Apuzzo was more effusive and colorful in a manner befitting his avant-garde publication. In an editor’s note, he compared Elliot Pellman’s MTBI committee to Galen of Pergamon, the Greek philosopher and medical researcher who studied the wounds of the Roman gladiators. “Football’s participants dwarf Rome’s gladiatorial combatants in number, and, in its most sophisticated form, the game’s pageantry matches or exceeds the spectacle of Roman-designed events,” Apuzzo wrote. “As in the ancient contests, modern football is attended by myriad injuries, the most frequent of which involve the brain.”

  “As in the past,” Apuzzo continued, “the modern arenas of sport offer laboratories for the study of the mechanisms and events attendant to multiple injury end points in athletes, and they offer a substrate of important information for our general comprehension of the problem of human trauma in general.”

  Apuzzo described the research by “Pellman et al.” as “highly responsible NFL-sponsored studies” combining field analysis with lab work and offering “significant new insights” into concussions, including “important data for consideration in the development of new directions in helmet design and testing.”

  The NFL’s era of scientific exploration had begun.

  The early reviews were glowing. In its first paper published in Neurosurgery, in October 2003, the NFL (Pellman et al.) not only had brought science to the question of why the lights were going out for so many players, it also had addressed an issue on the minds of many researchers who thought deeply about the subject. The paper suggested that the standards used to measure the effectiveness of football helmets in preventing head injuries had to be reassessed. The standards were set by a body known as the National Operating Committee on Standards for Athletic Equipment; everyone called it NOCSAE (pronounced NOC-SEE). It had the ring of a government agency—maybe part of the FTC or the Consumer Protection Agency—but in fact, NOCSAE was a private nonprofit organization funded mostly by the sporting goods manufacturers it regulated, including the helmet companies.

  Not surprisingly, NOCSAE hadn’t changed the way it tested and certified helmets for years. But now here was the NFL, with all its power and authority, using science as a catalyst for reform. NOCSAE focused primarily on the ability of helmets to withstand blows to the periphery and crown of the helmet, but the NFL’s study indicated that many injuries occurred when players got hit in the face mask and the side and back of the helmet. This was progress. Cantu, who served as a consultant to NOCSAE, knew that the standards needed updating. In a review appended to the article, he called the NFL’s first paper “the most extensive study to date on the biomechanics of athletic concussion in football” and praised “Pellman and his collaborators for this exciting, innovative and unique study and the NFL for funding this research on a topic very critical to its athletes.”

  Three months later, the NFL published another study in Neurosurgery. This second paper—“Concussion in Professional Football: Location and Direction of Helmet Impacts”—drilled down on where the concussive blows were delivered. Again it was illuminating. Pellman received credit as lead author, but most of the heavy lifting was done by Biokinetics, the Ottawa biomechanics firm brought in by the NFL, and Dave Viano, a biomechanical engineer at Detroit’s Wayne State University who had done crash-test studies for the auto industry. This time the NFL divided the human head into quadrants. The league found that 71 percent of the concussive blows were being struck on the side and back quadrants of the helmet, another repudiation of NOCSAE standards.

  Again the reaction was positive. Julian Bailes, the neurosurgeon whose work with Barry Jordan had ind
icated that alarming numbers of retired football players had signs of dementia, wrote that the NFL had “ushered in a new era in the study and analysis of the many nuances of these high-speed bodily collisions.” Alluding to the concussion videos, the NFL, Bailes wrote, was “studying by darkroom analysis an important laboratory for head injury, the football field.”

  An aura of good feeling settled over the Mild Traumatic Brain Injury Committee. The NFL had revealed itself as a force for good. Yes, the commissioner had appointed a rheumatologist to oversee scientific research into brain injuries, and yes, most of the doctors had ties to the league, but the science was the science. The NFL had resources that no other researchers had at their disposal: a vast library of videotape, an army of willing research assistants, a closed pool of subjects (the players), and, of course, gobs of money. The concussion research community stood by and waited to see what the Mild Traumatic Brain Injury Committee would produce next.

  The wait lasted only a month. In the next issue of Neurosurgery, the league published NFL Paper Number 3.

  This one was different; that much was clear.

  The much praised biomechanical studies were over. This time, Pellman et al. had taken the statistics from the NFL Mild Brain Injury Surveillance Study and used them to paint a panorama of concussion in professional football.

  It was in many respects a very pretty picture. The NFL didn’t have much of a concussion problem, the study concluded. The injury occurred at an extremely low rate—about one every three games—a rate strangely similar to the statistics spouted by Tagliabue and the NFL’s PR department for a decade, long before the study had been put in place. When concussions did occur, 92 percent of all players returned to the field in less than seven days—that is, they never missed a game. Pellman and his fellow authors interpreted this as an indication not that players were being rushed back on the field or hiding their injuries but that concussions were minor events whose symptoms went away quickly with few, if any, long-term consequences. “More than one-half of the players returned to play within 1 day, and symptoms resolved in a short time in the vast majority of cases,” they wrote.

  The response from the scientific community this time was guarded, even puzzled. Many researchers noted the obvious flaw that blew an enormous hole in the NFL’s claims that concussion rates were low: the reluctance of players to report their injuries to coaches and team medical personnel.

  Nine months later came yet another NFL study in Neurosurgery. This one dealt with repeat concussions. Numerous previous studies had shown that one concussion left the brain vulnerable to another concussion if the brain wasn’t given time to heal. Guskiewicz had taken it a step further: Repeat concussions, he’d found, appeared to increase the probability of dementia later in life greatly. But that wasn’t a problem in the NFL, according to Pellman et al. The league looked at how quickly players went back on the field and concluded that they were at no greater risk than if they had never been concussed at all. The logic was that because players returned to the field so quickly, they must have been okay or the medical staff wouldn’t have cleared them. This flew in the face not only of previous research but of widely known realities on an NFL sideline. First, players often didn’t report their injuries. Second, they hid their symptoms whenever they could. Third, NFL doctors often deferred to the wishes of coaches and players, just as Pellman had deferred to Parcells. As Steelers doctor Tony Yates had said: “Only a head coach can pull a player off.” The entire NFL culture was incentivized toward risk.

  For the first time, the NFL also took on the issue of football and brain damage, a growing concern among researchers. The league’s scientific opinion? This wasn’t a problem in the NFL either. Boxers got brain damage. Football players didn’t. It was as simple as that. “This injury has not been observed in professional football,” Pellman and his colleagues wrote.

  That was technically true: No one had yet cut open the skull of a dead football player to examine his brain for signs of neurodegenerative disease. But after the findings of researchers such as Bailes, Jordan, and Guskiewicz, few doubted that day was coming. Pellman and his colleagues noted that the NFL’s study was “admittedly not the best vehicle to search for evidence” of long-term brain damage in football players. Why? Because the league, in fact, hadn’t studied the issue. But that didn’t stop Pellman and his colleagues from offering an opinion. Yes, there were players who left the game with long-term symptoms after suffering repeated concussions. “They clearly did not have [brain damage] as that seen in boxers,” Pellman et al. wrote.

  The response to NFL Paper Number 4 was like a cannon going off in the tightly knit concussion research community. Before the paper was published, Cantu, as sports section editor at Neurosurgery, sent it around for peer review. Bailes and Guskiewicz were among the reviewers. The two researchers could hardly believe what they were reading. Not only was the NFL dumping on their research, but the league had taken a giant deductive leap by essentially declaring that pro football players were impervious to brain damage, as if they were superhuman. Bailes and Guskiewicz informed Neurosurgery that they were rejecting the paper’s major findings. They weren’t alone. Even Cantu, the editor, had misgivings about the NFL’s conclusions and the paper’s scientific underpinnings.

  In most peer-reviewed journals, rejection by a preponderance of reviewers—particularly the assigning editor—is usually more than enough to prevent a paper from being published. Many scientists feel that’s exactly the point of the peer-review process: to prevent science of questionable origin or credibility from making it into the literature—the engine of scientific progress. But Neurosurgery, at Apuzzo’s direction, used a different process. Reviewers could raise their objections in a comments section appended to the paper, but the paper itself would stand.

  Even in the stilted language of science, the comments on NFL Paper Number 4 were scathing. Guskiewicz called the NFL’s conclusion that repeat concussions were of no real consequence “potentially dangerous.” Bailes stated that the concussion rates calculated by the NFL do “not indicate a true ongoing incidence.” In other words: wrong. Cantu wrote: “At first glance, the NFL’s experience with single and repeat concussion (no difference) and management (more than 50% of players return to the same game, including 25% of those with loss of consciousness) seems to be at odds with virtually all published guidelines and consensus statements on managing concussion.”

  The fact that the comments were published provided no solace to the reviewers. “We were like, ‘Who reads the commentaries?’ ” said Guskiewicz. “It’s a published paper. It became the gospel.”

  NFL Paper Number 4 now stood as peer-reviewed science. The NFL’s research arm could hardly have staked out a more aggressive position. The league could now claim authority over the questions that soon enough would most threaten its future. It was judge and jury. The NFL was just getting warmed up.

  8

  ONYEMALUKWUBE

  In normal circumstances, Mike Webster’s body wouldn’t have ended up on the slab. In 2002, there were roughly 17,500 deaths in Allegheny County. Fewer than 1,000 were handled by the coroner’s office, which intervenes only when death results from unknown or suspicious causes. Webster had died of a heart attack: Case closed. But for his fame, his very public descent into madness, and the unusual foresight of one man, his body would have been cremated after the funeral.

  The man who stepped in was Joe Dominick, the chief deputy coroner. Dominick was a burly Pittsburgh native and die-hard Steelers fan. The son of a carpenter, he had been raised in the milieu of the steel town and then had become part of the new economy when Pittsburgh transitioned into health care. “I watched Mike Webster play football every Sunday, man!” he said. Dominick’s 14-year-old son, Alexander, played center on his midget team, and Dominick had raised him on the legend of Iron Mike. Like every Steelers fan, Dominick had heard the stories about Webster’s tortured post-football life. When he learned that he had died, Dominick decided to impou
nd the body.

  “The first thing I thought was this is a good way to put this issue to rest,” he said. “My concern was if Mike died as a result of a drug overdose or he died as a result of injuries sustained that we were able to link to football, it changes the dynamics here. It’s no longer a natural death.”

  The body arrived on a Saturday, and this too was a fortuitous key to the secret inside Mike Webster’s head. At the time, the coroner’s office had more than a half dozen people qualified to perform an autopsy. The one who happened to be working that day, Dominick thought, was the perfect man for the job. For one thing, Bennet Omalu was a neuropathologist, a specialist in diseases of the central nervous system, although neuropathology was just the latest medical specialty Omalu had picked up. A pathologist by training, he seemed to collect degrees and certificates with the ease of a man picking out produce at the supermarket. Technically, Omalu was a neuropathology student, having completed his studies in that discipline at the University of Pittsburgh Medical Center three months earlier. He hadn’t yet passed the exams, but he was brimming with curiosity and fresh ideas. “I was intellectually hard,” Omalu said. “I had just finished my training.”

  At this point, it would be hard to conjure up a more unlikely character to wander into the Webster saga than Bennet Omalu. Nigerian by birth, short and stocky, he spoke English with a mesmerizing singsong accent, the pitch of his voice often rising and falling in the same melodic sentence. When Omalu swore, which was often, he made motherfucker sound like poetry. His face was equally expressive, conveying a wide range of emotions. Omalu was the ultimate open book: He had no filter, and whatever he was thinking in that moment would be fully expressed, often with no apparent concern for how it might sound to the person on the receiving end. Even his priest, Carmen D’Amico, was sometimes startled by what came out of his mouth: “He’ll say things, and it’s just like, ‘Oh! Bennet, don’t say that!’ ” The more controversial material often focused on his beliefs, a fusion of Roman Catholicism and Igbo tribal mysticism that sometimes became entwined with his medical practice. Omalu believed that the body was a vessel for the soul and that even in death—especially in death—the soul had to be honored. He was convinced that spirits inhabited the coroner’s office and that the nights belonged to them. Once, while working alone with a dozen or so refrigerated bodies, Omalu thought he saw a figure leaning against the door, staring at him. When he looked again, the figure vanished. He then spotted another shadowy form walking away. Omalu looked at his watch; it was 7:30 P.M. “I said to myself, ‘Bennet, you’re trespassing. There’s usually nobody here at this time; just get the fuck out of here.’ And guess what? What did I do? I quickly stopped what I was doing. I shut off the light. And I got the fuck out of there.” On another occasion, Omalu was driving around with a brain in the backseat of his car. The car got a flat tire, and that night the empty dishwasher in Omalu’s apartment started without explanation. He attributed these events to the brain’s former owner.