Fall 2018

Life and Health

Cause of Death: Sports

Donald Winchester

Isla Veal

In the face of mounting evidence that repeated head injuries can lead to a fatal brain disease, why isn’t more being done by sports organizations to care for players?

Jeff Astle was a hero to many. He played football, or soccer, professionally from the age of 17 until retirement in his mid-30s. It was a full career, and by most estimations a successful one. His fans, who watched him score 174 goals over a decade for West Bromwich Albion, called him “the King” and still sing his name in their stadium decades later.

He played in a different age, with tactics and ticket prices that are alien to modern spectators. Perhaps most notably, the ball was different too—made of thick leather that absorbed water and became extremely heavy in play. It had a visible impact on players, who routinely headed the ball; a magazine of the time wryly referred to football’s “punch-drunk” players.

Astle was known as a prolific goal scorer, especially with his head. It was this talent that brought him a new kind of fame when he died in 2002, at the age of 59, of a degenerative brain disease. The coroner, Andrew Haigh, ultimately pronounced him dead “by industrial disease,” meaning that his sickness was caused at least partly by his work: Astle had suffered repeated micro brain traumas (more commonly known as concussions and subconcussions). A Telegraph report on the inquest quoted Haigh: “His type of dementia was entirely consistent with heading a ball. The occupational exposure has made at least a significant contribution to the disease which caused death.” It was the first time a direct link had been made between football and death.

Footballer Jeff Astle heads the ball in a 1966 match. His death in 2002, at the age of 59, was eventually blamed on a degenerative brain disease caused by repeated heading over a long term.

© Mirrorpix

The verdict on Astle’s death coincided with some groundbreaking research on the other side of the Atlantic. Nigerian-American physician Bennet Omalu worked with American football players, drawing his best-known case study from the postmortem of former player Mike Webster. Webster died at 50, following years of cognitive impairment and depression. Omalu hypothesized that repeated concussive blows to the head had caused Webster’s dementia. His further study of other deceased American football players established Chronic Traumatic Encephalopathy (CTE) as a cause of their—and Astle’s—cognitive decline, with the evidence suggesting that their profession had triggered it.

CTE is most often found in contact sport athletes and military veterans, likely because these are some of the only roles in modern life that involve purposeful, repetitive hits to the head.”

Concussion Legacy Foundation, “What Is CTE?”

Traumatic Brain Injuries and CTE

In the years since Omalu’s initial work, our understanding of CTE has broadened considerably, assisted by amplified awareness of mental health in general. It is, simply speaking, a neurodegenerative disease that causes progressive decline in a broad range of functions. Symptoms can include memory loss, confusion, impaired judgment, aggression, impulse control issues, depression, anxiety and possibly even suicidal behavior. Few of these have hitherto been perceived as sporting ailments.

The theory behind CTE is relatively simple. Our brain floats in a substance called cerebrospinal fluid. When our head suffers a collision, the brain hits the hard skull surrounding it, which damages the cerebral tissue and causes a concussion. In the short term, a concussion may involve temporary impairment of brain functions as fundamental as thinking and vision. Subconcussions are a lesser form of this but in a way are more sinister: they may cause damage without generating symptoms. It’s now been established that multiple concussions and subconcussive impacts can be a precursor to CTE. Over time, these repeated events cause normally useful tau proteins in the brain to clump together, leading to short- and long-term neurological symptoms.

Concussions occur commonly in contact sports—perhaps more frequently than most realize. From punches in boxing to headers in football to helmet-to-helmet impacts in American football, the potential for concussion has been a part of sporting life for decades, and it seems likely that the vast majority of such injuries have gone undetected. A recent study estimated that 1.6–3.8 million sports-related traumatic brain injuries, including concussions, occur in the United States alone every year. Another US-based study reported that in American football, 1 in 30 players between the ages of 5 and 14, 1 in 14 high school players, and 1 in 20 university-level players suffer at least one concussion in any given season. And this is far from the whole story. While American football is notorious for its high risk of concussions, other sports (including, among others, rugby, ice hockey, lacrosse, wrestling and boxing) all have concussion rates rivaling or, in some cases, exceeding it.

There’s growing evidence of high concussion rates in soccer too, including some disturbing short-term effects. In 2016, a study by the University of Stirling found that players who headed the ball 20 times, using force typical in a match, suffered a marked reduction in memory performance during the subsequent 24 hours. (It wouldn’t be too tongue-in-cheek to suggest that this might be a factor in the selective memory that some display during post-match interviews, when asked about controversial incidents.

The best available evidence tells us that CTE is caused by repetitive hits to the head sustained over a period of years. . . . [And it] points towards sub-concussive impacts, or hits to the head that don’t cause full-blown concussions, as the biggest factor.”

Concussion Legacy Foundation, “What Is CTE?”

All this makes for a disturbing picture, especially if we consider the millions of people worldwide who regularly engage in contact sports. It should be noted, of course, that the picture is still developing. Research to pinpoint the exact causative factors in CTE is ongoing.

Serious Questions

Meanwhile, medical practitioners, commentators and leading figures in the world of sport are asking what these findings should mean for the lives of athletes.

Omalu’s discovery sparked numerous investigations across the sporting world, as well as heightened media exposure (including a high-profile cinematic portrayal titled Concussion, starring Will Smith). That sports, conventionally seen as a source of health, should be deemed a cause of death raises serious ethical questions. After all, that outcome is generally associated with industries perceived as more dangerous, such as mining and logging. Do the organizations that attract, encourage and foster interest in athletic careers bear responsibility for the short- and long-term health of their employees? Should we view stadiums and arenas any differently than a conventional workplace? What role does care have in a pursuit that has become less and less recreational and more and more profitable? As in so many human activities, money has a huge part to play, and it all makes for a murky ethical quandary.

The chorus of those supporting measures to prevent CTE is growing. Among them is John Stiles, former professional footballer and son of Nobby Stiles, another notable former footballer suffering with dementia. “Coaches shouldn’t be throwing missiles at kids’ heads for them to head it back. Until we know, they should absolutely stop kids heading balls,” he said.

There is no doubt that few consider long-term consequences when embarking on sporting careers. Former footballer Alan Shearer commented: “I went into football knowing that at the end of my career I could probably expect to have some physical issues, which I do—I have dodgy knees, a dodgy back and dodgy ankles. But what I never contemplated for a second back then was that there is a chance that heading the ball could affect my brain. If that is the case, then people need to be aware of it.”

The Institute of Medicine, organizations such as the National Football League (or NFL, American football’s premier organization) and the National Collegiate Athletic Association, as well as many former players have voiced public support for further research, although in the case of sports leagues, the research they endorse often appears more self-serving than objective. Still, most athletic bodies acknowledge that steps should be taken now to limit future harm. Concussion guidance has been in existence in varying forms since 2001. For example, the American College of Sports Medicine is among those recommending that participants should immediately cease playing in the event of an actual or suspected concussion. It’s known as the “concussion protocol,” where an athlete must pass a series of tests before returning to play or practice. Suspension of activity allows normal brain cellular function to be restored after the insult to the brain tissue. This is important, as it has been demonstrated that subsequent impacts to the brain, before concussion symptoms dissipate, cause significantly greater damage.

The actual implementation of this safety precaution has been less than smooth, however, especially in professional sports. Concussion is not always easy to diagnose as there are no definitive, objective criteria for identifying it. Clinicians rely on subjective measures such as headache, dizziness and similarly nonspecific symptoms. The assessment is often complicated by external pressures (whether perceived or otherwise) to return the player to the game, as well as by the player’s desire to do so. The only prescribed response to diagnosed concussion is rest, which is frustrating even for fans, never mind for those whose livelihoods depend on it.

Duty to Children

Much of the early response has focused on youth sports, especially in the United States. Heading the ball in soccer is no longer allowed for children younger than 11. And between 2009 and 2014, all 50 states passed laws, generally known as “Return to Play,” concerning prevention and treatment of concussion in sports for youth and/or high school athletes. Such legislation requires participants, parents and coaches to receive information on the dangers and risks of concussion. Like the concussion protocol, it requires removal from play at the time of a suspected concussion and written clearance for the athlete’s return by a licensed and trained health-care provider.

Another law, the Safe Youth Football Act, has been proposed in five states (Illinois, Maryland, California, New Jersey and New York). The legislation would establish a minimum age requirement for tackling in American football programs. Maryland’s version stretched across multiple sports, proposing to eliminate heading in soccer and body checking in lacrosse and hockey. (Banning body checking has produced the strongest evidence yet of reducing rates of concussion.) To date, no state has succeeded in passing its version of the law.

Similar calls have been made in Britain, where the Professional Footballers’ Association has proposed a ban on heading the ball for children under 10 years of age. Association CEO Gordon Taylor advised, “We don’t want to put off the next generation but we need to be very mindful. The game needs to have a duty of care to all its participants.” Others use less cautious language; neuropathologist Willie Stewart commented to the Telegraph, “If I put boxing gloves on my hands, went into a school and offered to bang the kids around the head with the same force as a football, I would be locked up. If I take a football in and did the same thing, I would be appointed coach.”

Underlying these ventures is a hope that reducing the number of years a person is subjected to cranial impacts will significantly reduce the risk of developing CTE. Cofounder and CEO of the Concussion Legacy Foundation, Chris Nowinski (himself an ex-WWE wrestler), says, “We have to shorten the number of years you play this game, like you would shorten the number of years you smoke to reduce your risk of lung cancer.”

The research is clear—when children participate in high-impact, high-contact sports, there is a 100 percent risk of exposure to brain damage. Once you know the risk involved in something, what’s the first thing you do? Protect children from it.”

Bennet Omalu, quoted in press release to promote California’s “Safe Youth Football Act” (February 2018)

The Professionals’ Dilemma

Significant measures have been taken in the professional arena too. The NFL has implemented numerous rule changes to reduce the number of head injuries, including banning helmet-to-helmet tackling. While this is a laudable move, it’s worth noting that the league’s motives are inherently complex and compromised. Injuries to star players harm the brands of individual teams as well as the league, so it’s not only altruistic but in their financial interest to reduce the incidence of CTE. It makes no monetary sense for a major sporting association to be perceived as uncaring, or to be associated with a debilitating condition. The question the NFL no doubt grapples with is how far prevention of CTE can go before it reduces the commercial appeal of the game. It’s a sport largely based on physical contact, after all. Profit and outgoing care can walk hand in hand for a time, but there’s often a breaking point.

It turns out that the preservation of an athlete’s health and the pursuit of success do not always coincide, which is the crux of this dilemma. A team’s medical staff frequently faces a complex choice between players’ welfare and the success of the organization that pays their wages. It’s not an enviable situation, and in high-profile sports the wrong decision can have enormous financial implications—for the athlete, the medical staff and the organization.

The power in these cases often lies with those who employ the athletes and pay their medical bills. The question is, what should be their priority? Should their attention be on care for individual athletes or on the financial bottom line? Historically, in a capitalist society where numerous potential replacement athletes await their chance on the big stage, the focus has been on profit, with scant care for short- or long-term consequences for individuals.

Part of the difficulty lies in how society, which funds the game through various forms of fandom, views sport. It might seem an obvious point, but it’s worth noting that a fan is interested in active players. They see individual players come and go. They don’t pay to watch retired athletes wallow in post-career luxury; nor, indeed, do they pay to watch them stumble confusedly around care homes. Money is generated by those who play. The retirement lives of athletes, which hold (at best) negligible profit value, are from this perspective less important. But this is at odds with employment practices in many other industries.

As Omalu suggests, it makes sense that much of the early focus of CTE campaigners has been on youth sports. But it cannot be a coincidence that this is also the area with the least short-term financial consequences. Implementation of similar measures in professional sports is proving much more difficult. The CTE battleground features a classic conflict between fear of short-term loss and the longer (and less certifiable) perspective.

For too long, it might be argued, athletes have been treated as consumable raw materials for the production of a sporting spectacle. That a proportion of them earn large wages for accepting this role is beside the point; no amount of money, not even the stratospheric wages that many prominent athletes earn, can resolve the irrevocable onset of dementia. On the contrary, athletes are people in the same way that a factory worker, an office employee or a CEO is. It seems unreasonable to ignore the need to look out for an employee’s safety just because he or she works in a different field.

Football must look after old players with dementia and put an end to this sense that once you’re done with playing you can be put on the scrapheap.”

Alan Shearer, Dementia, Football and Me, BBC One (2017)

The capitalist system claims to operate free from the vagaries of humanity. The “invisible hand” of the free market, a principle that underlies the most prominent of professional sports, functions without emotion and without bias, at least in theory. The laws of supply and demand have made some sports among the most profitable businesses in the world today. The welfare of nonactive individuals is at best low on its priority list.

While research underpinning CTE recommendations continues, it’s growing increasingly clear that there is an issue here. As competition grows stronger, as sporting success depends on increasingly narrower margins, athletes are pushing their bodies more and more. Many are remunerated handsomely, you might say; but it would seem churlish to argue that the organizations employing them, which are also making enormous profits, don’t bear responsibility for the potentially damaging consequences of their sport.

Consistent implementation of the guidance regarding concussion, implementing risk-reducing concussion directives, and making people aware of the evidence regarding immediate and potential long-term risk of CTE would seem intuitive, at the very least. But the repeated conflicts over its implementation show that employee care is not often the uppermost concern.

It would be no surprise if market forces remain the major driving force in all this. It is, after all, probably no more than coincidence that the policy changes made so far chime with time-honored principles of care for other people. While greed for money (which, as biblical wisdom says, is a root of all kinds of evil) remains the primary focus, it’s unlikely that the issue will be resolved.

The NFL, where the average player’s career lasts just three years, is battling a particularly serious image problem, with all sorts of factors; and research related to CTE is a major part of that. But without a threat to its actual survival, as other industries have experienced, it would be surprising if the focus of the sporting world in general took the admirable move of turning practically and wholly to the idea of caring for others.