Sports Nut

Did League of Denial Get It Right?

Debating the Frontline documentary on the NFL and concussions.

Trent Edwards suffers a concussion

Trent Edwards of the Buffalo Bills suffers a concussion after getting hit by Adrian Wilson of the Arizona Cardinals on Oct. 5, 2008, in Glendale, Ariz.

Photo by Donald Miralle/Getty Images

On Tuesday night, PBS aired a Frontline documentary called League of Denial that examined the NFL’s alleged role in suppressing research about football and concussions. Dan Engber and Stefan Fatsis watched the film, based largely on the research of sibling investigative reporters Steve Fainaru and Mark Fainaru-Wada, and reached different conclusions about what they saw on the screen. Their email debate is below. (You can also listen to an interview with Steve Fainaru on Slate’s sports podcast Hang Up and Listen.)

Dan Engber: I found myself a bit annoyed by League of Denial for relying on a few widely held misapprehensions about the science of concussions to tell its story, e.g., that there’s good evidence football-related head trauma leads to depression, suicide, and early death. But the main point of the program—and the book on which it’s based—is not to explain the long-term effects of playing the sport, but to ask what the National Football League knew about them and when.

In this regard, the documentary makes a lot of the NFL’s response to the early work—from neuropathologist Bennet Omalu in particular—documenting signs of brain damage in former professional football players. When Omalu and several colleagues published a case report on deceased former Pittsburgh Steeler Mike Webster in the journal Neurosurgery, several members of the league’s Mild Traumatic Brain Injury Committee, led by neurologist Ira Casson, responded with a long complaint. They wrote a letter to the journal arguing that Omalu had been wrong to say that Webster suffered from “Chronic Traumatic Encephalopathy” and that his paper had neglected to include Webster’s detailed clinical history. Based on these two complaints—regarding nomenclature and a lack of supporting detail—the league’s scientists suggested that the paper be retracted or significantly revised.

This letter makes it clear the NFL was playing defense and worrying over the implications of a novel diagnosis (at least for football players) with a scary-sounding name. But it was a feeble move. Neurosurgery published a convincing reply from Omalu’s group alongside Casson’s letter, along with thoughts from other researchers in the field—both facts that the documentary fails to mention. In League of Denial, we learn that Casson was a die-hard skeptic who would roll his eyes at evidence of CTE in football players. He refused to comment on the implications of this work, saying only, “I’m a man of science.” All this makes him seem like a big-league jerk, but I think the gist of his response was not unreasonable. What he was saying is that he (and, presumably, the fellow members of his committee) didn’t consider Omalu’s autopsies as evidence of causality. That is to say, there wasn’t proof—well, there’s never really proof in medicine, but there wasn’t even solid reason to suspect—that playing in the NFL destroyed Mike Webster’s brain, and that damage to his brain in turn produced his many psychiatric symptoms. That’s a strong position, but it was not insane or willfully obtuse. In fact, you could make the same argument today. 

Stefan Fatsis: When Ira Casson rolls his eyes and says he’s a “man of science,” he’s also saying that these other jokers sure as hell aren’t. The Fainarus’ book makes a very strong case that the papers Casson and his colleagues produced—16 in all, published in the same journal as the Omalu group’s paper on Webster—were indefensible even at the time. They relied on incomplete data and reached conclusions that make “football damaged Mike Webster’s brain” seem the scientific equivalent of “the Earth is round.” The NFL doctors flat-out asserted there was no connection between football and brain trauma, that it was entirely safe for concussed players to return to the same game, that there were no long-term cumulative effects of multiple brain trauma. In one paper they even speculated that “it might be safe” for high-school players to return to games in which they were concussed.

By comparison, Omalu et al.’s Webster paper was modest in its claims. It said the autopsy revealed “neuropathological changes consistent with long-term repetitive concussive brain injury.” Webster’s was a “sentinel case that draws attention to a possibly more prevalent yet unrecognized disease.” Seems more reasonable than stating that it might be safe to let high-school football players return to a game in which they have been concussed, without studying high-school football players.

Engber: From watching the documentary, you’d think there’s no way that anyone could have believed these things that papers written by Casson et al. said, because they’re obviously false. But there was uncertainty in this field, and some uncertainty remains. Frontline makes it seem like Omalu’s pathology work, and the follow-up studies from Ann McKee of Boston University, gave a final answer: Concussions cause brain damage, and brain damage causes suicide. Casson rejected both those inferences out of hand; the makers of the program would like us to think that they’ve since been proven beyond a shadow of a doubt. Both attitudes seem off the mark. I think the more important, telling work was that which revealed that NFL retirees suffer from higher rates of early dementia than other men. Why are we so focused on the brain anatomy, instead of the lived experience of the players themselves?

Fatsis: Yes, the NFL commissioned that 2009 study by the University of Michigan’s Institute for Social Research, and when the troubling results arrived—former players were 19 times more likely to have Alzheimer’s and other disorders—the league discredited its methodology. Let me repeat that: The NFL discredited the methodology of a study that it had commissioned. I think the documentary and especially the book make the pathology work seem like what it is: a path to a possible answer to the question of whether repeated football collisions may cause or at least contribute to brain disorders—a path that the NFL was unwilling to acknowledge existed let alone start walking down. When Ira Casson and other NFL officials were asked in the 2000s whether there was any evidence that football causes brain damage, they could have said, “We don’t know, but there is some troubling evidence emerging, and we want to learn more.” Instead they said, “No,” and continually asserted the sport was safe. Rather than accepting the research as a starting point for further inquiry, the NFL tried to undermine it or bury it. In any case, scientists draw preliminary conclusions from their work all the time, don’t they? And then they keep studying. 

Engber: Yes, it’s true: Casson could and should have been more eager to find out as much as possible about the cause and effects of the brain damage that Omalu had described. Still, the league’s MTBI Committee did listen to presentations from Julian Bailes (on Omalu’s work) and Ann McKee, as well as others who felt there was a real problem. We learn that they gave these researchers a cool reception—the documentary even accuses them of being sexist (against McKee), and, more obliquely, of being racist (against Omalu)—but they held those meetings.

This brings me to something about the documentary that I found confusing. At some points we’re led to believe that “dissenters” like McKee and Omalu were a small band of idealistic neuroscientists attacking the misguided, mainstream view. At other points, these same people are described as being leaders in their field, representatives of consensus science. So which is it? Were McKee and Omalu fringe researchers, pushing an argument that most of their peers weren’t ready to accept? Or were they spokesmen for academia, doing battle with industry hacks? Frontline seems to have it both ways. 

Fatsis: Why can’t they be both? Yes, the Fainaru brothers and the Frontline producers sorted through a murky and complicated set of facts and occurrences and created a dramatic narrative, one featuring good guys and bad guys. Isn’t that what good storytelling does? I’ve read the entire book, and while it certainly champions the researchers who fought the league, it also explores their personal and professional flaws, their tangled alliances, and their potential conflicts.

The documentary is, of course, the form most susceptible to dumbing down, and Frontline does slather on your standard ominous music, baritone narration, slow zooms, and dark statements. (It totally overdramatizes a scene in which the agent Leigh Steinberg is horrified as his concussed client, Troy Aikman, repeats himself over and over after suffering a concussion. That’s a fairly common concussion aftereffect.) But it also points out that McKee has examined a small sample of brains with a big selection bias (players who had committed suicide or died of brain-related disease), and that it’s not known how common CTE might be among the general ex-NFL population. It’s also unclear how many brain traumas one might need to develop CTE, or why only some ex-players develop it, or whether there might be other causes or contributing factors, like the ApoE4 gene that David Epstein writes about in his recent book The Sports Gene.

Engber: Sure, there’s a discussion of remaining gaps in our understanding, and then we have McKee speculating that every NFL player, or almost every player, has the disease. I forget if there’s ominous music at that point, but it’s certainly an ominous idea. Or is it? If every NFL player had the neuroanatomical signs of CTE, we might conclude that having CTE isn’t really all that bad. Mike Webster had a miserable existence as a retiree, suffering from heart disease, chronic pain, drug addiction, and deep depression, among other problems. He died young. Most former NFL athletes have a very different experience, even those who suffered from concussions or repeated subconcussive knocks to the head.

So what does it tell us if every player has brain damage? It tells us that brain damage is not a good predictor of cognitive decline. Of course it’s reasonable to assume that brain damage is bad for you, but the question of whether asymptomatic CTE exists, and how prevalent it is, strikes me as being vital to understanding this crisis, or even to evaluating whether it is a crisis at all.

Once again, the most important research looks at the actual prevalence of these disorders—dementia, ALS, Alzheimer’s—among ex-athletes. A 2012 study from the National Institute of Occupational Safety and Health hinted that former NFL players were more likely to die from diseases of the nervous system, but the effect was pretty small. That is to say, even if these deaths are more common among football players than they are in the regular population, they’re still uncommon. In fact, over the course of the study period, the players were half as likely as their peers to have died from any cause. What about suicide and depression? According to the NIOSH data, former players were 59 percent less likely to have killed themselves than their matched controls, and other research finds that NFL retirees are more depressed than their peers upon ending their careers—which seems intuitive to me—but that this gap diminishes over time. (If CTE were causing their depression, you’d expect to see the problem worsen over time.)

Despite these data, which suggest that playing football is protective, overall, the Frontline documentary begins and ends with dramatic case reports that create a false impression. We start with Mike Webster’s early death, which may well have more to do with his family history of alcoholism and heart disease, and his own anabolic steroid use, than it does with head trauma. And we finish with Junior Seau’s suicide, which appears to stem from many causes. (This overplaying of the connection between concussions and depression or suicide shows up everywhere, including an article this week in Slate.)

This bothers me because with all the talk of the concussion crisis, we lose any sense of scope. If concussions really make people suicidal, as the documentary implies, and if Ann McKee is right that almost every player suffers from CTE, then why don’t we see the terrible result of those inputs in the data? Why aren’t the effects more severe?

In the end, what really matters—I would say, the only thing that matters—is how the players are affected in their lives. And once you’re debating on that register, we have to ask: Are the effects of head trauma as bad, or even nearly as bad, as the effects of other more common disabilities? According to one survey of NFL retirees, almost half said they suffered from “severe pain” as a result of playing in the league, and chronic pain can be a risk factor for depression and suicide. (About one-fifth of the retirees reported having some mental impairment.) Arthritis and other long-term disabilities are commonplace. A large number of these ex-athletes are suffering from the brutality of the game they played for money, and many have been denied payouts from the league. When I hear people saying that they’ve grown uncomfortable with football, that the news about concussions makes it hard for them to be a fan, I wonder what they used to think. In seasons past they watched the players’ bodies go to ruin for their pleasure, yet they found a means to square away the guilt.

Fatsis: Here’s what Ann McKee said: “I’m really wondering where this stops. I’m really wondering on some level if every single football player doesn’t have this.” It’s a blockbuster quote (that, thanks to its inclusion in the film’s trailer, may have led the NFL to pressure ESPN to drop its name from the project), and it’s opened her to criticism. But I didn’t hear what McKee’s critics heard. She didn’t conclude that every player has CTE. Based on neuropathological findings to date, she asked a question that only science can answer but as of now remains open: Do the brains of all football players get this? The answer might be that not all of them do. Or it might be, yes, they all do, but not to the same degree and not with the same outcomes. The medical community doesn’t question the existence of dementia pugilistica, the brain damage found in boxers. Football’s different but—and I’m asking here logically and not scientifically—how different really?

Anyway, what’s the downside of scientists like McKee theorizing that football might directly cause CTE? Writing on Deadspin, a clinical researcher named Matt McCarthy (who specializes in AIDS, not neuropathology) said it has made ex-players “the subjects of a head-injury panic and, potentially, its collateral damage, too,” inasmuch as they might be worrying needlessly. McCarthy asked how many retired NFL players “think they’re walking around right now with a death sentence over their heads.” News flash: NFL players thought that before Bennet Omalu sliced up Mike Webster’s brain in 2002 and before he reported his findings in 2005. They think it while they’re still wearing NFL uniforms. One offensive lineman told me in 2006 that the fear about his mental and emotional future was so great that he and his wife just didn’t discuss it. I’d posit that what’s transpired is making players worry reasonably, not needlessly. Maybe now some will seek medical attention before it’s too late.

As for speculation that alcohol or steroids caused or contributed to the brain disease of Mike Webster or Justin Strzelczyk or Terry Long or any other player, maybe science will some day demonstrate a link. Or maybe that’s just a way to throw up scientific hurdles—Those guys played on AstroTurf a lot. Maybe that’s what gave them dementia. Who knows!—and also to blame the players. The Fainarus don’t ignore the steroids angle. They report that, in 2009, the NFL doctors asked an Alzheimer’s researcher named Peter Davies to examine Omalu’s slides of NFL brains. Davies concluded that the pathology he saw was caused either by repeated head injury, some other systemic factor—“steroid abuse?” he, um, wondered—or an interaction of the two, with the idea being that steroids might make some brains more sensitive to head injuries.

Was that speculation based on better science than Ann McKee’s speculation? Nope. But the league doctors seized on it with glee. “WOW!!! Amazing,” Ira Casson wrote back to Davies. “This seems to raise more questions than it answers.” The Fainarus report that a later study discredited the idea that steroid abuse causes neurodegenerative disease. But it’s still being trotted out as a way to seed doubt. Dave Meggyesy, an NFL linebacker in the 1970s and the author of the classic memoir Out of Their League, wrote this week in an email chain I’m part of that “discrediting the victims, implying alcohol and steroid use was a potential causal factor, is more than obscene, and that is the party line.”

The holistic health of all players is indeed what matters. But from the mid-1990s onward, head injuries became bigger and bigger news, because they were new, and also because former players were losing their minds and, in a few cases, killing themselves. The book and movie are about how brain trauma emerged as a football issue and a social issue, and how the multibillion-dollar enterprise in which they occurred chose to respond to it. 

Engber: Hold on, I wasn’t suggesting that drugs or alcohol caused Webster’s neuropathology. I was proposing that they might have contributed to his early death. That’s an important distinction. The fact that so much of what we know comes from autopsied brains can’t help but push people toward the idea that head trauma is actually killing these guys, when it could well be that the damage causes mild, nonfatal symptoms (or no symptoms at all).

You ask if there’s a downside to all the talk of CTE. I think it’s worse than making players worry over something that they can’t control. If athletes and their families think that symptoms of depression are caused by an as-of-yet incurable brain pathology, they might be less inclined to seek needed psychiatric care. Former defensive back Andre Waters, who shot himself in the head in 2006, hadn’t gotten treatment for his debilitating mental state. “I saw him suffer in silence,” one of his nieces told the Tampa Bay Times.

Anyway, this all bears on the question of whether we’re talking about a Big Tobacco­–style cover-up. Isn’t the league morally culpable for promoting violence, even as it knew that ex-players were ending up with lifetimes of chronic pain and arthritis? Isn’t it wrong for the NFL to glorify “hard hits” and then venue-shop for courts that are unfriendly to players’ disability claims? Don’t players return to games too early after musculoskeletal injuries, too, and thus endanger their long-term health? What’s the special significance of head injuries, when the long-term brain damage might have a much lower prevalence than these other serious problems? There has been a lot of coverage of the BU/McKee data saying that almost every football player’s brain has CTE, but how many players who get concussed end up like Mike Webster, and how many turn out like Steve Young?

Fatsis: I hope Steve Young lives a long and healthy life—love him on the teevee!—but Steve Young doesn’t know how Steve Young will turn out. It’s been obvious that big guys who crash into one another will suffer short- and long-term injuries to bones and joints and muscles since those Harvard boys were dying on the field when Teddy Roosevelt was president. (Players were getting concussed then, too.) The increasingly crippling nature of the NFL began to come under scrutiny in the 1970s and ’80s, when the league started compensating (and fighting against giving compensation to) debilitated retired players. But the sport’s ability to harm its participants’ minds was not yet known, or necessarily even suspected, until more recently. (A 2001 Sports Illustrated story about the broken bodies of retired NFL players, with Johnny Unitas’ gnarled hands on the cover, devoted a total of four paragraphs to “postconcussion syndrome.”) I think it’s natural to make a different moral calculus about the brain. Logically reasonable or not, it’s just more repugnant to think that the guy I’m watching throw a pass or make a tackle could have dementia in 10 or 20 years than it is to think he might need a hip replacement. The players agree. Arthritis at 50? Acceptable risk. Alzheimer’s at 50? Maybe not.

Engber: If those were equal odds, then sure. But what if you were confronted with a 75 percent chance of having arthritis at 50, versus a 2 percent chance of developing early onset dementia? The details matter. What’s clear is that the players should know the risks, from head injuries and joint injuries and steroids, and from the psychological rigors of retiring from a first career while still relatively young.

But the documentary sees everything in terms of the brain. We hear about the rejection of Mike Webster’s application for disability payments, with 100 pages of medical evidence, as if the NFL gave him an especially hard time because he was suffering from a disorder of the mind. The league gives lots of former players a hard time on their disability claims, no matter what their problems are.

Fatsis: Sure, but, again, for narrative and historical reasons, tracing Webster’s story makes sense. His brain was found to have something never before seen in a football player. If Webster is a good example of how disability board handled all claims, that’s an indictment of the NFL period, isn’t it?

Engber: Definitely. But it’s presented as if this was evidence of the NFL’s cover-up of the concussions crisis. No, it’s evidence of the NFL’s long-term, blanket policy of fighting disability claims. I don’t know why we would expect the league to do otherwise, especially when there’s so little pressure on this issue from the media. Instead, the media obsesses over brain injuries, to the exclusion of all else. (Why? Because journalists use their brains to make a living, so I guess brain injuries seem more important.) Anyway, it’s on both the league and the union to get more coverage to people who need it, whatever their condition.

Fatsis: Wait a minute. Webster’s case is presented as evidence of the NFL’s cover-up of the concussion crisis because it arguably was! In 1999, the league’s retirement board ultimately awarded him benefits, finding that Webster’s medical reports “indicate that his disability is the result of head injuries suffered as a football player with the Pittsburgh Steelers and the Kansas City Chiefs.” Was the commissioner at the time, Paul Tagliabue, aware of the retirement board decision? Were the NFL doctors who had asserted and continued for years to assert that there was no connection between playing the game and head injuries (even as players such as Al Toon, Merril Hoge, Troy Aikman, Steve Young, and others were being forced to retired because of them)? We don’t know. But I think it’s fair to say they should have been. You say the media “obsesses” over brain trauma as if it’s a bad thing. NFL brains have received so much media attention in the last few years because the issue was new, the science was evolving, and the images and stories were heartbreaking. But, here, I wrote this New York Times op-ed in 2009 about other NFL health care problems.

Engber: Fainaru and Fainaru-Wada imply that the NFL knew players were dropping like flies from concussion-related brain damage and hired a bunch of charlatans to mislead the public. Maybe it was more like the evidence on this stuff was in the early stages, so the NFL hired a bunch of skeptics who told league executives and the public what they wanted to hear. Tagliabue should have been less defensive and more interested in exploring the possibility that there was a major problem. But is that the same as a cover-up?

Fatsis: Not necessarily, but it’s just as bad. It’s bad science, bad medicine, and bad management. The point isn’t that the league should have known precisely that repetitive blows to the head might lead to early Alzheimer’s. It’s that it should have known that returning a player to a game when that player can’t stand on his own two feet was potentially doing harm, that it should have been more aggressive about doing and embracing actual science, and that it should have protected players better.

Engber: It’s not just as bad, in my opinion. The league was slow to respond, but was it criminally slow? They should have supported and encouraged more research, instead of making blanket denials for the first few years. The money for deeper research came too late in the process. The NFL waited until the commissioner had been hauled in front of Congress, and also until a point when McKee and others had more specimens. When more data had accrued, Roger Goodell changed the rules, handed out millions of dollars for deeper research, etc.

The Fainarus do a great job of showing how compromised the initial MTBI Committee was, but it’s not clear what could have happened instead. Between Omalu’s paper and Goodell’s semicapitulation to the dissenters, we had just three or four years of what we might call “denial.” I guess the NFL should have adopted Dr. Robert Cantu’s return-to-play guidelines right away? They should have banned helmet-to-helmet hits earlier? How much earlier?

Fatsis: I don’t know exactly. And I don’t care. This is about what happened, not what should have happened. The NFL failed to respond quickly and reasonably to an emerging medical crisis, it failed to support and encourage research that might help understand the crisis, it attempted to discredit research that would be viewed as troubling, and it adopted a scorched-earth campaign of denial. That’s all kind of Big Tobacco-y, if not in scope then at least in tactics. And, in understanding the scientific and political and human dimension of what’s happened in football, it’s enough for me.

In any case, I just don’t see how laying out that narrative amounts to journalistic moral certitude. Any reasonable viewer or reader of League of Denial would conclude that no one knew at the time what precisely was killing Mike Webster and other ex-players. Otherwise they might have received better care, and their final years might have played out less tragically. Thousands of autopsies, decades-long longitudinal studies, and other research would help identify precisely why some brains wind up destroyed after years of tackle football. But as the Fainarus and Alan Schwarz of the New York Times and other reporters revealed, the NFL seemed less interested in investigating a potential medical crisis than in covering its ass, for legal, public relations, and business reasons.

If the NFL’s behavior wasn’t so bad—and if the science was so unclear—maybe the league should have rolled the dice in court rather than agreeing to spend $765 million to settle a massive lawsuit. Or maybe it shouldn’t have fought the claims so aggressively and set up a bigger settlement fund and agreed to protect current and future players who succumb to debilitating brain disease, not because a link is proven but because it would be the right thing to do. But, hey, the NFL didn’t admit any culpability. Goodell is quick to remind us of that.

Engber: You say that the argument this documentary puts forward is “enough” for you. Enough for you to do what? Stop watching football?

Fatsis: I like football. I’ve experienced it up close. I won’t stop watching, but I watch now with no small measure of concern and sometimes disgust. I can’t be sure what’s happening inside the heads of the players but, just like Ann McKee, I wonder.