League of Denial: Dan Engber and Stefan Fatsis debate the Frontline documentary on the NFL and concussions.

Debating the Frontline Documentary on the NFL and Concussions

Debating the Frontline Documentary on the NFL and Concussions

The stadium scene.
Oct. 11 2013 12:38 PM

Did League of Denial Get It Right?

Debating the Frontline documentary on the NFL and concussions.

(Continued from Page 1)

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?