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.