The New Yorker
February 1, 2020
A few years ago, researchers at suny Buffalo undertook a study of twenty-one men who had played either professional football with the Buffalo Bills or professional hockey with the Buffalo Sabres. The men ranged in age from mid-thirties to early seventies; they were studied comprehensively, in all aspects of their health. It turned out that, compared with twenty-one men who’d been involved in swimming, cycling, or running, they suffered from clinical anxiety at a higher rate. In particular, they worried about their minds. They were acutely aware of a type of dementia, called chronic traumatic encephalopathy, or C.T.E., that was afflicting many players in the N.F.L. and N.H.L. The disease had been the subject of extensive media coverage. It could be caused by repeated blows to the head—exactly the kinds of blows they had suffered while playing professional sports.
And yet the Buffalo investigators found that the ex-pro athletes, despite their fears, were no more prone to early onset dementia than the ones who played non-contact sports. Though the study was small, it was presented to and by the media as reassuring proof that worries over C.T.E. were overblown. (“UB study of ex-Bills, Sabres finds CTE ‘much more rare than we thought,’ ” one headline read.) On Twitter, observers began to square off immediately. On one side were critics who saw the study as N.F.L. propaganda; they noted that suny Buffalo was home to the Buffalo Bills team physician, and that the research had been funded by Ralph Wilson, the team’s founder and owner. Barry Willer, the study’s lead investigator, played defense, tweeting that other small studies had arrived at similar results; he labelled the allegation of Wilson’s influence “#fakenews,” pointing out that the owner had died a few years earlier. A former Buffalo Bills free safety named Jeff Nixon—one of the players in the study—waded into the Twitter debate, describing speculations about industry bias as “conspiracy theories.” A Twitter user with the handle ConcernedMom9 objected: “Conspiracy theories? Lots of literature on funding sources.” She quoted from a blog post by Daniel Goldberg, a bioethicist at the University of Colorado Anschutz Medical Campus, which cited research showing that relationships with industry are “extremely likely” to bias physicians and scientists.
Football is both notorious and cherished for its unapologetic, brute-force violence. For decades, getting one’s bell rung on the field was considered unremarkable—even a badge of honor. Everyone knew that whacks to the head could have consequences, but concern was mainly reserved for moderate or severe traumatic brain injuries, or T.B.I.s, which could leave a person permanently impaired, in a coma, or worse. Then, in the mid-nineties, the picture started to change. Physicians and psychologists began to understand that a concussion, a mild form of T.B.I., was a serious medical condition in its own right: dizziness, depression, insomnia, memory loss, and other symptoms could linger for months, even years. More worryingly, by the late two-thousands, new evidence suggested that repeated exposure to subconcussive impacts that didn’t register as problematic in the moment might result in C.T.E. later in life.
In 1928, a medical report described boxers with “punch drunk syndrome.” The symptoms of what would later be called dementia pugilistica (unsteady gait, slurred speech, tremors, mental deterioration) came to be widely understood as the result of repeated, relatively mild blows to the head. In 1949, a British neurologist published a paper titled “Punch-drunk syndromes: The chronic traumatic encephalopathy of boxers”—the first use of the term C.T.E. Over the decades, it was sometimes suggested that dementia pugilistica might befall professional football players, too. But such concerns did not immediately transform the way people saw boxing and football. The sports were already dangerous; a little more danger didn’t matter.
Then, in 2002, a neuropathologist in Pittsburgh named Bennet Omalu examined the brain of Mike Webster, an N.F.L. Hall of Famer who died from a heart attack after a mysterious spiral into mental illness and homelessness. Through a microscope, Omalu, who would later be played by Will Smith in the 2015 film “Concussion,” saw abnormal clumps of a protein called tau; they looked like the lesions that had been seen in punch-drunk boxers. This was, he believed, evidence of C.T.E. in Webster’s brain. Similar clumps were soon detected in the brains of other former N.F.L. athletes who had died in shocking suicides. C.T.E. lesions have since been found in the brains of hockey, soccer, and rugby players, as well. In the preceding decades, interest in boxing had declined; some viewers were put off by the sport’s brutality, others by high pay-per-view fees. Football was now the most popular, most dangerous American spectator sport. In this new context, safety concerns registered more vividly.
The body of evidence linking head trauma to C.T.E. is now damning. “It’s like smoking and cancer,” Bruce Miller, a neurologist and Alzheimer’s expert at the University of California, San Francisco, told me. “It’s as clear as day.” And yet the exact mechanisms through which repeated blows to the head result, decades later, in tau buildup and neurological symptoms, remain unknown. Not everyone exposed to repeated head trauma will develop long-term neurological problems; the danger within any one group of players seems to be distributed unevenly, in the same way that some lifelong smokers get lung cancer and others don’t. (None of the players studied by the Buffalo researchers had developed obvious symptoms of C.T.E.; on the other hand, many were still young and, because they were still alive, their brains couldn’t be examined for tau buildup.) It’s also unclear how many athletes, over all, are at risk. The prevalence of C.T.E. in the pro-football population is unknown—estimates vary, with some approximating two per cent minimums, and others fifteen—as is its prevalence in the population as a whole (people get hit in the head in other ways, too), although the general expectation is that it’s rare. There is even less clarity about C.T.E. risk among college, high-school, and young athletes.
Last year, Fisher-Price was forced to recall the Rock ’n Play Sleeper, a wildly popular collapsible crib in which babies lay at a slight incline. The incline, it turned out, was dangerous; if a baby’s head fell forward, or if she rolled to the side or onto her stomach, her airway could become blocked. At least thirty-two infants had died in the Rock ’n Play since 2011. The decision to recall the sleeper was consequential—nearly five million had been sold—but it was also uncomplicated. When parents buy a sleeper, they expect it to be absolutely safe. There is no such thing as an acceptably risky crib.
High-impact sports occupy a different location in the landscape of risk. Their hazards are part of their attraction. We’ve come to realize that football is more dangerous than we thought—and yet we always thought it was dangerous. Players, coaches, and parents must now ask themselves a series of difficult questions with amorphous answers. How much risk is too much? How much scientific knowledge is enough, when the details are still emerging? How much do you have to know before making up your mind?
ConcernedMom9 is a stay-at-home parent in a small rural town in the Midwest. Several years ago, she and her husband enrolled their son, a third grader, in youth tackle football. (Tackle-football leagues exist for children as young as five.) They knew football was a helmet-clashing, body-bruising sport. But, since it was being offered through school, they assumed that it would be low risk and played in an age-appropriate, minimally injurious way. They were, for the most part, unconcerned.
That changed quickly. At practices, ConcernedMom9 saw how the coaches exhorted the boys to barrel into one another as forcefully as possible. Late one afternoon, during a tackling drill, she heard an ear- splitting crack: her son had smashed face masks with a larger opponent, bouncing backward. The back of his helmet struck the ground. It was his second helmet-to-helmet impact of the practice. A coach hauled him to his feet, but the boy, wailing in pain, was unable to walk off the field. No one stopped the practice or offered medical assistance. She watched in shock from the sidelines, unsure what to do.
For weeks afterward, the boy suffered from headaches and fatigue. The ground swayed beneath him when he closed his eyes; bright lights and loud noises bothered him; he struggled with math and reading at school. It took more than a month for the symptoms to subside. Meanwhile, his mother read about concussions and C.T.E. in the N.F.L. She learned that two other kids in her son’s league had had concussions; the program’s lack of education and oversight on the issue appalled her. She complained to the school district and joined Twitter, where she soon connected with others who were tracking sports-related brain injuries.
Although her son moved on from football years ago, she has become part of a community focussed on the head-injury issue. Her social-media friends include two mothers who filed a suit against Pop Warner for the early deaths of their sons, who played youth football and were diagnosed with C.T.E. in the postmortem. (The case was dismissed by a judge last December.) Since June, 2012, ConcernedMom9 has tweeted a hundred and sixty-one thousand times. Over morning coffee, she still scours Google and her network of connections for relevant developments to post, sometimes querying PubMed, a research database, for pertinent studies. “If a new paper shows up, I’ll just tweet it out,” she told me. In a typical forty-eight-hour period, she might share links, quotes, and retweets of media stories that range from the disturbing (“Volunteer volleyball coach accused of stealing underwear from female players”) to the political (a state bill that would ban youth tackle football before eighth grade). She curates what can seem like an endless stream of injury reports, many involving cringe-inducing blows to the head (“Nazem Kadri Concussed After Taking Big Hits Against Blues”). Moments of scientific controversy, such as the debate around the suny Buffalo study, bob in the stream.
The online debate about sports-related head trauma can sometimes feel like a fistfight: one side might deride findings about C.T.E. as “junk science” and “hysteria,” while the other disparages N.F.L.-affiliated scientists as “shills” who disseminate industry “talking points.” Scandals seem to erupt on a regular basis, adding to the atmosphere of distrust. In October, for example, the sports Web site The Athletic highlighted an analysis, conducted by two researchers, which questioned the scientific integrity of a prominent T.B.I. center at the University of North Carolina, Chapel Hill that received funding from the N.F.L.; the lead researcher and his colleagues described the allegations as baseless, while a nonprofit group that focuses on academic integrity in college sports called for an independent investigation. In January, a Washington Post feature about Bennet Omalu revealed that other leading C.T.E. experts see him as someone who “routinely exaggerates his accomplishments and dramatically overstates the known risks of C.T.E. and contact sports, fueling misconceptions about the disease.”
Even in the absence of scandal, the science of C.T.E. is like an absorbing spectator sport of its own. It’s simultaneously persuasive, contentious, and imperfect. After Omalu and his colleagues reported the initial case of C.T.E. in Webster, a rival research group at Boston University partnered with the Concussion Legacy Foundation, a nonprofit that solicits brain donations from athletes in football and other collision sports. The V.A.-B.U.-C.L.F. Brain Bank became the world’s largest repository focussing on C.T.E. and other traumatic brain injuries. In autopsy after autopsy, a team led by Ann McKee, a neuropathologist at B.U. and V.A. Boston, a hospital run by the Department of Veterans Affairs, has found tau clumps and signs of neurodegeneration. In 2017, in the Journal of the American Medical Association, the V.A.-B.U. team reported on the brains of more than two hundred deceased American football players, including a hundred and eleven former N.F.L. athletes. The researchers found that a hundred and ten of the football players had suffered from C.T.E.
A B.U. publication released an article describing the research; its headline declared, “C.T.E. Found in 99 Percent of Former N.F.L. Players Studied.” More headlines followed, at other outlets, that allowed casual readers to infer that ninety-nine out of a hundred football players were doomed. But the study’s analysis had focussed only on a specific subset of N.F.L. retirees who had undergone such dramatic transformations in mood, behavior, and cognitive status that they or their loved ones had donated their brains for study. (The researchers acknowledged the biases of the data set in their JAMA paper.) William Barr, a neuropsychologist at New York University and a former team clinician for the New York Jets—who, in the early two-thousands, criticized the N.F.L. for its management of concussions, and now provides expert testimony in litigation involving concussions and C.T.E.—told me that, in his opinion, although head trauma in football used to be a neglected issue, the pendulum has now swung in the opposite direction. “People who get hit in the head with a beach ball are coming to me, saying they have a concussion and they’re going to get C.T.E.,” he said.
Almost always, degenerative brain diseases present significant research challenges. Some neurological afflictions—brain tumors, aneurysms—can be detected from outside the skull with X-rays or cat scans. But, at the moment, no brain-imaging technology can reliably detect the unique tau lesions characteristic of C.T.E.; they can only be found after death, in an autopsy. (Some disagreement remains about how to correctly identify the tau lesions in the first place.) Years or even decades may elapse between traumatic head injuries and the onset of symptoms—depression, anxiety, rage, aggression, dementia—that can be caused by C.T.E., but can also result from other, unrelated illnesses.
For now, these complexities make certain questions about the disease unanswerable. If subconcussive blows are the cause of C.T.E., how much impact is too much? How do the tau clumps relate to the clinical syndrome—do the lesions fully explain the mood and memory problems? (Probably not; other kinds of brain abnormalities, such as inflammation or damage to neural wiring from head injuries, may play a role.) Ideally, while trying to answer these questions, researchers would also mount a decades-long study in which they used sensors to measure football players’ exposure to head hits; they would scan the players’ brains monitor their health until they died, and then conduct an autopsy. Such a study would be extraordinarily expensive and time-consuming. There is nothing like it on the horizon.
The uncertainties in concussion and C.T.E. research are typical of any scientific investigation of human disease. They also provide an opportunity for those who want to defend football from its detractors. As the ESPN journalists Mark Fainaru-Wada and Steve Fainaru detail in their book “League of Denial,” from 2013, the N.F.L. attempted to discredit Omalu’s initial diagnosis of C.T.E., demanding that he retract his report. Beginning in 2003, the league’s Mild Traumatic Brain Injury committee produced sixteen scientific papers that, among other things, shrugged off concussions as trivial injuries or suggested that, thanks to a “winnowing process” leading up to the big leagues, N.F.L. players might be less susceptible to traumatic brain injuries than people in the general population. Observers have argued that the N.F.L. was “manufacturing doubt” by financing skewed science. The N.F.L.—which maintains that the committee’s research “was consistent with the medical and scientific understanding of these complicated issues at the time”—argues that it has always sought to advance the science of head trauma.
The N.F.L. has continued to support studies of head injuries, but in ways that have alarmed some researchers. In 2012, it announced that it would donate thirty million dollars to the National Institutes of Health for “unrestricted” independent research—but then tried to stop the institute from awarding more than half of the money to a neuropsychologist in B.U.’s C.T.E. research group. The N.I.H. ended up paying for the study independently. (Other C.T.E.-related work at B.U. has been supported, in part, by millions in N.I.H. grants backed by the N.F.L.) The N.F.L. later dispersed the unallocated sixteen million to other government-supported research projects.
For those concerned about C.T.E., the league’s funding is a double-edged sword. In 2016, the league announced plans to pour sixty million dollars into helmet research and advanced brain-imaging technology; another forty million would go into neuroscience studies. (Some of that money has since been awarded to a Harvard project, called N.F.L. long, that tracks long-term brain health in retired N.F.L. players, and a Canadian surveillance network that counts and studies concussions in high-school athletes.) That year, the budget at the N.I.H. for the study of all traumatic brain injuries was a hundred and five million dollars. Arguably, the league’s funding push has given it outsized influence in the field. In 2018, Kathleen Bachynski, who was a research fellow in medical ethics at New York University at the time, published an Op-Ed in the Los Angeles Times titled “The N.F.L. is the Fox in the Henhouse of Football-Injury Research.” “It would and should raise eyebrows if even the most dedicated, accomplished lung cancer researchers accepted money from Philip Morris to fund their studies,” she argues. Head-trauma research funded by the N.F.L., she contends, “is fundamentally conflicted.”
There are system-wide connections between sports-injury researchers and corporate interests. Beyond the N.F.L., the N.H.L., N.C.A.A., and U.S.A. Football also have extensive relationships with scientists. Many head-trauma investigators serve as scientific advisers or clinical consultants to college or professional teams or leagues, or receive funding from affiliated charities. Many work at universities that derive significant income from N.C.A.A. football. Some serve as paid expert witnesses, for one side or the other, in concussion lawsuits against the N.F.L. and N.H.L. And, at a fundamental level, many sports-medicine clinicians have great affection for athletics. Their goal, usually, is to keep athletes healthy enough to stay in the game.
As ConcernedMom9 correctly pointed out on Twitter, a large body of evidence shows that, even in the absence of quid pro quo deals, studies sponsored by industry players—pharmaceutical firms, food companies, chemical manufacturers, and so on—tend to reach answers favorable to them. In 2009, an Institute of Medicine report cautioned that “financial interests may unduly influence professionals’ judgments about the primary interests or goals of medicine.” In one analysis, for example, ninety-four per cent of review articles by scientists with ties to the tobacco industry concluded that second-hand smoke wasn’t harmful to health, in contrast to thirteen per cent of reviews by independent authors. (The effects of industry funding aren’t always this large.) At well-run research institutions, rules should prevent funders from shaping how studies are designed, carried out, analyzed, written up, and published. But, even if such safeguards are in place, there is still a risk that close relationships with industry may shade how investigators look at data. (Some critics suggest that nonprofits might be sources of bias, too: the researchers at B.U. collaborate closely with an advocacy group, the Concussion Legacy Foundation, which is supported by families whose loved ones have suffered from brain trauma.)
Generally, medical ethicists call on researchers to forego industry funding altogether. Daniel Goldberg, the ethicist that ConcernedMom9 cited, told me that it was a “bad idea” for head-trauma researchers to accept funding from the N.F.L. “If scientists can’t raise non-industry money,” he said, practically yelling into the phone, “then, rather than publish skewed results, they shouldn’t do the research!” (The league, for its part, says that it intends to continue supporting “serious, impactful medical research” regardless of the outcomes of the work it funds.) Many researchers take funding where they can find it. “The money that’s required for research and clinical programs has to come from somewhere, but you don’t want to accept money that has restrictions on it,” Christopher Giza, a pediatric neurologist at the University of California, Los Angeles, told me. Giza is the director of BrainSPORT at U.C.L.A., a brain-injury treatment program that is supported, in part, by a ten-million-dollar gift from Steve Tisch, the co-owner and chairman of the New York Giants. The program is part of a $52.5-million multi-center concussion study sponsored by the N.C.A.A. and the Department of Defense. Giza also receives funding from the N.I.H. In line with U.C.L.A. policies, he doesn’t take grants with preconditions that infringe on his academic independence, and he fully discloses the sources of his funding.
Giza occupies a middle ground in the world of C.T.E. research. He doesn’t deny that C.T.E. exists, and said that it’s “quite likely” that it’s triggered by brain injuries, but he is wary of media hype. In his view, analysis of C.T.E. has become polarized. “When we sort of force people to take sides one way or the other, it blurs our view of what the real truth is,” he said. On Twitter, meanwhile, his industry connections haven’t escaped notice. When, in a news story last year, Giza commented that the link between youth football and long-term brain injury is difficult to prove, a former professional hockey player named Daniel Carcillo, who is himself part of a class-action concussion lawsuit against the N.H.L., tweeted, “Can he be trusted?” (Giza and Carcillo have since made amends.)
In the nineteen-fifties, an eminent statistician named Ronald Fisher argued that smoking didn’t cause lung cancer. Instead, he conjectured, an undiscovered third factor, perhaps genetic, both caused lung cancer and, coincidentally, drove people to crave smoking. Adam M. Finkel, an environmental-health scientist and expert on risk assessment at the University of Michigan School of Public Health, described this logic as “Fisher’s fallacy”: “It’s just a way to wave your hands around and ignore what’s in front of your eyes,” he told me. In Finkel’s view, many C.T.E. skeptics are waving their hands around. Some, for instance, have speculated that opioid abuse, not head trauma, may be the cause of the disease. There isn’t a lot of evidence to support that idea, but, for the moment, it’s impossible to disprove. It’s probable that, in the end, several factors will be found to contribute to C.T.E., because diseases are almost always multifactorial. But that still wouldn’t exonerate head injury as the major culprit.
To some extent, the dissension over C.T.E. reflects two different perspectives from which we can view disease. Clinicians tend to focus on one patient at a time; when faced with incomplete evidence, a doctor may prefer to refrain from speculation, to avoid making an incorrect diagnosis. By contrast, Finkel said, public-health analysts tend to make decisions based on probabilities, weighing the risks and benefits of taking protective actions in an effort to intervene before it’s too late. It might take fifty years of research to figure out exactly how blows to the head cause C.T.E. “A public-health person would never say, ‘We can wait fifty years,’ without thinking about the consequences of putting the decision off for that long,” Finkel said. He argues that football is so ingrained in American life that C.T.E. is best seen through the lens of public health.
A few years ago, the Harvard Football Players Health Study—which recently announced, having surveyed thousands of N.F.L. retirees, that athletes with longer careers showed more severe cognitive deficits—wanted to assess whether, in theory, O.S.H.A. could play a role in protecting pro athletes from head trauma. (The study was funded by the N.F.L. Players’ Association.) Its leaders hired Finkel, who used to be the chief regulatory official at O.S.H.A. Using the data from the 2017 B.U. report—which had posthumously diagnosed a hundred and ten N.F.L. players with C.T.E.—Finkel and the neuroscientist Kevin Bieniek made a back-of-the-envelope attempt to approximate the lowest possible risk of C.T.E. in the league. They started by presuming, conservatively, that B.U. had identified every single case of C.T.E. that had or would ever occur among N.F.L. athletes active from the nineteen-sixties to the mid-two-thousands. They then compared B.U.’s number to the total number of players who participated during that same time period. O.S.H.A. is empowered to regulate on-the-job risks that give workers at least a one in a thousand chance of becoming seriously ill; Finkel and Bieniek estimated that the risk of C.T.E. among professional football players is, at least, somewhere between six in one thousand and seventeen in one thousand. If the true prevalence of C.T.E. falls somewhere within this range of minimum estimates, the disease would be rare enough to evade small studies, such as the one conducted at the suny Buffalo, while remaining a serious occupational health problem. (There are, of course, many ways of arriving at a risk estimate. Using an alternative method—one focussed not on the projection of minimum risk but on the proportion of players who have died because of C.T.E.—Finkel calculated that the prevalence of the disorder may be closer to fifteen per cent. Other researchers have arrived at even higher numbers.)
Parents trying to evaluate the risks of youth football might find themselves bouncing between these different views of disease—fielding advice from a clinician one day and a public-health advocate the next. On the Web site for Football Matters—a campaign started by the National Football Foundation—a section about C.T.E. is reprinted from a fact sheet prepared by a panel of neuropsychologists, most of them affiliated with professional or school sports teams and leagues; the site concedes that “it appears appropriate to take reasonable measures” to avoid head trauma, while noting that “no clear-cut, definitive cause and effect relationship has been established” between hits to the head and C.T.E. Meanwhile, last fall, the Concussion Legacy Foundation released a video titled “Tackle Can Wait.” The P.S.A. suggests that parents should look at youth football the same way they look at smoking—the video shows young players standing on the field and lighting up—and then warns that starting kids in tackle football at age five, rather than fourteen, leaves them ten times more likely to develop C.T.E. (It’s tough to know how to judge such a claim, since the absolute risks remain unknown.) In an Op-Ed anticipating the P.S.A., Robert Cantu, the foundation’s co-founder and a researcher at B.U., made a public-health argument: the Surgeon General, he wrote, should ban tackle football for young children.
In a now-classic bit, the comedian George Carlin undertook a comparison of baseball and football. Baseball, he noted, is played in a “park”; football, on a “gridiron.” Baseball starts “in the spring, the season of new life”; football begins “in the fall, when everything is dying.” The games have starkly different objectives. “In football, the object is for the quarterback, otherwise known as the field general, to be on target with his aerial assault, riddling the defense by hitting his receivers with deadly accuracy in spite of the blitz, even if he has to use the shotgun,” Carlin said. “With short bullet passes and long bombs, he marches his troops into enemy territory, balancing this aerial assault with a sustained ground attack which punches holes in the forward wall of the enemy’s defensive line.” The object in baseball, by contrast, is “to go home! And to be safe! . . . . Safe, at home!”
In November, Bachynski, the public-health researcher who called the N.F.L. the “fox in the henhouse” of concussion research, published “No Game for Boys to Play: The History of Youth Football and the Origins of a Public Health Crisis.” Parents, players, fans, and physicians, Bachynski writes, have always wrestled with the violence of football and its consequences. In the early nineteen-hundreds, players died in savage Ivy League games, which one critic described as “boy-killing, education prostituting, gladiatorial sport.” By instituting new rules and introducing protective padding and helmets, officials tried to make the game safer; Bachynski suggests that such changes, by emboldening players, may have actually made it less so. In any case, football remained a spectacle combining balletic grace with extreme collisional assault—its immense popularity “deeply tied to the very violence that renders the game dangerous.”
In the nineteen-fifties, when football programs for children younger than high-school age first began to gain ground, many doctors, focussing mainly on bone and joint injuries, argued that the risks were too great. Defenders argued that the game could be safe, as long as kids were supervised by coaches, athletic trainers, and physicians in the newly emerging field of sports medicine. Invariably, these authority figures were male: football was and remains gendered—“a means,” Bachynski writes, “of teaching boys to become men.” In a sport that was seen as character-building and capable of instilling toughness, even patriotism, it was possible for some quantity of danger to be seen as an asset.
Assessing risk is like balancing an equation: benefits go on one side, perils on the other. C.T.E. threatens to destabilize an equation that, in the past, has allowed more than three million American kids to play tackle football each year. The risk of physical injuries, such as broken legs and torn ligaments, used to seem acceptable, given the merits of the game. But now players and their adult guardians must incorporate the uncertain prospect of irreparable brain damage, which reveals itself decades later, into their calculations. It’s one thing to be injured in the moment; it’s another to live for years with the spectre of possible harm still to come. And C.T.E. may change the risk equations of younger players more. It’s true that youth and high-school football tend to involve collisions of less force and intensity than the ones in college and professional sports. But kids’ brains are still maturing; compared to adults, their heads are bigger while their neck muscles are weaker. These biomechanical vulnerabilities make them more susceptible to repeated head injuries than adults.
In many risk equations, certain variables must go without assigned values. It’s not possible to conduct a randomized, controlled trial that measures the long-term effects of knocks on children’s heads; in the absence of such a trial, the existing evidence of long-term neurological harm in youth football is mixed. A Wisconsin-based study found that playing high-school football in the mid-nineteen-fifties wasn’t associated, on average, with a higher occurrence of cognitive impairment or depression in old age. (But the game has changed, in many ways, since then.) In contrast, in its latest paper, published in the fall of 2019, the B.U. group reported identifying C.T.E. in at least eighteen former athletes who had only played youth or high-school football, including a teen-ager who died after suffering two concussions in a single week. Over all, the brain-bank analyses suggest that the risk of being diagnosed with C.T.E. at death generally increases with each additional year of playing tackle football. There’s a reason that public-health analysts, when faced with imperfect scientific information, tend toward pessimism: they’re entrusted with the task of safeguarding the citizenry, so they err on the side of safety. Parents may find themselves in an analogous position.
It’s possible that, for many people, adjustments here and there could rebalance football’s risk equation. The N.F.L. has adopted new rules and safety protocols to reduce head injuries: in 2013, for instance, it banned players from initiating contact with opponents using the crown of the helmet. (The number of reported concussion in the league rose slightly last year, after a decrease from 2017 to 2018.) In recent years, every state has passed laws aimed at improving the management of concussions in youth sports. U.S.A. Football, the governing body for amateur play, has promoted “heads up” tackling techniques; it’s also introduced concussion safety training for youth leagues. But no one knows if these changes will be enough. A few state legislatures, including ones in New York and Massachusetts, are considering banning youth tackle football under age twelve altogether.
This past fall, as football season got underway, ConcernedMom9 tweeted about news stories in which coaches claimed that changes to the game had made it safer than ever. “What would we expect coaches to claim?” she wrote. She questions whether local leagues are properly putting the safety reforms into practice. Over time, she has come to a new understanding of football’s risks. Research has been finding that head trauma is also a risk factor for Alzheimer’s, Parkinson’s, and other degenerative brain disorders; considering the medical history in her family tree, she wishes she’d known this before signing her son up for youth football. She reads new stories about serious injuries among professional and amateur players—concussions, spinal injuries, ruptured spleens—and thinks of how the perils of the sport now extend into the realm of the mind, pushing some former players into an irreversible fog of darkness and forgetting. “There’s enough carnage out there that, personally, I’m questioning what this game is doing in our public-school system without meaningful changes,” she said. The game hasn’t changed. She has.