Brain Injury in Football Reaches the Tipping Point

Hello and welcome. I am Dr George Lundberg and this is At Large at Medscape.

Will the linked names of Vontaze Burfict/Antonio Brown and Ryan Shazier/Giovani Bernard be recorded in the annals of sports medicine alongside Ray Mancini/Duk-koo Kim and Larry Holmes/Randall "Tex" Cobb? The latter were icons to brain damage that created epiphanic "tipping points" in boxing. I do not know if the former will do the same, but I think so. Professional American football may well follow professional boxing into disrepute and marginalization.^[1]

Some of you are old enough to remember the media hullabaloo that followed the publication of the January 14, 1983, JAMA editorial^[2] entitled "Boxing Should Be Banned in Civilized Countries." The editorial said, in part:

The principal purpose of a boxing match is for one opponent to render the other injured, defenseless, incapacitated, unconscious. No caring person could have observed the events in professional prizefighting in the past few months and not have been revolted. No prudent physician could have watched the most recent debacle/mismatch on Nov 26, 1982, between Larry Holmes and Randall "Tex" Cobb and believe that the current boxing control system is functioning. The fact that this massacre came on the immediate heels of even more tragic fights serves to accentuate the uncontrolled situation.

This story led the TV evening news, made every wire service and all newspapers plus radio. (For you young folks, this was before the Internet.) Professional boxing back then was a really big deal, leading to worldwide adulation and giant purses for the best boxers and their promoters.

Sidebar: JAMA vs AMA, and a Growing Health Advocacy Voice

The sidebar to the story was that an official American Medical Association (AMA) Council Report published in that same issue disagreed, taking the position that boxing was dangerous; however, it should not be banned but should be better regulated. The public media went nuts with this dichotomy between the AMA and the JAMA positions.

This was my first editorial in which the Journal position was deliberately different from the owner—the AMA—position on anything. My editorship survived, shakily at first, and launched the Journal's ability (between 1983 and 1999) to take on intensely political subjects like prevention of nuclear war, tobacco, guns and violence, abortion, iatrogenic diseases, the autopsy, errors in medicine and patient safety, the medical-industrial complex, universal healthcare, euthanasia, and even complementary and alternative medicine. It was a grand time to be a medical editor with a large platform.

Meanwhile, JAMA became the centerpiece for numerous scientific and clinical articles over many years about boxing's virtues, such as they are (not many), and boxing's harms (many). Following the violence theme thread, I wrote editorials called "Boxing Should Be Banned in Civilized Countries—Round 2" in 1984,^[3] Round 3 in 1986,^[4] and Round 4 in 2005.^[5] These editorials complemented numerous articles on boxing ethics, economics, child abuse, eye damage (common), and other injuries, which then morphed into toughman contests, extreme fighting, and ultimate fighting.

Professional Boxing Continues, With Limits

Of course we were not successful in abolishing boxing. During the next several years, however, organized medicine worldwide came to support the ban. Representing the AMA, and seated next to Howard Cosell, I testified at a congressional hearing, laws were changed in many states, championship bouts limited to 12 rounds, ringside physicians were trained better and given more power, pre-fight medical exams became more rigorous, and referees became more likely to stop fights earlier. But mostly, the public at large, especially parents and children, were warned about the severe dangers, especially of brain damage. The overall result lowered the activity of boxing from its exalted status to a level of disrepute in most developed countries.

It is worth remembering that the original article^[6] describing the "punch-drunk syndrome" appeared in JAMA in 1928, foretelling a vast impending harvest of acute and chronic brain damage from contact-collision sports.

Is Football Any Different?

Over the years, many physicians have asked me why I was so avid in my condemnation of boxing and completely quiet about the hazards of American football. After all, blows to the head damage the brain, whatever the sport and whether or not the person delivering the blow is paid. I have always considered the moral difference between boxing and football to be stark. The best way to win in boxing is to intentionally harm your opponent's brain, a knockout. In all the other sports (except kick-boxing and the current iteration of mixed martial arts) one wins by scoring points, not by deliberately harming the opponent.

Until today, I have never answered those critics. I am biased. I have been in love with American football at least since Harry Gilmer led Alabama's Crimson Tide to a 34-14 victory over the University of Southern California in the Rose Bowl on January 1, 1946. At age 12, I was enthralled by the radio experience. I never stopped loving the Tide. I was a skinny kid but I was fast and I could catch any ball thrown near me. Three broken arms later, I gave up playing. The clarinet in marching band was a lot safer.

So, my huge bias delayed confessing reality. Football blows to the head damage the brain. We now have so much evidence, both clinical and, especially, from autopsies; plus research articles, books, testimonials, documentaries, court cases, and a full-length feature film. Just as in boxing, it is not only the knockout-defined concussions but the multiple repetitive subconcussive blows that tear small blood vessels and brain fibers each time the movable brain bounces around inside the rigid skull.

In boxing, helmets protect the face and scalp from bloody surface damage, but not the brain. It remains to be seen whether any helmet used in football can provide any real brain protection.

My Personal Tipping Point

Watching the recent travesty of the American Football Conference Playoff between the Steelers and the Bengals,^[7] with its horrible officiating, has been my "tipping point." The brutal, vicious, unnecessary head blows delivered by Vontaze Burfict on Antonio Brown and by Ryan Shazier on Giovani Bernard on January 9, 2016, harkened back to the Jack Tatum hit that paralyzed Darryl Stingley in the Oakland Coliseum on August 12, 1978.^[8] That event resulted in real, improved rules to protect the defenseless player.

The current college rules against "targeting" are applied instantly with the high visibility of not only a 15-yard penalty but also expulsion of the assailant from that game and part of the next, unless overturned by rapid review. That has an immediate effect on the game, the player, and the team and can serve as an actual deterrent. It is clear that, despite massive public knowledge about the hazards of serious traumatic encephalopathy, the current National Football League (NFL) leadership is simply not interested or effective enough to protect the safety of the players.

What Can We Do?

I still wish to abolish boxing; it is without sufficient redeeming social value to exist. But football has enough redeeming social value to continue if it cleans up its act. How?

First, continue, expand, and publish research on brain damage from football so policy decisions can be based on best evidence.

Second, apply heavy professional and public pressure on the football community at large, requiring prevention of the known hazards by improving the application of rules that deter concussions and minimize subconcussive impacts, including in practices.

Third, insist that for all players of organized tackle football at any level, there must be a written and fully informed consent (not a joke or a triviality paper to just sign and get on with it, as per usual, or simply a legal "CYA" document) acknowledging the known frequency and severity of brain damage, signed by parents or guardians of players under age 18 years and players themselves if over age 18, as a prerequisite for participation.

These approaches could preserve football as a sport in 2016 and somewhat mitigate problems from personal, family, clinical, public health, and ethical points of view. What happens in the courts is an entirely different avenue for redress and progress. I would expect the liability courts to ask: What did the respective governing bodies (such as NFL, National Collegiate Athletic Association [NCAA], etc, at all levels) know; when did they know it; and what did they do about it?

Considering the many millions of young and aging Americans who are walking around at risk from having played tackle football over the years, I suspect that there is a large enough reservoir of yet-to-be-recognized brain damage out there to bankrupt the NFL, the NCAA, and other major organizations that have failed in their duty to player safety.

That is my opinion. I am Dr George Lundberg, at large for Medscape.

Be sure to read Dr Lundberg's just published opinion piece on this topic in the New York Times.

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