ADAPTED from League of Denial: The NFL, Concussions, and the Battle for Truth. Copyright © 2013 by Mark Fainaru-Wada and Steve Fainaru. To be published by Crown Archetype, a division of Random House LLC, on Oct. 8.
Late in 1994, NFL commissioner Paul Tagliabue appeared with two other commissioners, the NBA's David Stern and the NHL's Gary Bettman, in the auditorium at New York City's 92nd Street Y to discuss the state of their respective leagues. The panel's moderator was the journalist David Halberstam, who had gone on to a career of writing books, including several about sports, after winning the Pulitzer Prize for his coverage of the Vietnam War for The New York Times.
After dispensing with questions about labor relations and league finances, Halberstam turned to the NFL's growing concussion problem. Tagliabue dismissed the matter as a "pack journalism issue" and claimed that the NFL experienced "one concussion every three or four games," which he said came out to 2.5 concussions for every "22,000 players engaged."
For Halberstam, it was a moment of déjà vu. He seemed to be taken back to the days of the Five O'Clock Follies, the name the Saigon press corps bestowed upon the surreal, statistics-crammed U.S. government press briefings. Halberstam compared the NFL commissioner with the U.S. defense secretary of the 1960s. "I feel I'm back in Vietnam hearing [Robert] McNamara give statistics," he told the audience, which howled.
Not long afterward, the NFL announced its own scientific initiative. At Tagliabue's behest, the league said, it was assembling a committee of experts to study concussions. It would be called the Mild Traumatic Brain Injury (MTBI) committee. The name itself, some researchers said, suggested the NFL's benign view of the problem.
In fact the committee, which held its first meeting in February 1995 at the NFL combine in Indianapolis, was made up almost entirely of NFL insiders. Nearly half the members were team doctors, the same men who had been sending concussed players back on the field for years. There were two trainers, a consulting engineer and an equipment manager. The committee did have one neurologist, Ira Casson, who had studied boxers and had made the recommendation to Jets receiver Al Toon that he retire in 1992 because of concussions, and a neurosurgeon, Hank Feuer, who worked for the Colts. The committee's epidemiologist -- the man charged with analyzing much of the committee's research -- was John Powell, the numbers cruncher behind the NFL's claim that concussions had held steady at one every three or four games.
The most perplexing choice was Tagliabue's handpicked chairman: Elliot Pellman. With the commissioner's endorsement, Pellman, the Jets' team doctor, had instantly become one of the most influential concussion researchers in the country, yet he had not produced a single piece of scientific literature on the subject. This was almost certainly due in part to his medical specialty, rheumatology, which deals primarily with bone and joint disorders such as arthritis. Pellman was genial and stout, a balding 41-year-old routinely described by colleagues as "a good administrator." Through his contacts with the NFL, Pellman would also come to work as a top medical adviser with other leagues, including the NHL and Major League Baseball. One executive who worked closely with Pellman described him as a kind of medical "concierge" whose primary responsibilities were to administer flu shots and recommend specialists.
The most complete professional biography of Pellman would be assembled years later by The New York Times after the newspaper discovered in 2005 that he had exaggerated his credentials in a biography he had sent to a committee of the U.S. House of Representatives. Pellman had claimed that he obtained his medical degree from the State University of New York at Stony Brook. In reality he had attended medical school in Guadalajara, Mexico, and received his medical degree from the New York State Department of Education. He also reported that he was an associate clinical professor at New York City's Albert Einstein College of Medicine, when, in fact, he was an assistant clinical professor, an honorary position held by thousands of doctors, and didn't teach at the school.
Pellman's views on concussions were perfectly aligned with NFL doctrine at the time. In 1994 he told SI that "concussions are part of the profession, an occupational risk." Former players described how Pellman, as the Jets' doctor, often allowed concussed athletes back on the field. One running joke on the team involved three words -- Red Brick Broadway -- that Pellman had players recite to determine if they were able to play after a concussion. According to Kevin Mawae, who played center for the Jets for eight seasons, "The three words were always the same. He would leave you and come back before the next series, and you'd go, 'Red Brick Broadway. I'm ready to go.' "
Once, Mawae said, he took a knee to the head and blacked out. "Next thing I know I'm laying prostrate on the ground," he said. After performing a "systems check," Pellman and the Jets' medical staff allowed Mawae to return for the next series, but the player says "my teammates were telling me that I was making calls that weren't even in our playbook."
Multiple sources said Pellman had been Tagliabue's personal physician, and they believed that was partly why he was named chairman of the MBTI committee. "That's my understanding," said Mark Lovell, a Pittsburgh neuropsychologist who worked with the Steelers and joined the committee at its inception. In a statement to ESPN, Tagliabue acknowledged being treated by Pellman but not until October 1997, three years after the formation of the MTBI committee. The commissioner said Pellman got the job "based on his experience in sports medicine ... and recommendations from Jets ownership and management." The committee didn't publish its first research until October 2003 -- six years after Tagliabue became Pellman's patient. Pellman would continue as one of the commissioner's personal doctors until '06.
Lovell was put in charge of setting up the NFL's neuropsychological testing program, which he based on the model that he and Joseph Maroon, a Pittsburgh neurosurgeon, had created for the Steelers. The league gave Lovell $12,000 in seed money to spread the gospel of neuro-psychological testing. He traveled from city to city, team to team, armed with a letter of support from Tagliabue, who wrote, "We strongly recommend that all clubs in the NFL implement such a testing program so that neuropsychological data is available to club physicians, or other treating physicians, in the event of player concussions."
By the end of 2001, the NFL had gathered a wealth of data on concussions in the league. All but three teams -- the Vikings, Panthers and Cowboys -- were using some form of the Lovell and Maroon test battery. The MTBI committee had conducted biomechanical reconstructions on crash-test dummies and completed a six-year epidemiological survey involving hundreds of players. The committee was ready to publish its research. But where?
There are hundreds of scientific and medical journals dealing with issues involving the brain, sports or both. But only one had an NFL consultant as its editor in chief. Michael L.J. Apuzzo was a professor of neurosurgery at USC who in 1992 had been appointed editor in chief of Neurosurgery, the journal of the Congress of Neurological Surgeons. Apuzzo's specialty was stereo-tactic neurosurgery, which uses three-dimensional mapping to place probes deep inside the brain. He had produced a 2,540-page textbook titled Brain Surgery: Complication Avoidance and Management and helped design instruments for microsurgery.
Some people around the NFL also considered Apuzzo something of a jock sniffer. Among his many endeavors, Apuzzo worked the sidelines as a consultant to the Giants. He was clearly thrilled by his association with the NFL. After working the 2001 Super Bowl between the Giants and the Ravens, Apuzzo told an interviewer, "When I was in the military I worked in a nuclear-powered submarine where we'd be submerged for three months doing very dangerous things. We were dependent on each other for life and death, and it was an extremely moving bonding experience. Until this game I'd never experienced anything else like it."
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Apuzzo wanted to expand Neurosurgery's readership and impact by moving the journal into what he called "an 'avant-garde' progressive position and internationality." That included putting abstract art on some of the covers and establishing a section on sports and the brain. Bob Cantu was his pick to edit the section. He was the logical choice. One researcher called Cantu "the King of Concussions." He had been looking into the relationship between sports and head injuries for perhaps as long as anyone alive. In the mid-1980s, Cantu was chief of neurosurgery service and chairman of the department of surgery at Emerson Hospital in Concord, Mass.; for fun, he worked the sidelines at high school football games. Cantu quickly realized there were no guidelines for how long a player should sit out after a concussion, and so he decided to come up with some himself. One of his sources of inspiration was an experiment in which UCLA researchers had bashed rats in the head and then checked their glucose levels, glucose being the chemical that powers the brain. The levels stayed depressed for an average of five days but sometimes as long as 10, a possible indication of how long it might take to recover from a concussion.
By the time Apuzzo tapped him as Neurosurgery's sports-section editor, Cantu had written dozens of papers on concussions and the criteria for returning to play. He believed the NFL's research was a perfect candidate for the sports section of Neurosurgery, and he suggested that the MTBI committee submit its first paper to the journal. It was published in the October 2003 issue under the title "Concussion in Professional Football: Reconstruction of Game Impacts and Injuries." The paper suggested, among other things, that the standards used to measure the effectiveness of football helmets in preventing head injuries should be reassessed. It also indicated that many injuries occurred when players got hit in the face mask and the side and back of the helmet. This was progress, Cantu believed. In a review appended to the article, he called the NFL's first paper "the most extensive study to date on the biomechanics of athletic concussion in football" and an "exciting, innovative and unique study."
Three months later, the NFL published another study in Neurosurgery. This second paper -- "Concussion in Professional Football: Location and Direction of Helmet Impacts" -- drilled down on where the concussive blows were delivered. Again it was illuminating. Pellman received credit as lead author. The league found that 71% of the concussive blows were being struck on the side and back quadrants of the helmet. Again the reaction to the paper was positive. Julian Bailes, a West Virginia University neuro-surgeon who had found that alarming numbers of retired NFL players had signs of dementia, wrote that the NFL had "ushered in a new era in the study and analysis of the many nuances of these high-speed bodily collisions."
Then, in the next issue of Neurosurgery, the league published NFL paper number 3. This one was different.
This time, Pellman, et al., had taken their six years of research and used it to paint a panorama of concussion in professional football. It was in many respects a very pretty picture. The NFL didn't have much of a concussion problem, the study concluded. The injury occurred about once every three games -- a rate strangely similar to the statistics spouted by Tagliabue and the NFL's p.r. department for a decade. When concussions did occur, 92% of all players returned to the field in less than seven days -- that is, they never missed a game. Pellman and his fellow authors interpreted this as an indication that concussions were minor events whose symptoms went away quickly with few, if any, long-term consequences.
The response from the scientific community was guarded, even puzzled. Many researchers noted the obvious flaw that blew an enormous hole in the NFL's claims that concussion rates were low: the reluctance of players to report their injuries to coaches and team medical personnel.
Nine months later came yet another NFL study in Neurosurgery. This one dealt with repeat concussions. Numerous previous studies had shown that one concussion left the brain vulnerable to another concussion if the brain wasn't given time to heal. But that wasn't a problem in the NFL, according to Pellman, et al. The league looked at how quickly players went back on the field and concluded that they were at no greater risk than if they had never been concussed at all. The logic was that because players returned to the field so quickly, they must have been O.K. or the medical staff wouldn't have cleared them. This flew in the face not only of previous research but of widely known realities on an NFL sideline. First, players often didn't report their injuries. Second, they hid their symptoms whenever they could. Third, NFL doctors often deferred to the wishes of coaches and players.
For the first time, the NFL also took on the issue of football and brain damage, a growing concern among researchers. The league's scientific opinion? This wasn't a problem in the NFL either. Boxers got brain damage. Football players didn't. It was as simple as that. "This injury has not been observed in professional football," Pellman and his colleagues wrote.
That was technically true: No one had yet cut open the skull of a dead football player to examine his brain for signs of neurodegenerative disease. But that day was coming.
Before NFL paper number 4 was published, Cantu sent it around for peer review. Bailes and University of North Carolina neuro-scientist Kevin Guskiewicz, whose own research was beginning to suggest that football-related concussions had serious consequences, could hardly believe what they were reading. They informed Neurosurgery that they were rejecting the paper's major findings. They weren't alone. Even Cantu had misgivings about the paper's conclusions and its scientific underpinnings.
In most peer-reviewed journals, rejection by a preponderance of reviewers -- particularly the assigning editor -- is usually more than enough to prevent a paper from being published. But Neurosurgery, at Apuzzo's direction, used a different process. Reviewers could raise their objections in a comments section appended to the paper, but the paper itself would stand. The comments on NFL paper number 4 were scathing. Guskiewicz called the NFL's conclusion that repeat concussions were of no real consequence "potentially dangerous." Cantu himself wrote, "At first glance, the NFL's experience with single and repeat concussion (no difference) and management (more than 50% of players return to the same game, including 25% of those with loss of consciousness) seems to be at odds with virtually all published guidelines and consensus statements on managing concussion."
The fact that the comments were published provided no solace to the reviewers. "Who reads the commentaries?" said Guskiewicz. "It's a published paper. It became the gospel." The league's research arm could hardly have staked out a more aggressive position. And it was just getting warmed up.
The NFL rolled out paper number 5 in Neurosurgery in November 2004. Paper number 5 dealt with the modest 8% of players who had missed at least one game because of a concussion, described by Pellman and his colleagues as "the most severely injured of the NFL concussion cases." Who were these players, and what happened to them? They were mostly quarterbacks, defensive backs, wide receivers and kick returners "injured in high-speed, high-acceleration collisions." Although this observation ignored the violence taking place at the line of scrimmage on every down, it made some sense. The players on the perimeter were being hit with extraordinary g‑forces. Not surprisingly, they had more acute symptoms: lingering memory loss, disorientation, sensitivity to light, lethargy.
From there, Pellman and his colleagues went on to draw a number of conclusions that left some of the nation's leading concussion researchers shaking their heads in wonderment. One finding was that even these severely injured players recovered very quickly and, when they returned, were not at greater risk for further injury. This ran counter to nearly all previous research, which held that one concussion left you predisposed to another. But the NFL's logic was the same as in the previous studies: The fact that players went back on the field was an indication that they were fine. "NFL team physicians and athletic trainers are extremely effective in screening out the most severely injured players on the sidelines within a short period of time after injury," and they might actually be "overly conservative and cautious," Pellman and his colleagues posited. "This 6-year study indicates that no NFL player experienced ... cumulative chronic encephalopathy [brain damage] from repeat concussions. While the study did not follow players who left the NFL, the experience of the authors is that no NFL player has experienced these injuries."
Not even the NFL believed that last statement to be true. In October 1999, the league's retirement board had determined that Hall of Fame center Mike Webster had suffered irreparable brain damage from repeated concussions related to his career. At the time Webster, who played for 17 years, was often delusional. He sometimes slept in his truck, put himself to sleep with a stun gun and fantasized about shooting NFL executives with an arsenal of weapons he kept under his bed. Webster's cognitive difficulties, the board wrote, were "the result of head injuries [he] suffered as a football player with the Pittsburgh Steelers and Kansas City Chiefs." Now, two years after Webster's death, as his lawyers pressed the board for more money for his family, they obtained confidential documents that showed, among other things, that the NFL retirement board had granted benefits to several other players with long-term brain damage. One document produced by the league showed that the same board had awarded permanent benefits to at least two other players whose doctors concluded they had gotten brain damage from playing pro football. The board redacted the names of those players, and the document was stamped CONFIDENTIAL.
If Hollywood talent scouts set out to create a reality series on the search for football-related brain damage, they would start with Ann McKee. She was in her 50s, with blonde hair and blue eyes, a Green Bay Packers nut from Appleton, Wis., with a girlish giggle and a knack for making the brain accessible and fun. Describing how she removed a brain for study, McKee would say, "The brain is very delicate. You can't just yank it out. We deliver it like we deliver a baby." Seeing a fresh brain is "always a little bit like Christmas," she said. "It's like, What do we have here?" Watching the telegenic McKee slice into a formalin-fixed brain was a little like watching Rachael Ray carve up a cured ham.
McKee was not an athlete, but she grew up surrounded by them. Her father had played football at Grinnell (Iowa) College. Her older brother Chuck, whom she idolized, had been a three-sport athlete who turned down a scholarship at Wisconsin because he didn't want Division I football to distract him from becoming a doctor. He played quarterback at Lawrence University, leading the Division III school to consecutive conference titles and earning All-America honors. Ann McKee had been a cheerleader at Appleton East High. A tomboy, she had played backyard football with her siblings.
McKee graduated from Wisconsin and enrolled in medical school at Case Western Reserve in Cleveland. It was there that she developed her love of the brain. McKee found it endlessly fascinating, the source of all humanity. She gravitated to neuropathology. She saw a connection between her first college major, art, and the patterns of brain disease. When she looked at the spread of tau, the protein that strangles brain cells in neurodegenerative diseases such as Alzheimer's, she couldn't help but admire it. She used words like pretty and lovely to describe the infinite patterns that tau formed. "I was a fanatic about tau," McKee said.
That made her perfect for Chris Nowinski, a Harvard graduate and former pro wrestler who had formed the Sports Legacy Institute, a brain-research group affiliated with the Boston University School of Medicine. Nowinski was looking for a neuropathologist to analyze brains for chronic traumatic encephalopathy (CTE), a disease that had been found in Webster and two other former NFL players. Nowinski feared the disease was widespread. McKee would have a unique understanding of CTE, a tau-based disease. Her passion, along with brains and art, was football. Her cluttered office at the Department of Veterans Affairs complex in Bedford, Mass., outside Boston, was filled with Packers memorabilia, including a Brett Favre bobblehead doll and a cheese-head resting atop a plastic heart.
Nowinski told McKee she could probably have as many Christmases as she wanted. He said he would go out and get the brains for her. McKee couldn't believe her good fortune.
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Nowinski got McKee her first brain in February 2008. It belonged to a former linebacker, John Grimsley, who had played in the NFL from 1984 to '93, mostly with the Oilers. Grimsley had a reputation as a hard hitter with a mean streak, the archetypal linebacker. About a decade after he left the game, his wife of nearly 25 years, Virginia, started noticing changes in her husband. First came short-term memory problems: forgetting why he went to the store, renting the same movie over and over. Then came the mood swings—anger and irritability. He would lose his temper without any warning or provocation.
Grimsley died at 45. He shot himself in the chest. Police ruled it an accident. It appeared that he had been cleaning his pistol. Virginia told the Houston Chronicle that her husband had bought a new handgun with which he wasn't familiar. "Anyone could tell you that John would not take his own life," she said. "He was a happy guy." Two days later, Nowinski called and asked to examine Grimsley's brain.
When McKee peered into the microscope after staining the brain for tau, she was stunned. There was tau everywhere, "like disease on steroids," she said, but there was no trace of beta-amyloid, one of the main components of Alzheimer's. McKee would never forget that moment. "You feel like, Oh, my God!" she said. Her first call was to her brother Chuck, the doctor. Ann explained the disease she had found in Grimsley's brain. It looked just like dementia pugilistica, a brain disease first discovered in boxers in the late 1920s. Chuck's response would stick with Ann for years. "This is going to change football," he said.
On May 25, 2008, another former NFL player died young: Tom McHale, 45, who had spent nine years in the league as a 6' 4", 290-pound offensive guard before retiring after the 1995 season. He died of a drug overdose. By then the story had become familiar: At the time of his death the once thoughtful and friendly McHale "was very, very different from the guy I married," his wife, Lisa, said. "It was like he was a shell of his former self," with the often vacant and disheveled look of a man who no longer cared.
McHale's brain tissue was analyzed by McKee and, separately, by Dr. Bennet Omalu, who had discovered football-caused CTE when he analyzed Webster's brain in 2002. Both he and McKee found CTE in McHale's brain. McHale was the sixth deceased NFL player found to have CTE.
At a press conference organized by Nowinski in Tampa in January 2009, the week before Super Bowl XLIII, McKee pointed out the brown splotches of tau that had eaten away at McHale's identity. This looked like the brain of a 72-year-old former boxer. "I have never seen this disease in the general population, only in these athletes," McKee said. "It's a crisis, and anyone who doesn't recognize the severity of the problem is in tremendous denial."
Not long after, McKee's phone rang. It was the NFL calling.
The message was from Ira Casson, who had replaced Pellman as co-chair of the MTBI committee. Casson, a combative New York neurologist, had earned the nickname Dr. No after repeatedly and emphatically denying to HBO's Real Sports in 2007 that football caused dementia, Alz-heimer's or any other neurodegenerative disease. McKee had never met Dr. No, but, she says, "I knew he wasn't a friend."
McKee returned the call nervously. Casson was pleasant and said the members of the MTBI committee wanted to invite her to New York City to present her work. McKee welcomed the idea; she hoped to persuade the NFL that CTE was something to which it should pay attention.
McKee invited along Nowinski and Daniel Perl, director of neuropathology at the Mount Sinai School of Medicine and a consultant to BU's Alzheimer's Center. Perl was expecting a straightforward academic presentation, the audience respectful and curious. "I didn't appreciate the political implications, O.K.?" he later said drily.
As McKee, Nowinski and Perl entered NFL headquarters on May 19, 2009, McKee was in awe. It was Cheesehead heaven. There was the Lombardi Trophy, a trove of Green Bay Packers memorabilia, Jim Brown's old jersey. There was a waiting room with lined green turf. Even Perl, a casual fan, was impressed.
The trio was ushered into a huge boardroom with a lacquered table surrounded by plush chairs. As some two dozen participants took their seats, McKee noticed that she was one of just two women in the room; the other turned out to be an NFL lawyer. Along with the MTBI committee members, there were a few other guests, including John Mann, a Columbia University neuroscientist and psychiatrist who specialized in suicide research; and Col. Michael Jaffee, the national director of the Defense and Veterans Brain Injury Center. One of the lawyers present, the visitors later learned, specialized in class-action litigation. "They were thinking about it already," Nowinski said.
McKee had prepared a PowerPoint presentation, but she also brought along a box of lantern slides with four-by-five-inch slivers of brain the doctors could hold up to the light. She passed those around first, and it quickly became clear that this was not going to be the academic discussion Perl had anticipated. Members of the MTBI committee seized on the absence of visible bruising to question how football-related head trauma could have caused the disease. If there was no contusion, there was no trauma. But no contusions was the point: Almost all the NFL brains had looked normal from the outside. This wasn't a disease caused by a single blow or even a few. The brain was deteriorating from the inside, McKee believed, as a result of repetitive pounding.
McKee turned to the slides. She pointed out the brown splotches representing neurofibrillary tangles of tau protein that had suffocated the cells. The tangles were indisputable signs of disease, and there was little or no beta-amyloid, which meant it wasn't Alzheimer's. And these were relatively young men with one common trait: All had played football for years. Members of the committee again challenged her. Some wanted to know why the tangles weren't closer to the surface of the brain, where the trauma had occurred. To many in the room, Casson seemed especially combative. "Casson interrupted the most," said Colonel Jaffee. "He was ...at times mocking. These were pretty compelling neuropathological findings, so to outright deny there could be a relationship, I didn't think [Casson] was really making an honest assessment of the evidence."
Hank Feuer, the Colts' physician and a charter member of the committee, sat across from McKee. "I honestly don't think we were any different with her than we were with anybody else," he later said. But the guests were increasingly uncomfortable with the line of questioning.
To Mann, the Columbia suicide expert, it was obvious that McKee had found a serious brain disease in these players. After she finished, Mann presented his own research, describing data that showed how people who had had mild head injuries as children or adolescents were at an increased risk for suicidal behavior. Casson tossed up his hand and interrupted. "It would be impossible to link a disease like CTE to suicide," he asserted.
"It's not just possible," Mann replied, "it's entirely plausible based on what I've seen from Ann McKee."
McKee was asked whether CTE wasn't just a "misdiagnosed case of frontotemporal dementia," a disease of the brain's frontal lobe. She replied, "Well, I was on the NIH committee that defined frontotemporal dementia's diagnostic criteria, so, no."
McKee had experienced heated debate before, but this, she thought, was almost personal. "I felt like they weren't really listening," she said, "like they had their heads in the sand." Casson, Pellman and others bombarded McKee and Perl with alternative theories: steroids, nutritional supplements, high blood pressure, diabetes. Finally McKee threw up her hands. "You are delusional," she told them.
The two-hour meeting ended cordially, with McKee and the others receiving thanks from the MTBI committee but no promises of follow-up discussions. McKee was relieved it was over. "We hadn't made a dent in anybody's opinion," she says.
More than four years later, in a building near McKee's office outside Boston, the largest collection of NFL brains (61) is stored in a freezer at -80º Celsius. By the fall of 2012, McKee had examined the brains of 34 former NFL players. Thirty-three had CTE. Asked what percentage of NFL players probably have the disease, McKee said, "I don't think everybody has it, but I think it's going to be a shockingly high percentage."
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