League of Denial: A review of the PBS documentary

49ers legend Steve Young
one of the great interviews on the
documentary, “League of Denial”

I watched the PBS Documentary “League of Denial” this week, and I’m sure many of you did as well.

In one word:  Bravo.

I thought the folks at PBS’ Frontline did a fantastic job, touching on many facets of what is arguably the biggest sport public health story of the last two decades.  There were so many dimensions to the nearly two hour documentary, it’s hard to know where to begin my review.  In nearly two hours, PBS (with a ‘redacted assist,’ if that’s the phrase, from ESPN), covered a lot of ground.

I thought I would highlight some of the major personas that showed up, and divide them into the following four categories: “Winners,” “Losers,” “Meh,” and “In Memoriam”

Winners

Bennet Omalu, the neuropathologist who broke the story of chronic traumatic encephalopathy (CTE), is my pick for the most compelling figure in this documentary.  A physician of great training and accomplishment, he had the mixed fortune of conducting the post-mortem examination of Mike Webster, the Pittsburgh Steelers icon who died young and whose brain showed the pathologic changes of CTE, the first case documented in an NFL player and reported in this study.

Dr. Omalu’s story, both personally and professionally, is worthy of its own documentary.  Originally from Nigeria, he knows little about American fooball and nothing about the Steelers icon when he first meets the latter’s corpse and goes about his job.  He reports being thoroughly unimpressed with the gross morphology of the deceased’s brain:  how it looked ‘normal.’  It was only on conducting his histopathologic exam that he made his stunning discovery.

For this and further efforts in investigating CTE in deceased NFL players’ brains, he was smeared by the NFL and its affiliated physicians.  Omalu poignantly states as a result, he wished he had never ‘met Mike Webster.’

As an Associate Editor of a medical journal, I found the calls by some in the NFL medical community (see below) for Omalu to retract his CTE study and their ad hominem attacks to be the more egregious sins (among many) reported in the documentary.  The process of science, spearheaded by peer-reviewed literature, is one of openness; disagreements are cause for further study, not suppression.  Retraction should be reserved for outright fraud.  The calls for retraction in this case are shameful.

Ann McKee, another neuropathologist now with the Boston Center for the Study of Traumatic Encephalopathy, has picked up the baton and is continuing to carry on the research into CTE in former professional football players, despite further pushback from vested interests and more ad hominem attacks that insinuate that, as a woman, what might she know about football?

Steve Young who experienced five or six concussions in his career, is one of the former players interviewed for this documentary.  I remember Steve Young well, as I lived in the Bay Area for many of the seasons of his glorious career with the 49ers, and I remember too when he had his career-ending concussion.Young makes for a great interview:  intelligent, articulate, humble, self-aware, and a Hall of Famer to boot.  The Frontline web page has links to material supplementary to the documentary iteself, including full-length interviews of Young and other principals.

Alan Schwarz, a New York Times sports reporter, has been a major figure in this on-going story, as has Chris Nowinski, a former Harvard football player, WWF wrestler, and author of the book Head Games.  I have a ‘personal connection’ to these two individuals (decidedly one-way:  they wouldn’t know me from Adam!).  I read Nowinski’s book in 2008.  It was the most comprehensive treatment of the growing ‘concussion crisis’ in football I had encountered up to that time.  The book was the first alarm bell, for me, of the size and depth of the problem.  Later that same spring I attended a conference on concussions in Boston, which I believe has become an annual affair.  Schwarz spoke.  Articulate and easy-going, his presence both on stage and on the screen must belie an underlying tenacity that would allow him to pursue this breaking story while the entrenched special interests were stonewalling.  Schwarz even describes a “Deep Throat” moment, referencing the famous scenes in the movie All the President’s Men, where he was forwarded a document from his source demonstrating what the NFL knew about the link between head injuries and CTE.

Losers

Sorry to say, it is two doctors, both former NFL physicians:  Elliot Perlman and Ira Casson are the biggest losers here.  I must say I am inclined to be as dismissive of them as they were of their own peers such as Bennet Omalu:  I won’t be writing much about them here, but I encourage you to watch the documentary and form your own opinions.  I place their stories among the long, sad litany of doctors who have been compromised by outside pressures, doctors who have decided not to serve their patients and science, but other masters.

Meh

How does Roger Goodell resemble
Pope Benedict XVI? Read on!

Paul Goodell, the NFL commissioner, deserves a ‘meh’ for his overall performance with regards to the concussion crisis during his tenure.  He certainly is an improvement over his predecessor, Paul Tagliaube, who maintained throughout his years at the top that there was no connection between head injuries and long-term player health. Goodell, I think, recognizes that unless fundamental changes are put in place, the multi-billion dollar industry that is the NFL will fall as surely as Lehman Brothers.  During his tenure he has been behind the moves to address rule changes and player safety, and is taking a great deal of heat for this from some of the players themselves.  He, too, as commissioner is behind the donations to Boston University and most recently to the NIH for on-going brain injury research in NFL players.

He can be rightly criticized, however, for moving slowly on this issue, and perhaps only waking up when the NFL was compared to “Big Tobacco” by a congresswoman during Congressional hearings on the issue, a clip highlighted in the documentary.  The $30 million to be donated by the NFL to the NIH is not only peanuts for the league, but is dwarfed by the $100 million the NFL Players Association will be donating to Harvard for research on the comprehensive health issues of NFL players.  And in the documentary itself, there are moments where he is depicted as having the health of the institution, rather than the players, paramount in his mind.  From the perspective of sociology, where one might predict that this is what an organizational leader is supposed to do, these behaviors make sense.  It still leaves one feeling rather, well, ‘meh’ about Goodell.  Mixing metaphors here and comparing the NFL commish to another leader of a large and wealthy organization,  Goodell more resembles Pope Benedict XVI than Pope Francis!

In Memoriam

Unfortunately, there are several individuals who can be discussed under this topic.  One of the more poignant stories, and more interesting as well from the perspective of clinical sports medicine, is Owen Thomas’, the University of Pennsylvania football player who killed himself in 2010.  This young man was found to have CTE on his post-mortem exam despite never having a documented concussion.  Stories like his are what drive the on-going research on the potential of subconcussive hits for causing long-term brain damage, spearheaded by Dr. McKee and Chris Nowinski and others.

Junior Seau: he died too young

Mike Webster and Junior Seau are profiled in this movie, and, unfortunately, are only a few of the former NFL players who have passed away with documented CTE on post-mortem examination.  Webster I grew up watching:  who can forget those games in the 70’s, if you were a young fan of the NFL, when the classic Steelers’ teams were dominant, and Webster would march up to his position on the O line with his massive biceps uncovered, even in the coldest weather.  His death and later life broke the story of CTE.  The toughest football player was a shell of his former self when he died.

And Seau’s story, perhaps more than any other, captures in microcosm all the threads of this issue:  from the brain damage presaged by a post-football life gone increasingly awry, to the back alley shenanigans associated with how his brain passed to Omalu, and then through his hands to the NIH where his post-mortem did, indeed, demonstrate CTE in his brain.  The documentary explores in some detail this strange story.

Under the lights: one stage for the on-going concussion drama

Though it made far less news than the documentary, there was an interesting opinion piece in the NY Times this week putting football’s concussion crisis in historical perspective, and even calling for the President of the United States to get involved to push for greater reform.  It is fascinating to be part of this phenomenon:  public health is clearly impacting how sports is being played.

I seriously wonder whether the NFL will be around when my son is my age. There’s at least a chance it may  not be.  As arresting a notion as that might be, I would suspect there were plenty of folks in 2007 who could never have fathomed that Lehman Brothers, an investment firm founded in 1850, would be dead by 2008.  One source is quoted in the movie as saying that it would take just 10% of the mothers in America to pull their kids from football for fears of head injury to bring the game down.  An entirely non-scientific and limited survey of the mothers in my own town would suggest we are well beyond that threshold in Bexley, Ohio!

We’ve written a lot about concussions, both in the journal and here on the blog.  We’ve talked about the injury as well. I encourage you to go to these links and look at the various studies and postings.  Let us know what you think.   And let us know what you think of the documentary:  it’s not too late to watch, it can be streamed on-line.   The conversation about concussions in sports–and football in particular–has only begun.