On vacation the past two weeks, I sometimes felt as though every time I checked in on the news, I came across yet another story about football and CTE, the terrible neurodegenerative brain disease that afflicts way too many football players. Its formal name is chronic traumatic encephalopathy, and it can only be diagnosed after someone dies and their brain is cut open.
The most important of these stories, which ran in late July, reported on the recent findings of Dr. Ann McKee, a neuropathologist who leads Boston University’s CTE Center. McKee had examined the brains of 202 former football players and had found evidence of CTE in 177 of them, including some athletes whose football days ended after high school. The real stunner, though, was that 111 of those brains had resided in former NFL players – and 110 had CTE.
The New York Times even published photographs of some of the brains, so that you could see the invasive effect of the tau protein that causes CTE, visible because the brain becomes darker in the areas where tau accumulates. The Times also noted that among the pro players whose brains McKee examined, the preponderance were lineman. This makes perfect sense. Although in the public mind CTE is associated with concussions – and that is unquestionably a serious problem – the bigger issue is sub-concussive trauma, the repeated blows to the head that linemen especially endure, and inflict, in every game.
That story was followed two days later by the news that John Urschel, 26, a lineman with the Baltimore Ravens, was retiring from football after only three seasons. A mathematician who is currently a Ph.D. candidate at the Massachusetts Institute of Technology, Urschel has career options that most of his football-playing peers don’t. But he clearly loved playing football, once describing the rush he got from hitting opposing players as “a feeling I’m (for lack of a better word) addicted to.”
But while Urschel and his agent downplayed the medical significance of his retirement, several news outlets reported that the McKee study had heightened his concern that continuing to play football would hamper his mental facilities and jeopardize his ability to do math.
There was also a flood of frightened commentary from former players, with the former Denver Broncos running back Terrell Davis telling the Denver Post – just prior to his induction into the Hall of Fame – that “we’re all scared,” and 44-year-old Warren Sapp, another Hall of Famer, telling the Players Tribune that he was donating his brain to CTE researchers. “My memory ain’t what it used to be,” he said. Boomer Esiason, the retired pro quarterback and current sports broadcaster, said on his radio show that he “most likely” had CTE – and that “all football players probably have it.”
And finally, on Friday, the Times reported that 28 months after a CTE-related legal settlement between the National Football League and former players was approved by federal district court judge Anita Brody, payments were finally being issued to some of the 21,000 former players who were part of the plaintiff class. (More about that shortly.)
All of which motivated me to seek out one of McKee’s Boston University School of Medicine colleagues, Robert Stern, a professor of neurology and neurosurgery who researches Alzheimer’s as well as CTE. One of his main focuses over the past few years has been searching for ways to detect and diagnose CTE during life, work that is being funded by the National Institutes of Health. (The NFL was originally going to fund some of the CTE research through the NIH, but the government wound up providing all of the funding. NPR recently reported that the NIH and the NFL ended their research partnership with million unspent.)
What all these recent stories about CTE made me wonder was whether Stern and other scientists involved in this work were making progress in their quest. When I got him on the phone, Stern could not have been more upbeat.
“We are making incredible progress,” he began. Then he continued:
“It is really an exciting time in the development of objective biomarkers for neurodegenerative diseases. Alzheimer’s is the most common neurodegenerative disease, of course. It is scary common. Well over 5 million people have it. CTE is very similar to Alzheimer’s. And all of the advances in diagnosing Alzheimer’s during life accelerate our ability to do the same with CTE. Just in the last two years, there have been tremendous strides in new blood-based biomarkers with these diseases, as well as new neuroimaging approaches.
“For years and years, it was believed that you could only diagnose Alzheimer’s after death. But because so many hundreds of thousands of people were studied over the years, and thousands of brains, scientists got good at diagnosing it in life. Blood-based and spinal fluid-based biomarkers as well as specific PET scans can diagnose it quite accurately, even before someone has significant symptoms – indeed even before someone has any symptoms at all. Things have changed so dramatically with Alzheimer’s, it allows us to feel confident about CTE. I run a registry of older individuals who we examine every year. After they pass, we examine their brains, and we can look at the relationship between what they were like in life and what changes are seen in their brains post-mortem. We don’t have that luxury yet with CTE, where we’ve only looked at hundreds of brains and haven’t examined anywhere near the number of people. It’s remarkable that we have made the gains we have.”
When I asked Stern how long he thought it would be before CTE could be diagnosed during life, he answered, “between five and 10 years,” with the former more likely than the latter. But when I asked the obvious follow-up question – what will a diagnostic tool for CTE mean for the game of football? – he gave a scientist’s response. “That’s beyond my focus,” he said.
Surely, though, the implications are profound. One implication is that once CTE can be diagnosed, scientists can work on developing drugs to treat the symptoms, as is currently happening with Alzheimer’s. But that will take years, and in the meantime, there will be other likely consequences that won’t be so pleasant to contemplate.
Take, for instance, that class-action settlement between the ex-players and the NFL. It’s estimated that pro football will ultimately pay out $1 billion or more to players who show certain symptoms of brain disease during their lives. But the symptoms laid out in the settlement – Alzheimer’s, Parkinson’s disease and ALS among them – don’t necessarily correlate to CTE. Indeed, there’s zero evidence that Alzheimer’s is a symptom of CTE, and not much evidence that Parkinson’s is related either.
Meanwhile, signs that someone does have CTE – including mood swings, uncontrolled anger, depression and suicidal tendencies – are nowhere to be found in the settlement. And the agreement between the NFL and the plaintiffs – or, rather, their lawyers, who stand to gain as much as million for their efforts – takes no account of the possibility that CTE will one day be diagnosed during life.
Thus you will have a situation where former players who have been diagnosed with CTE will get nothing because they have the “wrong” symptoms, while other former players who don’t have CTE will be compensated because they came down with Alzheimer’s, just like millions of people who never played football. Even though the settlement is ironclad in the sense that it prevents future CTE-related lawsuits – which of course is why the NFL agreed to it – I suspect that this situation will be untenable. Players and ex-players are unlikely to sit still as the absurdity of the situation becomes clear. There’s likely to be some kind of revolt.
The other, even more important implication will be on the game itself, of course. Esiason is surely wrong when he says that everyone who played the game has CTE. But once a diagnostic tool is developed, researchers will be able to calculate the percentage of players in high school, college and the pros who will get the disease. Suppose they find that half of former NFL players have it, and maybe another 10 percent of college players – numbers that seem plausible, given McKee’s findings. Even without knowing the precise odds, NFL players now realize that football is a crapshoot that might well lead to an early death. How will they react once they know how high the odds truly are?
What do players do once they know they can be diagnosed even before they show any symptoms? Do they get tested? Or do they avoid getting tested, not wanting to know? Or do they decide not to play at all? Will a lineman who gets through college without contracting CTE decide it’s not worth the risk of going pro? And parents – what do they do when they know the odds? Will they still let their kids gravitate to football, even in football-mad places like Texas and Alabama?
Will the existence of a diagnostic tool for CTE create an existential crisis for the NFL and the sport of football? I think that’s pretty likely.
For all the recent stories about CTE and football – for all the fear CTE has created among players and ex-players – the game’s moment of truth has not yet arrived. If Stern and his fellow scientists have anything to do with it, it should get here sometime between five and 10 years.