A few years ago, the serious brain injury condition known as chronic trauma encephalopathy (CTE) that was found after autopsies of former American football players made news and there were calls for reform. (I wrote several posts about this back then.) But it seems like those concerns have been forgotten and we have just seen yet another Super Bowl extravaganza with scarcely a mention of the fact that the players out on the field were likely destroying their brains, with each hard concussive hit cheered on by the millions watching the event

In an article in the New Yorker, Ingfei Chen highlights the research of medical historian Stephen Casper who has found that the revelations of brain injuries in football players that were treated as surprising new findings have been known for a long time in football, hockey, soccer, and rugby and each time the sports business complex has managed to suppress those concerns by arguing that the causal relationship of repeated collisions in sports to brain damage were not conclusively proven. The sports industry is adopting the same tactics as the tobacco industry did when the dangers of smoking were first raised. They bring forward their own paid ‘researchers’ to cast doubt and claim that the science is not yet resolved and demand standards of rigor in making causal connections that would take decades to obtain, all so that the people making money from the violence can ignore the problem.

Today, C.T.E. is the subject of furious controversy. Some of the debate has been stoked by researchers affiliated with the sports industry, who argue that we still don’t know for sure that head blows in football, hockey, soccer, or rugby can lead, decades later, to the dramatic mood problems, the personality changes, and the cognitive deterioration associated with C.T.E. These experts maintain that, before we rethink our relationship with these sports, we need scientific inquiries that meet highly rigorous standards—including longitudinal studies that would take fifty to seventy years or more to complete. In the meantime, millions of children and high-school, college, and pro athletes would continue butting heads on the field.

Casper believes that the science was convincing enough long ago. “The scientific literature has been pointing basically in the same direction since the eighteen-nineties,” he told me. “Every generation has been doing more or less the same kind of studies, and every generation has been finding more or less the same kinds of effects.” His work suggests that, even as scientific inquiry continues, we know enough to intervene now, and have known it for decades.

What needs to be done is shift the focus from treating the problem as a medical issue to a public health one.

The worldwide popularity of football, ice hockey, soccer, and rugby in youth leagues and school sports makes head trauma in those games an issue of public health. “Public health and medicine are two different things,” Adam M. Finkel, an environmental-risk expert at the University of Michigan School of Public Health who formerly worked at the Occupational Safety and Health Administration, told me. In the public-health paradigm, the responsible approach is to “warn people, inform people, protect people,” Finkel said. Public-health officials would fail if they sat on their hands for years or decades, then leaped to the most draconian measures to stop a suspected culprit; they succeed, Finkel said, when they weigh the potential costs and benefits across a continuum of sensible protective actions, which might be implemented well before accumulating science proves causation. “The simple question is, how much should we do based on how much we know?” Finkel said.
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“Concern about concussions has a history in football as long as the game of football itself,” Emily Harrison, a historian who teaches epidemiology and global health at the Harvard School of Public Health, told me.

Football’s “first concussion crisis”—which Harrison wrote about in 2014—ensued after a study of Harvard’s football squad in 1906 reported a hundred and forty-five injuries in one season, nineteen of them concussions. In a commentary, the editors of the Journal of the American Medical Association (JAMA) singled out cases in which “a man thus hurt continued automatically to go through the motions of playing until his mates noticed that he was mentally irresponsible.” This behavior, they noted, suggested “a very severe shaking up” of the central nervous system, which, they argued, might have serious consequences later in life. Football, they concluded, was “something that must be greatly modified or abandoned if we are to be considered a civilized people.”
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According to Harrison’s research, some leaders within the Progressive political movement had been calling for football’s abolition, on pacifist grounds. But that year President Teddy Roosevelt, the nation’s foremost mainstream Progressive, spearheaded the establishment of the Intercollegiate Athletic Association—a precursor to the National Collegiate Athletic Association. The association introduced reforms such as protective gear and the forward pass, which somewhat reduced bodily injuries and deaths. But the changes also introduced unintended effects. The incidence of concussions actually increased as players crashed into heavier body padding. As the First World War began, pacifism fell out of vogue, and football was valorized as a means of instilling manly values in boys.
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In her 2014 article, Harrison, the Harvard historian, wrote that the first concussion crisis in the U.S. faded, and then slipped from collective memory, “because work was done by football’s supporters to reshape public acceptance of risk.” The sport’s managers “appealed to an American culture that permitted violence, shifted attention to reforms addressing more visible injuries, and legitimized football within morally reputable institutions.” Back then, advertising and newspaper coverage glorified the young men who took on the risks of the sport. Today, football is marketed to fans in glitzy state-of-the-art stadiums, including at the college level. “A great deal of money and effort has gone into convincing people that risks that were unsettling should actually feel just fine,” Harrison told me.
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Last summer, a new systematic review of recent studies on C.T.E. found that they met a set of criteria for establishing that repetitive head impacts cause the disorder. The authors, led by experts at Boston University and the Concussion Legacy Foundation, a nonprofit, urged officials to swiftly implement aggressive measures that could “minimize and eliminate” recurring head hits, especially among children. It was a pivotal analysis, conducted according to modern scientific standards, and it validated what the historical record has said all along. But the fact that the report was even needed “made me very infuriated,” Casper told me. “How many more examples of Mike Webster do you really need? There’s something about it that seems sort of like Jonathan Swift to me.” In “Gulliver’s Travels,” Gulliver visits Lagado, the capital of a nation where doctors of “the Academy” conduct pointless and impractical experiments while everyone else lives in poverty. Researchers who are skeptical of C.T.E. strike Casper as similar to Lagado’s scientists: they are arguing about technicalities while ordinary people get hurt.

Banning football and the other concussion-prone sports like soccer, hockey, and rugby at the school and college level will be a tough sell since so many people seem to be actually attracted by the violence. But we can do what we did with tobacco and treat brain injuries in those sports as a public health issue and demand that, short of banning them altogether, warnings of the dangers be plastered all over the place, especially where students and other young people can see them, so that they (and their families) become far more aware of the dangers.

Contact-sports participants and their parents should be explicitly warned about chronic brain damage—especially college athletes, who are presumably attending school to improve their minds. The N.C.A.A. notes that, since 2014, it has provided fact sheets, which schools may voluntarily use to educate their student athletes, that mention possible long-term problems from concussions. “Ongoing studies raise concerns,” the handout says. “Athletes who have had multiple concussions may have an increased risk of degenerative brain disease and cognitive and emotional difficulties later in life.” But it’s not known whether every N.C.A.A. athlete actually receives these materials, Casper said—and, for an eighteen-year-old, the warning should be blunt and unequivocal, along the lines of the Surgeon General’s warning on cigarette packages. Athletic facilities should post huge warning posters, Casper told me, explaining what could happen to your brain. “Put ’em up in every locker room, and make sure they’re up every year. And that’s it,” he said. “That’s the best I think we’re probably ever going be able to do.”

Dave Zirin is a very good sports writer, who does not shy away from talking about the politics and economics of sports and the racism and sexism that have pervaded it. He is well aware of the dangers of football. In an article in the February/ March 2023 issue of The Progressive magazine (subscription), he describes his extended family as sports-obsessed and the problem that it has created with his son.

Sports have been the central part of my work and leisure for two decades, but that’s not the only reason I watch. For many members of my family, sports are the sole focus of conversation. If we’re not talking about football, we’re probably not talking. The result is that I’ve felt a lifelong pressure to follow the game as assiduously as possible so that I can communicate with my in-laws. Therefore, my son has been raised watching football, too, and now he wants to play it.
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Professional football is three hours of highly commodified violence, perfect for an American raised on the violence of our news, schools, politics, movies, and music. The NFL fits hand in glove with the United States.
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It is morally difficult to watch this sport, regardless of its entertainment value. And yet on Sundays, I am glued to the television, and I have a son who insists on playing, come hell or high water. His passion for the game mirrors Conroy’s love of basketball, and I like to think I’m a more supportive father than Conroy’s father was. But being so encouraging has a price. I can’t stand in the way of his desire to play. He will learn through experience whether this sport is for him. Yet I stay up nights worrying about the cost.

I can understand Zirin’s concern. I have two daughters so the issue never came up in my home but I now have two very young grandsons. I can only hope that they never decide to play these brain-damaging sports and I will take any chance that I get to discourage them from doing so.