engaging book, by respected investigative journalists (and brothers), explores
the evolving story of chronic traumatic encephalopathy (CTE) among professional
football players over the past four decades. It begins in 1974 at the start of
the career of Mike Webster, the All-Pro football center who played 15 seasons
for the Pittsburgh Steelers. Webster’s death in 2002 was attributed to CTE,
making him the first professional football player to be diagnosed posthumously
with the brain disease. The authors use Webster and other star players—such as
Dave Duerson and Junior Seau, both of whom committed suicide and were found on
autopsy to have suffered from CTE—to tell the larger story of National Football
League (NFL) players and league leadership as they grappled with the unfolding
story of brain trauma on the gridiron.
the incidence of CTE and its causal relationship with concussions are
controversial issues, and the science behind them is still unfolding. This book
is a retrospective review of the subject, with the advantage of hindsight and
the accompanying whiff of Monday-morning quarterbacking. The authors do an
excellent job documenting the debate surrounding the diagnosis of CTE, along
with its cause, prevalence, and outcome, and skillfully weave the personal player
accounts into the more complex story of public relations and legal liability. The
legal outcome remains unsettled after a federal judge in January denied the
preapproval of a $765 million settlement of NFL concussion claims to cover
20,000 retired players for 65 years.The medical
issues regarding CTE and the factors leading up to it, however, persist.
open discussion about the role that repeated concussions play in the
development of CTE started in 1996. The authors compare the NFL’s role in that conversation
to the role played earlier by tobacco companies as they refused to acknowledge any
relationship between lung cancer and cigarette smoking. That comparison seems
unfairly harsh, since the CTE story includes a complex interplay between willing
partners and publicity seekers (players, owners, scientists, doctors) who
unfortunately had to discuss a medical issue that had no clear definitions or
vocabulary at the time.
recently have scientists agreed upon the clinical definitions of concussion and
mild traumatic brain injury. Even today there is no gold-standard diagnostic test
for concussion and no clear data on when it is safe for a player to return to action.
For most of the time period this book covers, the science was even more speculative.
Nevertheless, the authors’ apparent agenda means that anyone associated with
the NFL is described as self-interested and corrupted by dollars, while dissenters
are characterized as world authorities, at a time when there really weren’t any.
Agenda aside, the authors create a highly readable account of the developing
story, and I enjoyed their prose and progression of ideas.
authors do an excellent job capturing the personal and behavioral
characteristics of all the participants in this complicated scenario. The
science on concussion is complex enough, and the subject tackled by the authors
is even more confusing because of the personalities involved and the jockeying
for personal gain that went on throughout the era. Industry-funded research has
an inherent conflict of interest, and the authors accurately characterize the
egos, self-promotion, and financial and reputational gain sought by all the
characters in this story. What the authors don’t adequately capture or
characterize, however, is how all the complex interpersonal relationships and
conflicts of interest obfuscated the central issue, which presumably is player
safety. The authors also downplay the athletes’ own role in the story. Self-promotion,
greed, and conflict of interest at multiple levels made this a much more
complex issue than it needed to be.
the authors suggest throughout the book that CTE is an epidemic, although at
the time of publication there was a total of only 50 reported cases, 33 of
which occurred in NFL players. The hyperbolic prose helps to lead readers to
the authors’ preordained conclusion. Both
the NFL and the dissenters were unfortunately guilty of not following the
age-old rule of the scientific method. As a scientist, I would propose a null
hypothesis and take a prospective rather than retrospective approach: eliminate
all the confounding variables and prospectively follow patients with the
intention of demonstrating statistical significance. Future data will always be
confounded by drugs, smoking, alcohol, and other risk factors, such as
genetics, family history, and ethnicity. But rather than being led to the
authors’ conclusion, readers would be better served by being helped to understand
how complex the diagnosis and treatment of mild traumatic brain injury and its
possible outcome, CTE, can be.
I found League of Denial to be a
great weekend read. The authors are to be commended for their compilation of
data and description of circumstances that, although flavored, are accurate. The
book clearly demonstrates that we need more data, which should be derived from
independently funded studies to eliminate accusations of bias. I totally agree that
research funds should be directed through the National Institutes of Health. The
NFL appears to be continuing its support for definitions, protection, and rule
changes. Only if all parties remain focused on the science, and on player
safety, will this issue be resolved fairly.