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This October, the American Academy of Pediatrics (AAP) came out with a position paper supporting the current organization of reforms of youth tackle football—that is, supporting the current status quo, in which youth football remains a part of public schools. Two University of Minnesota bioethicists, Dr. Steven Miles and Dr. Shailendra Prasad, have challenged the AAP in an editorial for the American Journal of Bioethics's January issue (it's available to read online here). In it, they propose removing youth football from public schools as a form of "primordial prevention" of the long-term effects of head trauma resulting from tackle football.
Shailey Prasad is a family doctor and associate director of the University of Minnesota North Memorial Family Medicine Residency. Steven Miles is a professor of medicine and bioethics who practiced for 34 years. He spent about five years in the dementia-brain disorders section of the Minneapolis VA's Geriatric Research, Education & Clinical Center.
VICE Sports talked to both men about how they arrived at their conclusions and the issues facing the game of football and the medical community.
VICE Sports: What falls under the field of bioethics, and how we can apply bioethics to sports?
Miles: Bioethics is fundamentally about two things: No. 1, how do we relate the values of the goals of medicine to various practices and acts in society? Sometimes they are medical acts, like the ethics of treatments or surgery or resuscitation. Sometimes they're acts like policies with regards to pollutants, football practices, and so forth. The second thing that bioethics looks at in relationship with this kind of problem is how do we situate the decision-makers with regards to conflicts of interest. For example, if one had the decision about return to play made by a rotating doctor who had no association with the team that would be one thing. If the decision's made by a doctor who is part of the team in consultation with a coach, you've got a different set of interests bearing on the decision of return to play. You saw a nice example of that recently in the hit on Case Keenum, the [St. Louis Rams] quarterback who went down clutching his head, needed help to stand up. Cameras everywhere, coaches standing on both sides of the field, and he was sent back into play with a serious concussion, in a league that just paid $760 million to avoid that kind of supervision of play.
You cite a number of medical issues in football. Were these discoveries recent? How long have we had the information that you used to reach your conclusion?
Prasad: It's a sum total of many years. I think it's an ongoing work, but we've had some of this information for a long time. I think the challenge primarily is, a lot of people ask us the question "How do you say how many traumatic brain injuries will lead to dementia?" It's impossible to do such a study. What is concerning is, then, you get a lot of hits during a season of play. We used to think that children's brains can recover very well after an injury, after a concussion or a sub-concussive injury. But we are realizing now that there are a lot of structural changes that occur in the brain that could lead to a long-term problem. They don't recover as well as we think they would.
Miles: There are two kinds of ways to look at this. One is head trauma. There you get, per season of play and practice, around 250 hits per season for junior high and about 640, average, for senior high. The severity of head trauma comes in, and people try and distinguish between concussion, which is generally symptomatic, versus asymptomatic head trauma. It's not clear there is really a difference in terms of outcome. What we do know is that these kids are missing school, they're complaining of headaches, memory problems, decreased attention in school, which suggests this is having an effect on learning. The question then becomes, what's the appropriate public policy response to it?
Football's supporters claim that we don't have enough proof that the damage we're seeing is because of football, that there could be other causes for diseases like CTE. What do you say to those who argue that we need to see more research before taking such a dramatic step as ending football programs in public schools?
Miles: First off, only somewhere around one-seventh of football teams have any medical system sitting on the sideline to evaluate people. The fact that there's no data reflects the fact that there are no medical sensors to collect the data. We do know that we're having deaths from head trauma, and we know that we're having absenteeism, and we know furthermore that a concussion in one season is associated with a three-fold increased risk of concussion in the following season. But nobody has even measured the issue of how many concussions in one season—that is, they count have you had a concussion in a season of play and practice, but nobody has even counted how many in a season of play and practice. With that number of head hits, you know there are concussions. The fundamental question is, do you balance the well-being of kids against the simple institutional cultural value that's placed on football? The Academy of Pediatrics said we can put these two on a teeter-totter. You can't do that in medicine. You don't put a patient's welfare in relationship to the welfare of an institution. You may do it in the military, but you don't do it in school.
Prasad: As a primary care doctor, I'm all about risk communication. In risk communication, we always say, "Is the benefit worth the risk?" Yes, from a pure science viewpoint we can't track every individual kid with head injuries all the way until they end up with long-term damage. It's not feasible to do a study like that. So then you look at the risk versus the benefit. The concern is enough to say that the risk is too much.
The counterargument always has been that football will make them run around and play and exercise. Possibly, but is football the only way to do that? Football is not a lifelong sport. You don't see an old man's football league. You see basketball leagues, you see hockey leagues, you see runners. We should be encouraging more of those lifestyle aerobic exercises rather than a violent game.
Miles: The thing is, we require kids to be in school. So you go down to, you know, Glencoe, Minnesota [which has a population of 5,536]. If they're trying to put together a team, they only have one or two students in that school that can play linebacker, and there is pressure to do it. And furthermore, those kids don't only play defense; they play offense in the same game. So if you move it outside the schools, where the kids aren't required to be, then they can choose—really choose—whether they want to go play. And it doesn't shut the option down because three times as many kids play in the non-school leagues than in the school leagues. So freedom of choice is preserved but the peer pressure which shapes the choice is modulated.
You come to the opposite conclusion of the AAP. How much impact would it have if an organization like AAP came out against football in public schools?
Prasad: That would have a major impact. For a lot of our practice with healthy kids, we depend on some guidelines from people like the AAP. As a practicing physician, we look at primary research, but it's not always possible for us to look at primary research, because we don't have primary research in a lot of things. Then we look at opinions from established organizations, guidelines from organizations. For children's health, AAP does carry a lot of weight in this country. So yes, if they would come against football, it would carry significant weight.
Miles: In fact, in 1957 they said no tackle football for kids under 12. They just let that expire under a sunset rule. And then this statement they just came out with was strange because they said, well, maybe if the kids do better neck strengthening things, that will decrease the risk of neck trauma. Well, you don't put that in a standard of care—that's a direction for research. Of course, now they have a really big problem with the New York Times editorial ["Don't Let Kids Play Football," by Dr. Bennett Omalu].
Your paper calls existing consent forms for school football "deeply flawed." How much do you think a comprehensive consent form like the one you suggest would help?
Prasad: I think it's one step. I think if the AAP came up with strong guidelines, that would be more powerful than a consent form for sure. But the consent form would at least bring the question of accurate communication of risk. Having a comprehensive consent form would actually give pause to that idea, that there is something dangerous for us to consider here. I think there is a tendency sometimes for parents to believe in intermediate steps, saying that they would work. For example, there's the chin-up strategy of tackling [Heads Up Football]. The parents think that doing that will make the game safe, but it's not shown to be any safer with that, so I'm not sure where we're going with it. So, a consent form would actually give a little more weight to the argument that this is a dangerous sport. Is it the only way? No.
Miles: The American Academy of Pediatrics did not propose any consent form. They said people should just be informed of the risk as they consent to play, but they offered no template. One of the discussions I had as I started to get into this was I called up and spoke with one of the senior serious non-NFL researchers on this question in the country. And I asked this person, "Let's pretend I'm a parent, I want you to describe for me the risks of this so I can decide whether or not to let my son play football." And this person, who had spent two decades studying this, could not come up with one coherent sentence describing risk. They just said, well, you gotta decide for yourself whether or not this is worth it. That is not informed consent.
Do you think football's place in our culture and the aura around the game in this country makes truly informed consent harder to achieve?
Prasad: I lived down South, where football is considered part of the—it's religion there. There is a part of clearing your kid to go play football, the annual pilgrimage to the doctor's office to get a sports consent form filled. It's sort of a sham. We don't spend too much time on the sports physical. And every time I sign one, I'm like, what am I actually signing? I'm signing somebody to go and play a game, sometimes I don't even want to know what game they're playing.
Every time it's football, I try my best but it just seems like I'm not doing enough at the time to communicate the risk. I think the consent would be one step in raising the awareness further. Football culture is so pervasive, it's an integral part of the country and a lot of things that we do, but increasing awareness about that would actually help.
Miles: There's another way to look at it, though. We're so driven by consent, but if you look at the death of Charlie Mohr in Wisconsin in 1960, a college boxer, within a month after that death, the NCAA shut down the entire college boxing league across the United States. He wasn't the first death, but the effect of that was to move boxing off campus, and then the entire sport was reconstructed before it moved back on campus 20 years later. We have that kind of larger infrastructure available if we want to preempt this consent discussion and say, "Well, we're going to leave the consent question aside, or leave that with the Pop Warner leagues and the American Youth Football leagues." The question now, with regards to [football in] schools, is we're going to say, "It's not for an environment where peer pressure acts on them to make a particular choice."
I remember being a seventh grader in my middle school gym, we were the first class that had middle school football available to us, and I felt like I needed to sign up and play football because that was just what we did. How much does this dual loyalty contribute to the risks for these kids?
Miles: There are a whole bunch of sports we don't allow in school—BASE jumping, stock car racing—because they're just too dangerous. That doesn't mean we ban them. That doesn't mean we make them illegal. If kids want to go parachuting, they can go parachuting. If they want to go surf the 60-foot waves off of Waikiki, they can do that. That's not making it illegal, but it's saying, We're not going to put any school pressure on you to be on a team where there's a lot of pressure on you to not forfeit the surfing contest by not surfing the 60-footer coming in on the north side of the big island. I think we need to get a grip on this question, because I think schools are different. That's where the "nanny state" argument I think falls apart. People have been writing us, the people who think we argued for banning football. We're completely opposed, frankly. I'm not going to defend banning all football. That's not the way we as a society work. Moving it out of a tax-supported institution that kids are required to be in, that's a different story.
Prasad: Here's an example of that. There was a kid I saw down in Mississippi, tenth grade, 300-pounds plus, huge kid. He had high blood pressure. My instructions for him were, let's try and lose weight, what do we do here, that type of conversation. And I still distinctly remember every time he'd tell me, 'Coach wants me to put on more weight, coach wants me to put on more weight.' It's not that he wants to put on more weight. It's not that he wants to continue with this path. The guy, in 10th grade, had sleep apnea and bad joints and things like that.
It's almost like fattening for the slaughter, you know—literally, in this case.
You refer to the plan to move football away from public schools as "primordial prevention." Can you elaborate on that concept?
Prasad: We talk about prevention being multiple steps: primary prevention, so the disease doesn't start; secondary prevention, after the disease starts. Primordial prevention is to decrease the conditions that lead to the formation of the disease. It's like the root prevention of everything.
Consent wouldn't be primordial prevention. Primordial prevention is actually one step before that, like being an activist to actually discourage the sport itself. If as guardians of the health of kids, we are really concerned about their health, particularly their brain health—not just their brain health but the health of the rest of their bodies, too -- what can you do to prevent an institution that is continuously causing the problem. How can we be advocates for that? You know, you can probably see the Vikings stadium from here, the massive investments that go into things like that, how can we be advocates against these kinds of things? The primordial prevention goes to that, changing the culture around the formation of the product.
Miles: We can prevent people from getting lung cancer by doing chest X-rays. We can prevent people from getting lung cancer by giving them messages to quit smoking and making Nicorette gum available. But we can also prevent people from dying of lung cancer by not having cigarettes as a visible item on a counter where kids can simply see and pick up, and by not having advertising for cigarettes that's aimed at kids. Primordial prevention is out of that line. But none of it touches the fundamental liberty.
Prasad: The thing that bothered me also is that there's a lot of emphasis being given on baseline testing for concussions. They don't prevent concussions! There's an assumption that, oh, they do sideline checking or baseline checking for concussions. If anything, they might—might is the operative word— make you recognize that a concussion has occurred. Some people think that diagnosing a concussion is easy. I've done many—it's not very easy, unless it's very obvious. There's so many grades of concussion that you don't really see, especially with mild traumatic brain injuries, it's very difficult to diagnose. And you should be an expert in their baseline function and assume they're not fudging the baseline function, because we've heard of people dumbing down their baseline function so that when there's a change it won't seem like they have a concussion.
Miles: If the coaches don't want to see it, if the doctors can't diagnose it, and the kids don't want to report it, the screening system doesn't work.
The idea that it wouldn't prevent the concussion in the first place is also really important. People don't talk about that.
Miles: I did neuropsych testing for years at the VA. Neuropsych testing takes time, and the game clock is going while you're doing that. It's not something where you say, like, "Spell WORLD backwards." That is not neuropsych testing.
Prasad: The operative word in minor traumatic brain injury is they're sub-clinical, which means you might not see any changes at all—they're so subtle that you can't pick them, the absentees and the headaches that come on later. That's very difficult to pick up, and that's also a big concern.
Miles: In the NFL, you look at the league reports now on concussion. They have people on concussion watch after a game. And a remarkable number of these people clear up on day six or seven, before the next game. Keep in mind that's with the surveillance of the NFL, which is one thing. Now take a brain that is more susceptible to injury, like a junior high or high school brain, and subtract the screening mechanism that's available in the NFL, and ask yourself what you're really seeing as concussion detection and management. It's not there.
Do you think there's anything that improving equipment could do for the football problem?
Prasad: This is intriguing to me, because I've always looked at helmets as protecting the outside of the skull, like skull fractures. Concussion, essentially, is a jostling inside. Having big protective equipment on the outside doesn't protect that.
Miles: The laws of thermodynamics are preserved, OK? Force equals mass times acceleration is independent of a helmet. Now, there are some sports where a helmet may make a difference. For example, lacrosse. Some concussions in lacrosse are caused by the glancing blow of a mallet. Guys play with helmets. The mass times acceleration of a lacrosse stick is such that the helmet may actually deflect a concussive blow. Women, however, don't play with helmets; they only play with eye protection. Not surprisingly, concussion is the most reported serious injury in women's lacrosse.
Prasad: The other point, you've heard the argument about helmets being used as a weapon. I'm not sure we're actually making it healthier for concussion issues with helmets.
Is there any age where you believe the game becomes safe enough for a minor to play it?
Miles: That's not my job, to make a ruling on football. The bioethics job isn't that. The bioethics job is about fair play with regard to bringing out the facts and making for balanced decision-making. The question of football, yes or no—that's a social decision. You can't do that with deception. You can't do it with a quarter of parents believing their kids going into high school teams have a shot at the NFL when the odds are one in 1,300. I think that question's just not where Dr. Prasad or I work. We take care of health.