by Ken Dryden
“We learned to connect the extreme end, which was boxing,” Johnston says, “to people who were getting hit and experiencing symptoms but who were not being knocked out, and were not having abnormal imaging. We think of concussion now not as a structural injury to the brain—because when we do these scans, they are normal—but as a functional injury, as the brain not working in certain ways.” If there is something functionally wrong, there must be something wrong whether they can see it or not. And once the scientists and doctors thought to make the connection between the sports, they began to think: Why would a fist in hockey be different than a fist in boxing? Why would an elbow or a shoulder be different than a fist?
This had been so obvious. But they couldn’t see what they couldn’t imagine, just as they couldn’t understand what they weren’t looking for. Neurosurgeons and MRIs couldn’t see much of the damage present in a structural brain, but neuropsychologists could see that damage by looking at the functional, or dysfunctional, brain—by looking at people’s symptoms and behaviours. It was seeing the structural through the functional.
In the early 2000s, more time and resources were being dedicated to the field of concussion. Studies were being carried out and articles were being written—published not just in scientific journals but in newspapers and magazines. Sports medicine conferences included sessions on concussions. With all this attention and interest, scientists and sports medicine people began to collaborate. Concussion was still a field on the margins of both sports and science—and sports medicine was still on the margins of medicine—but whereas earlier, when each specialty had been too small to fight big fights, they had fought smaller ones among themselves. Now, with bigger ones to win, they began to fight together over the profound impact of concussion itself.
One more thing proved immensely important. Work on concussions had been carried out by pockets of single-minded people involved in different sports on different continents. Though they had all decided that concussions mattered, most didn’t know each other or know each other’s work. But the more advanced science and higher public priority gave them greater reason to connect, and with the Internet they now had the means of doing so. The importance of instant communication cannot be underestimated, Johnston says. It allowed them to begin thinking about a global conference, the effect of which would be profound.
—
In 2001, the first International Conference on Concussion in Sport was held in Vienna, organized by the International Ice Hockey Federation (IIHF), the International Olympic Committee (IOC), and the Fédération Internationale de Football Association (FIFA). Johnston was chair of the Concussion in Sport Group that wrote the conference’s final statement. Despite the fact the conference was held less than two months after 9/11, about 150 people from 15 sports organizations attended.
Grading systems were the conference’s focus. “The Vienna meeting was the turning point,” Johnston says, “because people declared their will to start working together, to start driving the science forward, not just the anecdotal stuff. That was a really big deal. At that meeting, we first started to hear about some of the great neuropsychological approaches. There were imaging studies. There was some good science that was just starting to take off. The other conferences that followed had the same goal in mind, but the first one changed the concussion world.”
Two years later, in 2003, Johnston and other Canadian scientists decided it was time to take this new information on the road. They called it the “Concussion Roadshow.” It was organized by ThinkFirst, the group headed by Dr. Charles Tator that had Paul Montador as a member of its board.
“We felt a necessity to take the message out to the public and to the teams,” Johnston says, “because we were starting to learn what symptoms were important, but also because doctors still thought that loss of consciousness was the big thing, [and because] teams had no clue what to do, and players were going back out and playing when they were injured. And we were starting to know that there were way more concussions than we thought.”
They travelled around Canada, gave talks, held conferences. “The presentations were built around athletes telling their story,” Johnston says. “We had talks about the background science designed to be digestible to a wide audience. We talked about protection, about rehabilitation, about some of the signs—what we know and what we don’t know. A team doctor talked about some of the issues that a team doctor faces. In the audience, we had athletes who had been concussed. There were medical doctors, physiotherapists, athletic therapists, coaches, and parents. And media.” Many more people were becoming aware of the problem of concussions in sports. Johnston and the others were achieving what they had set out to do.
As scientists, their job was to study, learn, and apply what they’d learned. But with the roadshow, they had gone a step further. They had shared. Now the public knew that concussions were not just about “feeling woozy,” “seeing stars,” or “having your bell rung.” They are brain injuries, and like injuries to a shoulder or a knee, they almost always go away—they heal—but sometimes they don’t, or they don’t heal completely. With a knee or a shoulder, sometimes function is affected, strength and mobility are lost or diminished, pain is increased; a shoulder that could once throw a ball ninety-five miles an hour can now throw it only eighty-eight. And injuries that do go away sometimes come back twenty or thirty years later, before regular advanced aging brings them back.
It’s the same with the brain. Concussion is an injury to the brain. It can lead to the brain’s diminished function, whether temporarily or for good. Losing seven miles an hour on a fastball is one thing; losing your equivalent capacity to solve problems or make decisions is quite another. Johnston and her colleagues had a message for the public: reducing the number of concussions is important.
In 2004, the second International Conference on Concussion in Sport was held in Prague. Two more followed in Zurich, in 2008 and in 2012. Another was held in Berlin in November 2016. The Mayo Clinic also held summits on concussions in hockey in 2010 and 2013. The scientists and sports medicine practitioners in the field were moving ahead. They were conducting more studies; they were using what they learned to better diagnose and treat their patients. The public were becoming more aware of the problem and of the best solutions. The decision-makers—coaches, on-ice or on-field officials, team owners, league and player executives—could then take this knowledge and apply it to their sports because now they knew, too. Because whatever uncertainties remained over the origins of CTE and other neurological disorders, over who gets them and how—through actions incidental or accidental, contrary to the rules or not—there was now no doubt, none, about the connection between blows to the head and brain injuries, between brain injuries and the resulting lousy things that happen to a person’s life.
Johnston and the others had built the awareness; they knew the decision-makers would come.
But the decision-makers didn’t come. At first, perhaps, they didn’t know about the life-affecting impact of concussions, but then they did—and they ignored, then denied, then considered the possibility, then acknowledged the possibility but with caveats. Then they took some action, then emphasized how difficult it is to take action, then emphasized the actions they had taken, especially as compared to other sports, other leagues, other anything, especially considering all the scientific doubts that still remained. In doing so, they avoided the only real question: Is the dimension of the actions they have taken consistent with the dimension of the problem they face?
When the decision-makers were slow to respond, Johnston and others grew frustrated. They tried patience. They tried perspective—we’re a lot further ahead than we were ten years ago. They tried understanding—change takes time. They tried generosity—I think Gary Bettman really gets it.
Busy with her patients and her research, Johnston occasionally still steps back, seeking perspective, and sees how slowly actions—true, meaningful actions—are being taken. She has decided it is her fau
lt. She hasn’t gotten the message across well enough, she thinks. “It has led me into the field of KT or ‘knowledge translation,’” she says. “How do we take this information and make it digestible and accessible to various groups of people?” She offers an example: “The way an athlete learns information is not necessarily the same way a neuroscientist or a family doctor does. So what models of education do we need to develop, and deliver, so that we are not just handing some pamphlet to everybody and they’re just trashing it? Shall we make another video? Shall we do this online? Does it need to be interactive? Shall we make an app for that?”
Johnston says she doesn’t have an answer. “It feels like a desperate measure, trying to find ways to convince people to buy in. Ultimately, maybe we need marketing people doing this. I don’t know. I’m a brain surgeon. What the heck am I doing trying to figure out ways to educate physiotherapists or hockey coaches about concussion? I was never trained in those skills. So, once again, you start collaborating with other people. All of this stuff is so outside the box from whatever I thought I would be doing.”
Johnston tries to be optimistic. “It’s why I like looking after my patients,” she laughs. They do what she tells them to do—mostly. But she knows that’s not good enough. She doesn’t want to have to see the people she is treating. She can help many of them be better than they were when she first saw them, but she knows that they would be so much better off if they had never been injured, if the games they love to play and can’t stop themselves playing were safer. But these decisions, she knows, are not hers to make.
Yet she sees hope. “Some schools have taken this on. Some teams have. Some of the stuff that’s come out of the NFL studies, the problems with dementia and mood disorders and suicide. They create a forum and a voice to talk about this. The athletes coming forward; they are the best spokespeople.” This is all about better “knowledge translation,” in Johnston’s words. But KT isn’t always the problem. Others have to decide that they want to listen in the first place.
Decision-makers know who decision-makers are. They know the difference between influence and authority. They know that influence may reside in someone else’s voice—someone like Johnston—but that authority resides with them. They know that they can say to Johnston or to everyone else—the scientists, researchers, media commentators, parents—“You and thousands and millions of others like you might be completely right. But you are not sitting in this chair; this is my decision not yours, and I have the right to do what I want to do.” Parents know that coaches make decisions that they, as parents, cannot make themselves; coaches know the same about minor hockey officials, and minor hockey officials know that about leagues, and leagues about provincial or state associations, and provincial or state associations about Hockey Canada or USA Hockey. And Hockey Canada and USA Hockey know, and the IIHF knows, that the NHL makes decisions that they cannot make. The NHL is the big decision-maker in hockey. It sets the tone, it determines the direction, because it creates the dream.
CHAPTER TEN
Gary Bettman never played the game. And he is American, a fact that has never gone unnoticed by Canadians. He attended Cornell University, where hockey is the biggest sport on campus, but hockey had not been a priority in his life before he became the NHL’s commissioner. When he took on that role in 1993, it instantly became his job to run a league that dominates the direction of the sport, worldwide, for all the players and fans who absolutely love the game. Bettman has not always had the trust of those players and fans.
He was also taking over a league that did not function much like a league, which made the NHL just like every other major North American professional sports league. For a long time, these leagues had operated as little more than a collection of individual teams with very individual owners, who ran what they owned the way they wanted to run them. Their message to the league officials whom they employed was: “Schedule the games, hire the referees, and get out of our way.” The teams made their money locally; it was certainly not the leagues that put “bums in seats,” or company logos around arenas and stadiums. Leagues were understood by team owners as an expense—apparently necessary, but one that needed to be minimized.
This perception began to change with the National Football League in the 1960s and 1970s. The league’s commissioner, Pete Rozelle, believed that a strong NFL would make a strong Chicago Bears or New York Giants even stronger, and he reinforced his case with team owners when he negotiated a big new network TV contract for the league.
David Stern believed the same of the National Basketball Association. Many of the NBA’s franchises had been weak for decades when Stern was hired as the league’s commissioner in 1984. He knew that the NBA’s great stars and great teams gave presence—and financial value—to the rest of the players and teams, who were not great. Again, it was a big network TV contract that persuaded the owners of the league’s value. Bettman had been third-in-command at the NBA before he was hired by the NHL, and had learned its lesson: a strong league is critical to the success of its teams. His problem, as it had been for Rozelle and Stern, was that for this to happen, he needed to sign a big TV contract in the U.S., which—given that hockey was nowhere near as popular as football, baseball, and basketball—was far from certain.
Bettman had a shaky first decade. He did get his initial big TV contract in the U.S.—at least, big by NHL standards—but that was followed by one that was smaller. The league had decided even before Bettman was hired that, to be relevant in the U.S., the NHL needed a fully national U.S. footprint. It developed a “Southern Strategy,” led and implemented by Bettman, which by expansion or by franchise transfer saw teams move into San Jose, Dallas, Anaheim, Florida, Colorado, Phoenix, Carolina, Nashville, and Atlanta; later Columbus and Minnesota, were the only northern exceptions. The results were decidedly mixed.
Bettman also had some bad luck. The Canadian economy turned downward, Canada’s federal and provincial governments ran up large deficits, commodity prices fell, and the value of the Canadian dollar plummeted from just over 80 cents to the U.S. dollar in February 1993 when Bettman began to 63 cents in August 1998, to its all-time low—61.79 cents—in January 2002. Most of the revenues for Canadian teams were in Canadian dollars; all player expenditures were in U.S. dollars.
Toronto was a rich enough city for the Leafs to cope with the currency gap and to compete with U.S. teams for free agents; Montreal and Vancouver less so. Calgary, Edmonton, and Ottawa had great difficulty. Their teams and their fans were losing confidence; they weren’t sure when and how they could compete at the top again. All of this—combined with the rise of European and American players in the NHL, Canada’s disappointing finishes in world and Olympic championships, and the departures of the Quebec Nordiques and Winnipeg Jets to the U.S. in the mid-1990s—made this American who had never played the game a very unpopular person in Canada.
Bettman wasn’t much more popular in the U.S. New cities got their teams, but many of the teams couldn’t seem to emerge from their apparently perpetual struggle to survive. It seemed that the commissioner’s job, much of the time, was to keep the many franchise fires from getting out of control, then find new owners to stabilize things a little until the next fire popped up. With all this uncertainty, franchise values were not increasing the way they were in other sports, which didn’t make team owners happy. And what made them even less happy were player salaries. Despite the fact that the NHL was a distant fourth in popularity among professional sports leagues in the U.S., its players, on average, were paid more than players in the NFL—and not much less than those in Major League Baseball. In fact, their salaries had increased by a larger percentage the previous decade than those of players in all of the other leagues except basketball. The NHL also was the only league, other than MLB, that had no salary cap. To NHL team owners, this wasn’t the way things should be.
The existing collective bargaining agreement between the NHL and the National Hockey League Players’ Association (NHL
PA) was set to expire in 2004. The owners were looking for greater revenues, higher franchise values, and lower expenditures. They wanted a big network TV contract in the U.S., and the wage certainty that a salary cap would bring. It was Bettman’s job to deliver this. These were office issues that fundamentally affected the on-ice game: how it is played; the playing life and non-playing lifestyle of the player; and, most crucially, who controls the game.
Bettman is a businessman with a lawyer’s training and instincts. This is who the league hired, it is what Bettman wanted to be, it is what the league got. In his new role as commissioner, he attended games and was visible in the seats. He watched; he listened; he learned. He learned enough to ask the right, probing, revealing questions. He weighed arguments; he applied logic. But he was not an expert in hockey. He hadn’t been a player. He wasn’t Canadian. He couldn’t pretend he was any of these things, and he knew how ridiculous it would be to try. Sports fans can detect poseurs light years away.
To the owners he would be businessman and lawyer, and to the fans he would surround himself with “real hockey guys.” Heart and soul ex-players, their pedigree displayed in stitches and limps earned in the trenches of the game. Canadians—maybe even those from small towns—who had lived the story of the game, who were authentic, who for Bettman would be the game’s institutional memory and its conscience. Bettman could learn the language of hockey, but they knew its idioms. Anything about the game itself went through them. This only made sense; it was also publicly defensible. If ever Bettman got too lawyerly or said something cringeworthy, he had people around him to bring him back to the real world: To how things are done. To how hockey players think. To how the game is played.
