League of Denial

by Mark Fainaru-Wada

  By the mid-2000s, ImPACT had taken off. When the company was founded, Lovell’s overlapping roles didn’t draw much attention. But as the torrent of NFL papers continued, many researchers saw an obvious conflict. Lovell was overseeing the NFL Neuropsychology Program at the same time he was pushing ImPACT to NFL teams. The league’s research helped him promote his company. Paper Number 12 read almost like an advertisement: “Many studies using the ImPACT have indicated that it is reliable and valid.” Lovell’s financial stake was disclosed in small print at the end of the paper. Soon, nearly every NFL team was using ImPACT. So was most of the NHL, which adopted mandatory neuropsychological testing in 1997. As concerns about concussions grew, the association with the NFL proved a gold mine for the company’s marketers, who turned ImPACT into a Kleenex-like synonym for concussion assessment. Micky Collins, Lovell’s brash protégé, became an ambassador and indefatigable marketer, hitting the road to promote both the research and the test behind it. “I’ve given a thousand lectures, two thousand lectures,” he said, emphasizing that his primary focus was on concussion awareness and management. “I mean, I’ve been spending time away from my family because of it, educating and really promoting the data.” By the end of the decade, with the national hysteria over traumatic head injuries peaking, over 90 percent of the high school trainers who used computerized testing to assess concussions were using ImPACT, according to the company. The test, which sold in kits for $350 to $750, had been translated into 17 languages.

  Collins, like Lovell, went to great lengths to try to distance himself from the NFL committee. Within minutes of sitting down for an interview in Pittsburgh, he declared: “First of all let’s make this on the record: I wasn’t involved in any of the NFL research, none. I just want to make sure you’re clear on that. I’m not on any papers. I’m not on an NFL committee. I’ve never been on an NFL committee.”

  That was technically true. Collins had never had a direct role with the committee. But after a while it became hard, if not impossible, to figure out where the NFL ended and ImPACT began. A case in point was Pellman’s pet project: the concussion-resistant superhelmet. After the early tests involving the crash-test dummies, the idea had been forgotten, buried under the avalanche of disputed research the NFL was cranking out. But the idea was very much alive. After the first biomechanical studies, Riddell, the NFL’s official helmet maker, got to work designing the concussion-resistant helmet, which was based on specs that had come out of the NFL’s research. For $500,000, Riddell even hired the Ottawa biomechanics firm, Biokinetics, that had performed the crash-test studies for the league.

  Early on, the helmet project suffered a setback. In November 2000, Biokinetics sent a confidential report to Riddell warning that no football helmet—no matter how new and improved—could prevent concussions. That assessment confirmed what researchers such as Cantu and others had believed all along and essentially torpedoed Pellman’s grand vision. The report, unearthed years later by Frontline’s Sabrina Shankman, went so far as to state that even if Riddell created a helmet that surpassed industry safety standards, there was still a 95 percent likelihood that a player would sustain a concussion from a strong enough blow. “No helmet can prevent a concussion. Full stop,” Chris Withnall, the Biokinetics senior engineer who wrote the report, told Shankman.

  Riddell built the helmet anyway, with Withnall’s name on the patent. The company called it, ambitiously, the Revolution. Its principal defining features were flaps that extended over the lower jaw and additional protection around the ear hole. The NFL’s video reconstructions had found that most concussions resulted from blows to the face mask, jaw, and side of the head. The Revolution’s main selling point was that its design was based on research aimed at reducing concussions.

  But how could Riddell make that claim after Biokinetics had privately warned that no helmet could prevent concussions? The answer came in summer 2002, a few months after the Revolution was released. Collins got together with Thad Ide, Riddell’s senior vice president for research and development. “For the record, I don’t know who approached whom,” said Collins. Together, they came up with an idea for a research project involving ImPACT, Riddell, and the University of Pittsburgh Medical Center. “Both Thad and I reciprocally thought it was a really good idea to do a study,” Collins said. “Riddell was coming out with this new helmet technology. I’m not an engineer. All I know is that we could create a methodology that could study it.”

  The idea was to compare high school football players, some wearing the Revolution and others wearing their old helmets. The study would use ImPACT to determine recovery time after a concussion was diagnosed. Riddell provided the helmets and paid $75,000 to UPMC to subsidize the salaries of Lovell and Collins while they worked on the study.

  The potential for conflict was obvious. Lovell was a member of the NFL’s influential concussion committee. He was on record as saying the creation of a concussion-resistant helmet was “a fantasy,” yet he had taken money from the NFL’s official helmet maker to produce a study examining whether its new helmet reduced concussions.

  Collins, who led the study, suggested that he was motivated in part by the need to bring in research dollars to justify his position at UPMC. “I needed money to fund my salary,” he said. “I was going to get my ass fired, you know? So I’m looking for any kind of funding to do this research. Any struggling academic is looking for that. So that was part of it.” He said he understood that Riddell probably was shopping for research that would support its claim that the Revolution reduced concussions. “I’m not an idiot; I know Riddell wanted the results to look good, okay?” he said. “I mean, obviously. I understand that. But I am one of the leading experts in concussion; I’ve done as much research as anyone. I can be trusted as an academic to do a good research project.”

  Lovell, Maroon, and Riddell’s Ide were listed as coauthors. Although this paper would be published in Neurosurgery, the study was not technically part of the NFL series.

  Not surprisingly, the study concluded that wearing the Revolution helmet reduced the “relative risk” of concussion by 31 percent and the “absolute risk” by 2.3 percent. The change in helmet design that grew out of the NFL’s research, Collins and his colleagues wrote, “appears to have beneficial effects in reducing the incidence of cerebral concussion in high school football players.”

  Riddell rushed out a press release:

  RESEARCH SHOWS RIDDELL REVOLUTION FOOTBALL HELMET PROVIDES BETTER PROTECTION AGAINST CONCUSSIONS

  The study, which will be published in February’s edition of Neurosurgery, found that athletes who wore the Riddell Revolution helmet were 31 percent less likely to suffer a concussion compared to athletes who wore traditional football helmets. The authors of this study estimate that the Revolution’s patented technology could translate to 18,000 to 46,000 fewer concussions among the 1.5 million high school players who participate in football each season.

  Later, a UPMC spokeswoman provided e-mails that she said showed how the university had tried to prevent Riddell from misrepresenting and exploiting the research. The e-mails included Riddell’s press release with proposed corrections. Riddell made a few changes, including striking the sentence, “There is now proof that one football helmet provides better protection against concussions.” But most of the press release, including the banner headline, stood.

  Cantu was still the section editor at Neurosurgery when the Riddell-funded Revolution study came across the transom. It seemed that his worst fears had been realized. Years earlier, Pellman had announced to the world that the NFL planned to create a concussion-resistant superhelmet. And now here was the result: a helmet that couldn’t prevent concussions any more than any other helmet, created with the NFL’s stamp of approval and peer-reviewed research that was funded and even coauthored by the company that planned to sell it to kids.

  Cantu attached a blistering commentary to the study, suggesting that it failed to pass the “sniff test” and writing:
“This article, in my opinion, suffers from a serious, if not fatal, methodological flaw.”

  That flaw was that the new Riddell helmets had been compared with random older models of indeterminate age.

  Collins conceded that the varying ages of the helmets was “a major flaw” that skewed the results.

  Years later, when asked about Cantu’s criticism, Collins launched into a tirade that was very much of its time. “For him to criticize this study is a bunch of fucking bullshit,” Collins said. “The flaws in this study were outlined. Everything was fair and balanced in that paper. And Cantu, he was part of the editorial staff! If he didn’t want to publish it, why was it published? I have no problem with Bob wanting to reject the paper. There were serious flaws with the study, okay? I understand that. But when I picked up the paper for the first time and read the comments, I was like, ‘Holy shit. Bob is ripping the shit out of me.’ I’m like, ‘Are you kidding me? Didn’t pass the sniff test?’ ”

  Micky Collins was a headstrong young researcher who once had admired Cantu as a giant in the field. “I was a young kid, and I respected the shit out of Bob Cantu,” he said. But tests like ImPACT, which revealed an endless variety of concussions, had made Cantu’s grading scales obsolete, Collins thought. “And guess what Bob did? Bob defended them until he looked like an idiot,” said Collins. “Basically it was like an ugly death.”

  For his part, Cantu was still the King of Concussions. He had spent more time studying the injury than any researcher in the country. His voice carried a lot of weight.

  But there was a larger issue beyond the debate over the Revolution helmet and the conflicts of interest and the competition between an older researcher and a younger researcher.

  Collins, whether he acknowledged it or not, had aligned himself with the NFL, like Lovell, his mentor.

  Cantu was a Dissenter.

  That epic battle was building.

  10

  “THE LADY DOTH PROTEST TOO MUCH”

  Not long after Omalu and Co. submitted their paper on Mike Webster to Neurosurgery, two things became clear. One was that the widely held view in some circles that Neurosurgery had been converted into a house organ of the NFL—the Official Journal of No NFL Concussions—was not entirely true. Apuzzo continued to rubber-stamp the NFL’s research despite the mounting protests that it was flawed and self-serving. But now, in February 2005, he agreed to publish Omalu’s paper as well. The publication of the Webster study set up competing narratives in the same medical journal: One said NFL players didn’t get brain damage from football, and the other said they did. This development seemed to support Cantu’s theory that Apuzzo more than anything was interested in topics that “sizzled” and boosted his readership. Whether Apuzzo had totally thought this through was unclear. The Webster paper would prove so hot that it ended up scorching almost everything it touched, especially the NFL.

  That was the second thing: The big wet kiss Omalu had been expecting from the league would not be forthcoming. Instead, the NFL’s doctors took out their scalpels and long knives. Omalu had gotten a hint of how controversial his study would be during the torturous review process, as he was asked to cleanse the paper of any suggestion that the NFL’s MTBI committee should have confronted the issue of long-term brain damage years earlier. An original version of the manuscript included a preamble detailing the history of the MTBI committee. It gave a summary of the retirements of Al Toon and Merril Hoge and stated that after Hoge’s premature retirement, for the first time “NFL executives and medical personnel took notice of the possible neurodegenerative sequelae of professional football.” None of that made the final draft.

  The paper was published as a “Special Report” in the July 2005 issue of Neurosurgery. After a brief period of deceptive calm, Omalu received a call from a man who identified himself as Donald Marion, a member of Neurosurgery’s editorial board. Marion told Omalu that doctors from the NFL’s MTBI committee were calling for his paper to be retracted.

  “You know what that means, what that would mean to your career?” Marion said.

  Omalu knew. He sat down and wept. He knew that in the world of scientific research, a demand for a retraction was the nuclear option. It generally was reserved for allegations of fraud, plagiarism, or cheating.

  “But I haven’t done anything wrong,” Omalu pleaded.

  Marion said that he had been asked by Apuzzo to mediate the dispute. He told Omalu that he would receive a copy of the NFL’s demand and that he should confer with his coauthors to put together a response. That evening, Omalu e-mailed DeKosky and Hamilton, summarizing the conversation.

  Omalu indicated that he had the impression Marion believed the demand was without merit and might have been directed by the league office. “Interestingly he thinks their paper is laughable and politically motivated,” Omalu wrote to his colleagues. “He has asked me, however, to write up a very simple scientific explanation without becoming political. He said they all know that it was the NFL that may have instructed Dr. Pellman and his group to pen the commentary.”

  Despite Marion’s reassurances, Omalu was terrified. As he prepared to read the NFL’s letter at his Pittsburgh apartment, he poured himself a shot of Johnnie Walker Red and gulped it down. The letter was signed by the three leading members of the MTBI committee: Elliot Pellman, Ira Casson, and Dave Viano.

  “We disagree with the assertion that Omalu et al.’s recent article actually reports a case of chronic traumatic encephalopathy in a National Football League (NFL) player,” the letter began. “We base our opinion on two serious flaws in Omalu et al.’s article, namely a serious misinterpretation of their neuropathological findings in relation to the tetrad characteristics of chronic traumatic encephalopathy and a failure to provide an adequate clinical history.

  “These statements are based on a complete misunderstanding of the relevant medical literature on chronic traumatic encephalopathy of boxers (dementia pugilistica). A review of the relevant medical literature, including that cited by Omalu et al., in the chronological order in which it was published demonstrates the flaws in Omalu et al.’s assertions.”

  As Omalu read on, he began to relax. “By the time I got to the third paragraph I smiled,” he recalled. “I even laughed. I knew that Pellman, Casson, and Viano did not know the subject and that their letter was embarrassing and shameful. I said to myself, ‘Isn’t it un-American?’ I respect this country, I’m a foreigner, but I came here to chase my dreams, that the three doctors who are the heads of the NFL Brain Injury Committee don’t even know the basic science of brain damage. I became angry.”

  The letter was six pages long, longer even than the original paper, much of it a scientific overview of the history of CTE in boxers. Pellman, Casson, and Viano used phrases such as “complete misunderstanding,” “completely wrong,” and “completely lacking.” They made two primary arguments: that Omalu et al. had a case that didn’t meet the criteria for CTE and that there wasn’t enough clinical evidence showing Webster was mentally impaired. They insisted Omalu’s findings met only one of the four standards necessary to call this CTE even though Omalu and his colleagues had never claimed this was identical to what was found in boxers. The NFL doctors suggested that the clinical history on Webster was essentially useless because it had been limited to a few phone calls with family members. They pointed out that Webster had no history of concussions or any indications that he had ever left a game because of a blow to the head.

  “Omalu et al. go on to state that ‘there was no known history of brain trauma outside professional football.’ In fact, there was no known history of brain trauma inside professional football,” they wrote, suggesting that during his 17-year career in the NFL there was no evidence that Webster’s brain was so much as jostled.

  Casson, Pellman, and Viano suggested alternative theories for what might have happened to Webster’s brain, theories that the league would continue to cite for years: alcohol, steroids, possible drug abuse. Ironically,
the theories were reminiscent of those proposed by defenders of boxing after Martland, like Omalu a medical examiner, described Punch-Drunk Syndrome in boxers in 1928.

  “We have demonstrated that Omalu et al.’s case does not meet the clinical or neuropathological criteria of chronic traumatic encephalopathy,” they wrote. “We, therefore, urge the authors to retract their paper or sufficiently revise it and its title after more detailed investigation of this case.”

  It was signed:

  IRA R. CASSON

  ELLIOT J. PELLMAN

  DAVID C. VIANO

  New York, New York

  The doctors didn’t identify their connection to the NFL, as if they were merely independent physicians who had banded together in their outrage.

  Omalu wondered about their backgrounds. He did some quick research and had to laugh: Pellman, the committee chairman and now one of Omalu’s main critics, was a rheumatologist. The head of the NFL’s brain committee was an arthritis expert?

  When he finished, Omalu e-mailed Hamilton and DeKosky. “To say the least, it is a laughable commentary,” he wrote.

  Hamilton wasn’t at all amused. “I read over their critique and I do not think it is laughable.… It is very serious indeed,” he responded. Hamilton was more confident than ever about the validity of their research; the criticism was baseless, he felt. What concerned him was the NFL’s attempt to erase their work from the record. He thought it was the work of a self-interested corporation trying to censor his independent research. “I like to think of them as being honorable scientists who are simply stating an alternative hypothesis, but the fact that they wanted me to trash the paper and say that it was bad science, that cued me in to that they were kind of, oh, setting up walls,” he said. “Trying to set up a barrier. To shut it off. To try to make sure that everybody knew that these Hamilton and DeKosky, Wecht, Omalu characters were just insane.”